Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients.

BACKGROUND: While ostomies for diverticulitis are often intended to be temporary, ostomy reversal rates can be as low as 46%. There are few comprehensive studies evaluating the effects of socioeconomic status as a disparity in ostomy reversal. We hypothesized that among the elderly Medicare population undergoing partial colectomy for diverticulitis, lower socioeconomic status would be associated with reduced reversal rates. METHODS: Retrospective cohort study using a 20% representative sample of Medicare beneficiaries >65 years old with diverticulitis who received ostomies between January 1, 2010, to December 31, 2017. We evaluated the effect of neighborhood socioeconomic status, measured by the Social Deprivation Index, on ostomy reversal within 1 year. Secondary outcomes were complications and mortality. RESULTS: Of 10,572 patients, ostomy reversals ranged from 21.2% (low socioeconomic status) to 29.8% (highest socioeconomic status), with a shorter time to reversal among higher socioeconomic status groups. Patients with low socioeconomic status were less likely to have their ostomies reversed, compared with the highest socioeconomic status group (hazard ratio 0.83, 95% confidence interval 0.74-0.93) and were more likely to die (hazard ratio 1.21, 95% confidence interval 1.10-1.33). When stratified by race/ethnicity and socioeconomic status, non-Hispanic White patients at every socioeconomic status had a higher reversal rate than non-Hispanic Black patients (White patients 32.0%-24.8% vs Black patients 19.6%-14.7%). Socioeconomic status appeared to have a higher relative impact among non-Hispanic Black patients. CONCLUSION: Among Medicare diverticulitis patients, ostomy reversal rates are low. Patients with lower socioeconomic status are less likely to undergo stoma reversal and are more likely to die; Black patients are least likely to have an ostomy reversal.

Value-Based Healthcare in Ostomies.

In order to achieve significant improvements in quality, cost, and accessibility (the health "iron triangle"), innovation in organizational and service delivery models is necessary to increase the value of healthcare. The aim of this study is to evaluate the efficiency of a model of organizational innovation based on advanced practice nurse in the care of people with ostomies (APN-O) versus usual care. An observational, exploratory, analytical, prospective study with a six-month follow-up was carried out at 12 hospitals that implemented this model in Andalusia. A total of 75 patients who had undergone a digestive elimination ostomy and/or a urinary ostomy were followed for six months. Clinical outcomes, healthcare resources, health-related quality of life, and willingness to pay (WTP) were analyzed. The economic evaluation was conducted from a societal perspective, including healthcare costs and indirect costs. The cost difference between the two models was €136.99 and the quality-adjusted life year (QALY) gained was 0.05965 (€2297 per QALY gained). At six months, the mean of WTP was €69 per APN-O consultation. This model contributes to increasing the value-based healthcare in ostomies. Results of this study suggested that APN-O is an effective patient management model for improving their health status and is highly efficient.

Is "free" really free? Ethical implications of short-term discounts and giveaways to hospitals.

Canadian hospitals participate in provincial and national procurement processes to help reduce healthcare costs. This allows for redirection of funds to direct patient care, along with creating networks, integrating services, and improving innovative solutions. To be competitive, vendors offer creative solutions and provide free or low-cost supplies to hospitals with the hope that patients will continue to purchase those items when discharged. What is not always factored into the procurement decision-making processes is the potential financial impact of the supplies required for patients when discharged from hospital services and other ethical implications of accepting free/reduced-cost supplies. This column provides some guidance for health leaders in this respect.

The Financial Impact of Living in Canada With an Ostomy: A Cross-sectional Survey.

PURPOSE: The aim of this study was to explore how living with an ostomy financially impacts Canadians. METHODS: A descriptive, pan-Canadian, cross-sectional online and paper-based survey was conducted using a convenience sample. RESULTS: Surveys were completed by 467 individuals. Seventy-six percent (n = 355) reported spending more than $1000 annually on ostomy supplies, with 58% (n = 271) paying partially out of pocket. Atlantic regions relied primarily on insurance (n = 81), and the central, prairies, and western regions used a combination of funding (provincial government funding and/or insurance) (n = 385) with no significant out-of-pocket funding differences between regions (χ = 18.267, P = .079). Fifteen percent (n = 70) reported frequent peristomal skin problems, and 19% (n = 89) indicated that having an ostomy negatively affected their ability to work. When experiencing ostomy-related problems, 60% (n = 280) sought assistance from a nurse specialized in wound, ostomy, and continence (NSWOC) and spent significantly less on ostomy supplies (χ = 231.267, P < .001). CONCLUSION: This study demonstrated that living with an ostomy may result in financial burden and that Canadian regional variations in funding and access to an NSWOC should be explored.

Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study.

