Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients.

BACKGROUND: The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU). METHODS: Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from$200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80). RESULTS: Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis. CONCLUSIONS: Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors

When Collecting Patient Data Gets Electronic: The Upsurge of Ehealth and The Importance of Big Data to Shape Modern Health Care

peer reviewe

What is the Profile of Individuals Joining the KNEEguru Online Health Community? A Cross-Sectional Mixed-Methods Study

BACKGROUND: The use of the Internet for seekers of health-related information provides convenience and accessibility to diverse sources (of variable quality) for many medical conditions. There is a suggestion that patients may find empowerment by engaging with Internet health care strategies and communities. The profile of consumers of online health information on knee pain has not been explored. OBJECTIVE: Our objective was to identify the characteristics and motivations of online health information-seekers accessing the online health community, KNEEguru (KG). The study was designed to obtain the respondents' sociodemographic profile, together with their main reasons and motivations for joining such a community, their health information-seeking behavior, the extent of their knee problems, and their general Internet usage. METHODS: We undertook an online questionnaire survey, offered to users of the KG website from June to July 2012. A mix of open and closed questions was used to facilitate inductive enquiry. Quantitative responses were analyzed using univariate analysis; qualitative thematic analysis of the open responses was completed and a conceptual model was developed. RESULTS: One-hundred and fifty-two respondents took part (11.56% response rate, 152/1315), with a mean age of 40.1 years. Of this cohort, 61.2% were female, 68.4% were in domestic partnerships, 57.2% were employed, 75.0% had higher education qualifications, and 80.3% were of white/Caucasian ethnicity. Females were associated with joining KG in order to get emotional support from other users (OR 2.11, 95% CI 1.04 - 4.27, P=.04). Respondents' self-perception of health was associated with reported quality of life (OR 10.86, 95% CI 3.85 - 30.43, P<.001). Facebook users were associated with joining KG to share experiences (OR 2.34, 95% CI 1.04 - 5.56, P=.03). Post-surgery respondents were associated with joining KG to compare symptoms with other users (OR 7.31, 95% CI 2.06 - 39.82, P<.001). Three key themes were induced: condition, emotion and support. Respondents expressed distress and frustration at uncertainty of prognosis around various knee conditions, with some users preferring to initially observe rather than engage. Conversely, a strong desire to inform and support other community members was stated with reciprocation of ideas and experiences. KG was conceptualized as a filter that takes an individual's condition and emotional response to that condition as basis for support; this filter facilitated validation as the outcome of engagement. CONCLUSIONS: This study, in line with wider literature, suggests that users of an online knee-specific community are typically female, middle-aged, white/Caucasian, married, employed, and have attained a level of higher education. These users demonstrate a pragmatic approach to health care information with altruistic motivations and a desire to share experiences as a means of validation. This finding emphasizes a means of promoting efficient and appropriate online health care, and demonstrates the benefits of the Internet as a viable complement to clinical engagement

Retention of the posterior cruciate ligament versus the posterior stabilized design in total knee arthroplasty: a prospective randomized controlled clinical trial

Background: Prosthetic design for the use in primary total knee arthroplasty has evolved into designs that preserve the posterior cruciate ligament (PCL) and those in which the ligament is routinely sacrificed (posterior stabilized). In patients with a functional PCL the decision which design is chosen depends largely on the favour and training of the surgeon. The objective of this study is to determine whether the patient's perceived outcome and speed of recovery differs between a posterior cruciate retaining total knee arthroplasty and a posterior stabilized total knee arthroplasty. Methods/Design: A randomized controlled trial will be conducted. Patients who are admitted for primary unilateral TKA due to primary osteoarthrosis are included when the following inclusion criteria are met: non-fixed fixed varus or valgus deformity less than 10 degrees, age between 55 and 85 years, body mass index less than 35 kg/m(2) and ASA score (American Society of Anaesthesiologists) I or II. Patients are randomized in 2 groups. Patients in the posterior cruciate retaining group will receive a prosthesis with a posterior cut-out for the posterior cruciate ligament and relatively flat topography. In patients allocated to the posterior stabilized group, in which the posterior cruciate ligament is excised, the design may substitute for this function by an intercondylar tibial prominence that articulates with the femur in flexion. Measurements will take place preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively. At all measurement points patient's perceived outcome will be assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures are quality of life (SF-36) and physician reported functional status and range of motion as determined with the Knee Society Clinical Rating System (KSS). Discussion: In the current practice both posterior cruciate retaining and posterior stabilized designs for total knee arthroplasty are being used. To date no studies have been performed determining whether there is a difference in patient's perceived outcome between the two designs. Additionally, there is a lack of studies determining the speed of recovery in both designs as most studies only determine the final outcome. This randomised controlled study has been designed to determine whether the patient's perceived outcome and speed of recovery differs between a posterior cruciate retaining total knee arthroplasty and a posterior stabilized total knee arthroplasty

The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study

BACKGROUND: We performed a matched case control study to assess the effect of prior high tibia valgus producing osteotomy on results and complications of total knee arthroplasty (TKA). METHODS: From 1996 until 2003 356 patients underwent all cemented primary total knee replacement in our institution. Twelve patients with a history of 14 HTO were identified and matched to a control group of 12 patients with 14 primary TKA without previous HTO. The match was made for gender, age, date of surgery, body mass index, aetiology and type of prosthesis. Clinical and radiographic outcome were evaluated after a median duration of follow-up of 3.7 years (minimum, 2.3 years). The SPSS program was used for statistical analyses. RESULTS: The index group had more perioperative blood loss and exposure difficulties with one tibial tuberosity osteotomy and three patients with lateral retinacular releases. No such procedures were needed in the control group. Mid-term HSS, KSS and WOMAC scores were less favourable for the index group, but these differences were not significant. The tibial slope of patients with prior HTO was significantly decreased after this procedure. The tibial posterior inclination angle was corrected during knee replacement but posterior inclination was significantly less compared to the control group. No deep infection or knee component loosening were seen in the group with prior HTO. CONCLUSION: We conclude that TKA after HTO seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no HTO previously

Epidemiology of Knee and Hip Arthroplasty: A Systematic Review§

We present a systematic review of epidemiologic studies of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). The studies summarized in this systematic review provide us with estimates of arthroplasty utilization rates, underlying disease frequency and its trends and differences in utilization rates by age, gender and ethnicity among other factors. Among these, many studies are registry-based that assessed utilization rates using data from major orthopedic centers that may provide some understanding of underlying diagnosis and possibly time-trends. Several studies are population-based cross-sectional, which provide estimates of prevalence of TKA and THA. Population-based cohort studies included in this review provide the best estimates of incidence and utilization rates, time-trends and differences in these rates by important patient characteristics (age, gender, ethnicity and others). This article reviews the current published literature in the area and highlights the main findings