Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation The ACUTE economic data at eight weeks

AbstractObjectivesThe aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period.BackgroundThe Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored.MethodsTwo economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies.ResultsA total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively ($6,508 vs.$6,239; difference of $269; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups.ConclusionsIn patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy

A group randomized trial of a complexity-based organizational intervention to improve risk factors for diabetes complications in primary care settings: study protocol

<p>Abstract</p> <p>Background</p> <p>Most patients with type 2 diabetes have suboptimal control of their glucose, blood pressure (BP), and lipids – three risk factors for diabetes complications. Although the chronic care model (CCM) provides a roadmap for improving these outcomes, developing theoretically sound implementation strategies that will work across diverse primary care settings has been challenging. One explanation for this difficulty may be that most strategies do not account for the complex adaptive system (CAS) characteristics of the primary care setting. A CAS is comprised of individuals who can learn, interconnect, self-organize, and interact with their environment in a way that demonstrates non-linear dynamic behavior. One implementation strategy that may be used to leverage these properties is practice facilitation (PF). PF creates time for learning and reflection by members of the team in each clinic, improves their communication, and promotes an individualized approach to implement a strategy to improve patient outcomes.</p> <p>Specific objectives</p> <p>The specific objectives of this protocol are to: evaluate the effectiveness and sustainability of PF to improve risk factor control in patients with type 2 diabetes across a variety of primary care settings; assess the implementation of the CCM in response to the intervention; examine the relationship between communication within the practice team and the implementation of the CCM; and determine the cost of the intervention both from the perspective of the organization conducting the PF intervention and from the perspective of the primary care practice.</p> <p>Intervention</p> <p>The study will be a group randomized trial conducted in 40 primary care clinics. Data will be collected on all clinics, with 60 patients in each clinic, using a multi-method assessment process at baseline, 12, and 24 months. The intervention, PF, will consist of a series of practice improvement team meetings led by trained facilitators over 12 months. Primary hypotheses will be tested with 12-month outcome data. Sustainability of the intervention will be tested using 24 month data. Insights gained will be included in a delayed intervention conducted in control practices and evaluated in a pre-post design.</p> <p>Primary and secondary outcomes</p> <p>To test hypotheses, the unit of randomization will be the clinic. The unit of analysis will be the repeated measure of each risk factor for each patient, nested within the clinic. The repeated measure of glycosylated hemoglobin A1c will be the primary outcome, with BP and Low Density Lipoprotein (LDL) cholesterol as secondary outcomes. To study change in risk factor level, a hierarchical or random effect model will be used to account for the nesting of repeated measurement of risk factor within patients and patients within clinics.</p> <p>This protocol follows the CONSORT guidelines and is registered per ICMJE guidelines:</p> <p>Clinical Trial Registration Number</p> <p>NCT00482768</p

The Determinates of the Provision of Charity Medical Care by Physicians

We provide a theoretical model and an empirical analysis of the factors affecting the magnitude of a physician's provision of free or reduced-fee medical care. The theoretical basis of our analysis is Becker's theory of the allocation of time. Our empirical model also accounts for other factors that affect the provision of charity care. Our results indicate that physicians are likely to reduce charity care as the opportunity cost of their time increases. We also found some indirect evidence that physicians who lower their fees for low-income patients are behaving charitably and may not be engaging in price discrimination.

Comparison of adverse events rates and hospital cost between customized individually made implants and standard off-the-shelf implants for total knee arthroplasty

Background: This study compares selected hospital outcomes between patients undergoing total knee arthroplasty (TKA) using either a customized individually made (CIM) implant or a standard off-the-shelf (OTS) implant. Methods: A retrospective review was conducted on 248 consecutive TKA patients treated in a single institution, by the same surgeon. Patients received either CIM (126) or OTS (122) implants. Study data were collected from patients' medical record or the hospital's administrative billing record. Standard statistical methods tested for differences in selected outcome measures between the 2 study arms. Results: Compared with the OTS implant study arm, the CIM implant study arm showed significantly lower transfusion rates (2.4% vs 11.6%; P = .005); a lower adverse event rate at both discharge (CIM 3.3% vs OTS 14.1%; P = .003) and 90 days after discharge (CIM 8.1% vs OTS 18.2%; P = .023); and a smaller percentage of patients were discharged to a rehabilitation or other acute care facility (4.8% vs 16.4%; P = .003). Total average real hospital cost for the TKA hospitalization between the 2 groups were nearly identical (CIM $16,192 vs OTS$16,240; P = .913). Finally, the risk-adjusted per patient total cost of care showed a net savings of $913.87 (P = .240) per patient for the CIM-TKA group, for bundle of care including the preoperative computed tomography scan, TKA hospitalization, and discharge disposition. Conclusions: Patients treated with a CIM implant had significantly lower transfusion rates, fewer adverse event rates, and were less likely to be discharged to a rehabilitation facility or another acute care facility. These outcomes were achieved without increasing costs. Keywords: Adverse event rate, Hospital cost, Length of stay, Customized individually made implant, TK