INTRODUCTION: Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions. METHODS: The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic. RESULTS: During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial. CONCLUSION: The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.

A Resource Guide to Improve Nursing Care and Transition to Self-Care for Patients With Ostomies.

Clinical management of patients with an ostomy can be complex and stressful. With only 10% of Wound Ostomy Incontinence Nurses working in home health, home healthcare nurses need to be knowledgeable about care of patients with new ostomies. This article provides an overview of the resources available to guide nurses caring for ostomy patients. In addition, resources nurses can share with patients as they transition into the community are provided.

A Randomized Controlled Trial Determining Variances in Ostomy Skin Conditions and the Economic Impact (ADVOCATE Trial).

PURPOSE: To compare ostomy-related costs and incidence of peristomal skin complications (PSCs) for ceramide-infused ostomy skin barriers and control skin barriers. DESIGN: The ADVOCATE trial is a multi-centered randomized controlled trial, and double-blinded international study with an adaptive design. SUBJECTS AND SETTING: The sample comprised 153 adults from 25 sites from the United States, Canada, and Europe. Participants were seen in hospital and outpatient care settings. METHODS: Data were collected by investigators at each site during face-to-face visits and during telephone check-in calls between visits. Cost of care data were collected using a questionnaire developed specifically for the study. The peristomal skin was assessed using the Ostomy Skin Tool. Health-related quality of life was measured using the SF-12v2. Patient-reported outcomes were collected using a patient-centered study-specific questionnaire. Cost of care was analyzed via analysis of covariance comparing total cost of care for 12 weeks between the 2 groups. The incidence of PSC was analyzed via Barnard's exact test comparing the incidence of PSCs between the control and treatment groups. Tertiary outcomes were exploratory in nature and not statistically powered. RESULTS: Use of the ceramide-infused barrier significantly reduced stoma-related cost of care over a 12-week period, resulting in a $36.46 decrease in cost (14% relative decrease). The adjusted average costs were $223.73 in the treatment group and $260.19 in the control group (P = .017). The overall incidence of PSCs in the study was 47.7%; PSC incidence was 40.5% for the treatment group versus 55.4% for controls (P = .069, 95% confidence interval of the difference: -1.2 to 30.4). Significantly more participants using the ceramide-infused skin barrier were "very satisfied" with barrier performance (75% vs 55%; P = .033), prevention of leakage (63% vs 38%; P < .01), and prevention of itching (53% vs 31%; P = .016). General postoperative improvement in health-related quality of life was noted in both groups. CONCLUSIONS: The use of a ceramide-infused barrier significantly decreased cost and increased satisfaction with patient-reported outcomes.

EXPLORING PATENT ACTIVITY AND ITS POTENTIAL ASSOCIATION WITH HEALTHCARE OUTCOMES: A CASE STUDY OF OSTOMY PRODUCTS IN SWEDEN.

OBJECTIVES: The aim of this study was to evaluate whether ostomy industry patent activity (PA) is associated with patient outcomes and healthcare costs. METHODS: Two groups of ostomy pouch users based on manufacturer PA (low or high) were compared in terms of ostomy-related wear patterns, adverse events, and healthcare expenditure. Using Swedish registry data, all patients with newly formed stomas were divided between each group and were followed during a 2-year period (2011-12). Propensity score matching and parametric duration analysis were used to compare outcomes between patients of similar characteristics such as sex, age, and ostomy surgery type. RESULTS: In both one- and two-piece systems, the high PA group had significantly lower monthly ostomy-related expenditure than the low PA group (one-piece: 197.47 EUR versus 233.34 EUR; two-piece: 164.00 EUR versus 278.98 EUR). Fewer pouch and skin wafer purchases per month were an important driver of cost differences. Both groups had similar likelihood of purchasing dermatological products for skin complications over time. CONCLUSIONS: PA in the ostomy care industry was associated with reduced healthcare costs, but not necessarily with fewer skin complications. It suggests that there is a health economic benefit from products made by patent intensive companies which may differentiate them from generic comparators, but more research is needed to understand the impact of activities conducive to medical innovation on health outcomes.

Cost effectiveness of stoma accessories.

Gill Skipper, Stoma Care Sister, The Queen Elizabeth Hospital, King's Lynn NHS Trust, looks at aspects to consider when prescribing stoma care accessories.

A Cost-Utility Model of Care for Peristomal Skin Complications.

