RESUMEN
INTRODUCTION: Office administration of intradetrusor onabotulinumtoxinA is commonly used to treat overactive bladder. For preprocedure analgesia, either 50 mL 2% intravesical lidocaine instillation for 20 to 30 minutes or 200 mg oral phenazopyridine can be used. Phenazopyridine is associated with shorter appointment times and is noninferior to lidocaine for pain control in this setting. We performed a cost analysis of phenazopyridine vs lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder. METHODS: A health care sector-perspective cost analysis was performed. The following assumptions were made: (1) similar efficacy of each medication in providing adequate analgesia, (2) similar physician ease of performing the procedure with either analgesic, and (3) similar patient satisfaction with either analgesic. Average cost of medications, adverse reactions, nursing tasks, and office visit time were found in publicly available data. Sensitivity analyses were performed using TreeAge Pro 2021, R1 software. RESULTS: Phenazopyridine is less costly compared to lidocaine per visit for office intradetrusor onabotulinumtoxinA injection ($827 vs $925). A difference of $98 per procedure provides a total annual cost savings of over $24 million if all procedures are performed with phenazopyridine instead of lidocaine. Sensitivity analysis showed that phenazopyridine remained less costly under most circumstances, and threshold analysis provided exact circumstances under which phenazopyridine is no longer cost saving. CONCLUSIONS: Phenazopyridine provides cost savings compared to lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder. If adopted by providers nationwide, phenazopyridine may reduce health care spending and minimize office visit time while maintaining patient pain control and satisfaction.
Asunto(s)
Anestésicos Locales , Toxinas Botulínicas Tipo A , Lidocaína , Fenazopiridina , Humanos , Toxinas Botulínicas Tipo A/administración & dosificación , Toxinas Botulínicas Tipo A/economía , Toxinas Botulínicas Tipo A/uso terapéutico , Lidocaína/administración & dosificación , Lidocaína/economía , Lidocaína/uso terapéutico , Fenazopiridina/administración & dosificación , Fenazopiridina/economía , Fenazopiridina/uso terapéutico , Administración Intravesical , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Anestésicos Locales/uso terapéutico , Vejiga Urinaria Hiperactiva/tratamiento farmacológico , Vejiga Urinaria Hiperactiva/economía , Administración Oral , Costos y Análisis de Costo , Manejo del Dolor/economía , Manejo del Dolor/métodos , Cuidados Preoperatorios/métodos , Cuidados Preoperatorios/economíaRESUMEN
BACKGROUND: Pre-incision wound infiltration using NSAID is an alternative method to manage post-operative pain in surgery. It is postulated that NSAID delivered peripherally exerts efficient analgesic and anti-inflammatory effect with minimal systemic complication. This study explored the efficacy of using diclofenac for wound infiltration in open thyroidectomy and parathyroidectomy as compared to conventional agent, bupivacaine. METHODOLOGY: The study was designed as a double-blind, randomized controlled trial involving 94 patients who underwent open thyroidectomy or parathyroidectomy in Hospital Pulau Pinang, Malaysia, from November 2015 to November 2016. The study compared the efficacy of pre-incision wound infiltration of diclofenac (n = 47) versus bupivacaine (n = 47) in post-operative pain relief. Wound infiltration is given prior to skin incision. Mean pain score at designated time interval within the 24-h post-operative period, time to first analgesia, total analgesic usage and total analgesic cost were assessed. RESULTS: Ninety-four patients were recruited with no dropouts. Mean age was 49.3 (SD = 14.2) with majority being female (74.5%). Ethnic distribution recorded 42.6% Chinese, 38.3% Malay, followed by 19.1% Indian. Mean duration of surgery was 123.8 min (SD = 56.5), and mean length of hospital stay was 4.7 days (SD = 1.8). The characteristics of patient in both groups were generally comparable except that there were more cases of total thyroidectomy in the diclofenac group (n = 31) as compared to the bupivacaine group (n = 16). Mean pain score peaked at immediate post-operative period (post-operative 0.5 h) with a score of 3.5 out of 10 and the level decreased steadily over the next 20 h starting from 4 h post-operatively. Pre-incision wound infiltration using diclofenac had better pain control as compared to bupivacaine at all time interval assessed. In the resting state, the mean post-operative pain score difference was statistically significant at 2 h [2.1 (SD = 1.5) vs. 2.8 (SD = 1.8), p = 0.04]. During neck movement, the dynamic pain score difference was statistically significant at post-operative 1 h [2.7 (SD = 1.9) vs. 3.7 (SD = 2.1), p = 0.02]; 2 h [2.7 (SD = 1.6) vs. 3.7 (SD = 2.0), p = 0.01]; 4 h [2.2 (SD = 1.5) vs. 2.9 (SD = 1.7), p = 0.04], 6 h [1.9 (SD = 1.4) vs. 2.5 (SD = 1.6), p = 0.04] and 12 h [1.5 (SD = 1.5) vs. 2.2 (SD = 1.4), p = 0.03]. Mean dose of tramadol used as rescue analgesia in 24 h duration was lower in the diclofenac group as compared to bupivacaine group [13.8 mg (SD = 24.9) vs. 36.2 mg (SD = 45.1), p = 0.01]. The total cost of analgesia used was significantly cheaper in diclofenac group as compared to bupivacaine group [RM 3.47 (SD = 1.51) vs. RM 13.43 (SD = 1.68), p < 0.01] or [USD 0.83 (SD = 0.36) vs. USD 3.21 (SD = 0.40), p < 0.01]. CONCLUSION: Pre-incision wound infiltration using diclofenac provides better post-operative pain relief compared to bupivacaine for patient who had underwent open thyroidectomy or parathyroidectomy. Diclofenac is cheap and easily available in the limited resource setting. This approach offers a superior alternative for post-operative pain relief as compared to bupivacaine.
Asunto(s)
Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Diclofenaco/administración & dosificación , Dolor Postoperatorio/prevención & control , Paratiroidectomía , Tiroidectomía , Anestésicos Locales/economía , Bupivacaína/economía , Diclofenaco/economía , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Cuidados PreoperatoriosRESUMEN
PURPOSE OF REVIEW: Chronic thoracic pain, even though not as prevalent as low back and neck pain, appears in approximately 30% of the general population. The severity of thoracic pain and degree of disability seems to be similar to other painful conditions. Despite this severity, interventions in managing chronic thoracic pain are less frequent, and there is a paucity of literature regarding epidural injections and facet joint interventions. RECENT FINDINGS: As with lumbar and cervical spine, a multitude of interventions are offered in managing chronic thoracic pain, including interventional techniques with epidural injections and facet joint interventions. A single randomized controlled trial (RCT) has been published with a 2-year follow-up of clinical effectiveness of the results. However, there have not been any cost-utility analysis studies pertaining to either epidural injections or facet joint interventions in thoracic pain. Based on the results of the RCT, a cost-utility analysis of thoracic interlaminar epidural injections was undertaken. Evaluation of the cost-utility analysis of thoracic interlaminar epidural injections with or without steroids in managing thoracic disc herniation, thoracic spinal stenosis, and thoracic discogenic or axial pain was assessed in 110 patients with a 2-year follow-up. Direct payment data from 2018 was utilized for procedural costs and indirect costs. Costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 or addition of 40% of cost to accommodate for indirect payments and arrive at overall costs. Cost-utility analysis showed direct procedural cost of USD $1943.19, whereas total estimated costs year per QALY were USD $3245.12.
Asunto(s)
Anestésicos Locales/economía , Antiinflamatorios/economía , Dolor de Espalda/tratamiento farmacológico , Análisis Costo-Beneficio , Inyecciones Epidurales , Adulto , Anestésicos Locales/uso terapéutico , Antiinflamatorios/uso terapéutico , Método Doble Ciego , Quimioterapia Combinada/economía , Quimioterapia Combinada/métodos , Femenino , Humanos , Inyecciones Epidurales/economía , Inyecciones Epidurales/métodos , Masculino , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Vértebras Torácicas , Resultado del Tratamiento , Articulación CigapofisariaRESUMEN
INTRODUCTION: We conducted a descriptive study to evaluate any changes in practice behaviour regarding the provision of hydrocortisone and lignocaine (H&L) injections among doctors and how an H&L injection is priced following a disciplinary proceeding decision. A doctor had been fined SGD 100,000 for failing to obtain informed consent before an H&L injection. METHODS: We performed a survey shortly after the disciplinary decision to ascertain: (a) the category of the respondent; (b) whether the respondent provided H&L injections and how much he charged before the decision; and (c) after the decision. All members of the Singapore Medical Association and College of Family Physicians Singapore are doctors and were invited to participate. RESULTS: 1,927 doctors responded to the survey. Prior to the decision, 804 doctors did not perform H&L injections; this increased by 20.4% to 968 after the decision. The number of doctors who gave H&L injections decreased by 164 (14.6%), from the previous 1,123. Pre-decision, doctors who determined their own price for H&L injections charged a median pricing ≤ SGD 100. Post-decision, the median charge rose to > SGD 100 to SGD 200. At higher price bands, the number of doctors who charged > SGD 1,000 increased eight-fold, from eight to 65. CONCLUSION: The study demonstrated how a disciplinary decision can affect practice behaviour, and specifically how doctors may choose to not offer a service, an example of defensive medicine through avoidance behaviour. It also showed how prices for a service can rise following such a decision, which demonstrates the concept of negative general deterrence in sentencing.