PURPOSE: The aim of this study was to evaluate the economic and humanistic implications of using ostomy components to prevent subsequent peristomal skin complications (PSCs) in individuals who experience an initial, leakage-related PSC event. DESIGN: Cost-utility analysis. METHODS: We developed a simple decision model to consider, from a payer's perspective, PSCs managed with and without the use of ostomy components over 1 year. The model evaluated the extent to which outcomes associated with the use of ostomy components (PSC events avoided; quality-adjusted life days gained) offset the costs associated with their use. RESULTS: Our base case analysis of 1000 hypothetical individuals over 1 year assumes that using ostomy components following a first PSC reduces recurrent events versus PSC management without components. In this analysis, component acquisition costs were largely offset by lower resource use for ostomy supplies (barriers; pouches) and lower clinical utilization to manage PSCs. The overall annual average resource use for individuals using components was about 6.3% ($139) higher versus individuals not using components. Each PSC event avoided yielded, on average, 8 additional quality-adjusted life days over 1 year. CONCLUSIONS: In our analysis, (1) acquisition costs for ostomy components were offset in whole or in part by the use of fewer ostomy supplies to manage PSCs and (2) use of ostomy components to prevent PSCs produced better outcomes (fewer repeat PSC events; more health-related quality-adjusted life days) over 1 year compared to not using components.

Teleostomía y telecura. También en el paciente urológico / No disponible

La teleostomía y la telecura son consultas virtuales que permiten al paciente recibir cuidados especializados en el propio domicilio. Con esto vamos a conseguir que los pacientes tengan que desplazarse con menor frecuencia al centro de referencia, mejorando así el confort y tranquilidad que les ofrece su propio hogar. Dicha consulta facilita la tarea diaria de enfermería de Atención Primaria contando con el apoyo de profesionales expertos, que pueden orientar, ayudar y guiar en la realización de los cuidados específicos relacionados con las heridas crónicas y/u ostomías. Esto le permitirá al profesional ser más resolutivo, a la vez que se reducirán los ingresos hospitalarios y consecuentemente el gasto sanitario

No disponible

Key Messages in prescribing for stoma care.

With £248 million spent on stoma appliances and accessories throughout England in 2013 (Health and Social Care Information Centre, 2014) value for money and control of this process is seen to be of high priority. This does not have to mean restricted access of appliances, rather that there is appropriate usage of the budget. This article looks at how the stoma care team collaborated with the local clinical commissioning group (CCG) in order for the local surgeries to gain a better understanding of the needs of their local stoma care population. It was hoped that this would facilitate further control in the ordering (by the patient or GP) of stoma care products. The Key Messages produced are to be used as a tool to aid cost-effective stoma care.

Strategies to reduce treatment costs of peristomal skin complications.

Peristomal skin complications (PSCs) are common and troublesome and the consequences are substantial both for the patient and from a health-economic viewpoint. The purpose of this article is to demonstrate that early detection and treatment of PSCs, combined with the use of a correctly fitted and appropriate pouching system, can reduce treatment costs-in the UK, it is estimated to save £28.1m annually. A model for cost estimation of PSCs and a real-life global data set of people with stomas are used for the calculations. A high priority should be given to ensuring resources are available to provide education, guidance and assistance to people with a stoma. This would support increased awareness of the first signs of PSCs and enable self-management at an early stage.

Accessories or necessities? Exploring consensus on usage of stoma accessories.

Usage and opinion of accessory products in stoma care vary enormously. The aim of this study was to identify what constitutes an accessory product and to find out whether there is any standardization regarding their recommendation. Views of both patients and stoma nurses were examined. Patients identify accessory products as being necessary both physically and psychologically in improving their quality of life. While stoma nurses identify that the psychological effects of having a stoma should never be underestimated, there is still concern regarding the cost of recommending these products and their clinical necessity. It would appear that clinical necessity is based on nurses' opinions and is not always evidence or research based. Since accessory products have been shown to be essential to many patients with a stoma, should stoma nurses be more empathetic when considering their recommendation?

Ostomy appliance prices in Europe.

OBJECTIVE: This article aims to compare market prices (i.e., third-party reimbursement and patient co-payment) of one-piece and two-piece colostomy, ileostomy and ureterostomy appliances in Belgium, Denmark, England and the Netherlands in 2005. METHODS: Data were collected through contacts with health authorities, health insurance companies, manufacturers, industry associations and distributors. The price difference between Belgium and another country was expressed as a proportion of the Belgian price. RESULTS: A total of 64 out of the 72 ostomy appliance products considered were cheaper in Belgium. Prices of one-piece colostomy appliances and two-piece ileostomy appliances were consistently lower in Belgium. The highest prices of ostomy appliances were observed in the Netherlands. Sixteen out of 20 products and 21 out of 25 products were more expensive in Denmark and England, respectively, than in Belgium. Colostomy appliances were more expensive in England than in Belgium. CONCLUSIONS: Market prices varied substantially between countries, indicating that manufacturers adapt their pricing strategy to the policy environment existing in the ostomy appliance market of each country. Also, there appears to be scope for reducing prices in some countries.