Asunto(s)
Anestésicos Locales , Antiinflamatorios , Toma de Decisiones , Hidrocortisona , Lidocaína , Errores Médicos , Médicos/economía , Médicos/psicología , Pautas de la Práctica en Medicina , Anestésicos Locales/economía , Anestésicos Locales/uso terapéutico , Antiinflamatorios/economía , Antiinflamatorios/uso terapéutico , Combinación de Medicamentos , Disciplina Laboral/economía , Humanos , Hidrocortisona/economía , Hidrocortisona/uso terapéutico , Lidocaína/economía , Lidocaína/uso terapéutico , Errores Médicos/economía , Errores Médicos/psicología , Relaciones Médico-Paciente , Médicos de Familia , Pautas de la Práctica en Medicina/economía , Singapur , Sociedades Médicas , Encuestas y CuestionariosRESUMEN
BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.
Asunto(s)
Anestésicos Locales/administración & dosificación , Artroplastia de Reemplazo de Rodilla , Bupivacaína/administración & dosificación , Osteoartritis de la Rodilla/cirugía , Dolor Postoperatorio/prevención & control , Anestésicos Locales/efectos adversos , Anestésicos Locales/economía , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/economía , Bupivacaína/efectos adversos , Bupivacaína/economía , Análisis Costo-Beneficio , Costos de los Medicamentos , Estudios de Equivalencia como Asunto , Humanos , Liposomas , Estudios Multicéntricos como Asunto , Osteoartritis de la Rodilla/diagnóstico , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/economía , Dolor Postoperatorio/etiología , Método Simple Ciego , Factores de Tiempo , Resultado del Tratamiento , Reino UnidoRESUMEN
OBJECTIVES: To compare the efficacy, safety and cost of combinations of perineal pudendal nerve block + periprostatic nerve block and intrarectal local anesthesia + periprostatic nerve block with the standard technique (periprostatic nerve block). METHODS: The study was designed as a randomized prospective controlled trial. Patients with elevated serum prostate-specific antigen values (prostate-specific antigen ≥4 ng/mL) and/or abnormal digital rectal examination findings were included in the study. Patients with anorectal diseases, chronic prostatitis, previous history of prostate biopsy and anorectal surgery were excluded from the study. A total of 148 patients (group 1 [periprostatic nerve block], n = 48; group 2 [intrarectal local anesthesia + periprostatic nerve block], n = 51; group 3 [perineal pudendal nerve block + periprostatic nerve block], n = 49) were included in the final analysis. Pain during insertion and manipulation of the transrectal ultrasound probe was recorded as visual analog scale 1, pain during penetration of the biopsy needle into the prostate and sampling was recorded as visual analog scale 2, and pain during the entire procedure recorded as visual analog scale 3. RESULTS: The mean visual analog scale 1 score was significantly lower in group 3, when compared with group 1 and group 2 (P < 0.001). There was no significant difference between the groups in terms of the mean visual analog scale 2 score. The mean visual analog scale 3 score was significantly lower in group 3 when compared with other groups (P < 0.001). The total cost for transrectal ultrasound-guided biopsy in the intrarectal local anesthesia + periprostatic nerve block group was significantly higher than the other two groups. CONCLUSIONS: The combination of perineal pudendal nerve block and periprostatic nerve block provides more effective pain control than intrarectal local anesthesia plus periprostatic nerve block and periprostatic nerve block alone, with similar complication rates and without increasing cost.
Asunto(s)
Anestesia Local/métodos , Bloqueo Nervioso/métodos , Dolor Asociado a Procedimientos Médicos/prevención & control , Neoplasias de la Próstata/diagnóstico , Anciano , Anestesia Local/efectos adversos , Anestesia Local/economía , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Biopsia con Aguja Gruesa/efectos adversos , Biopsia con Aguja Gruesa/economía , Biopsia con Aguja Gruesa/métodos , Análisis Costo-Beneficio , Humanos , Biopsia Guiada por Imagen/efectos adversos , Biopsia Guiada por Imagen/economía , Biopsia Guiada por Imagen/métodos , Lidocaína/administración & dosificación , Lidocaína/economía , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/efectos adversos , Bloqueo Nervioso/economía , Dimensión del Dolor/estadística & datos numéricos , Dolor Asociado a Procedimientos Médicos/diagnóstico , Dolor Asociado a Procedimientos Médicos/etiología , Próstata/diagnóstico por imagen , Próstata/patología , Neoplasias de la Próstata/patología , Nervio Pudendo/efectos de los fármacos , Recto/cirugía , Ultrasonografía Intervencional/economíaRESUMEN
Aims: Effective postsurgical analgesia hastens recovery, reduces hospital length of stay (LOS), and decreases hospitalization costs for total hip arthroplasty (THA). Improving these outcomes is critical for value-based surgical bundled payment programs such as the Medicare Comprehensive Care for Joint Replacement and similar programs for commercial insurance providers. This study compared clinical outcomes and hospitalization costs for patients undergoing THA with and without liposomal bupivacaine (LB).Materials and methods: This retrospective, comparative cohort study used data from the Premier Healthcare Database from the 10 hospitals with highest use of LB for THA from January 2011 through April 2017. A cohort undergoing THA with LB at those hospitals was compared with a propensity-score matched cohort at those hospitals who had THA without LB. Descriptive, univariate, and multivariable analyses compared post-surgical inpatient opioid consumption, hospital LOS, discharge status, same-hospital readmissions, and total hospitalization costs. Analyses were performed using the Pearson Chi-square test (categorical variables) and Wilcoxon or Student t-test (continuous variables).Results: For patients with Medicare (with LB, n = 3622; without LB, n = 3610) and commercial insurance (with LB, n = 2648; without LB, n = 2709), use of LB was associated with lower post-surgical inpatient opioid consumption (105 and 81 mg, respectively; p < 0.0001), a 0.7-day shorter LOS (p < 0.0001), a 1.6-1.7-fold increased likelihood of home discharge (p < 0.0001), and no increase in readmissions (p ≥ 0.103). Total hospitalization costs were $561 lower with LB in the Medicare population (p < 0.0001) and $41 higher with LB in the commercial population (p = 0.7697).Limitations: Hospitalization costs were estimated from the hospital chargemaster. Findings from these 10 hospitals may not represent other US hospitals.Conclusions: At select hospitals, THA with LB was associated with reduced post-surgical inpatient opioid consumption, shorter hospital LOS, increased likelihood of home discharge, and lower hospitalization costs. Post-surgical pain management with LB may help hospitals in value-based bundled payment programs.
Asunto(s)
Anestésicos Locales/uso terapéutico , Artroplastia de Reemplazo de Cadera/métodos , Bupivacaína/uso terapéutico , Tiempo de Internación/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Adulto , Anciano , Analgésicos Opioides/administración & dosificación , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Bupivacaína/administración & dosificación , Bupivacaína/economía , Femenino , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Revisión de Utilización de Seguros , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Readmisión del Paciente/economía , Estudios Retrospectivos , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures. METHODS: The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed. RESULTS: During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups. CONCLUSIONS: The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.
Asunto(s)
Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Procedimientos de Cirugía Plástica/economía , Pared Abdominal/cirugía , Abdominoplastia/economía , Abdominoplastia/estadística & datos numéricos , Anestésicos Locales/economía , Bupivacaína/economía , Costos y Análisis de Costo , Femenino , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Liposomas , Mamoplastia/economía , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Estados UnidosAsunto(s)
Anestesia General/economía , Anestesia Local/economía , Laringectomía , Laringe Artificial , Complicaciones Posoperatorias/cirugía , Fístula Traqueoesofágica/cirugía , Anciano , Anestésicos Generales/economía , Anestésicos Locales/economía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Thoracic Epidural has long been the most recommended treatment for postoperative pain management in general thoracic surgery. This study compares liposomal bupivacaine (LB) as an alternative method for pain control and compares it to the standard. METHODS: LB was compared to thoracic epidural bupivacaine hydrochloride (TE BH) in 387 patients who underwent video-assisted thoracoscopic pulmonary resection (VATS-R) at our institution. Patients received either continuous TE BH or intraoperative LB at a predetermined dose. A total of 237 patients received TE BH from April 2010 to March 2014 and 143 patients received LB from April 2014 to March 2016. After propensity matching, 95 patients in each group had similar demographics and clinical characteristics including gender, age, race, American Society of Anesthesia (ASA) classification, Zubrod scores, and FEV1 and DLCO percent predicted measurements. Outcome measures included hospital costs, length of stay (LOS), adverse events, postoperative opioid medication use, and pain scores. RESULTS: Compared to the TE BH group, the LB group had significantly lower pain scores (average visual analogue scale the day of surgery: 3.9 versus 4.5, pâ¯<â¯0.05), decreased postoperative opioid medication (morphine equivalent dose during the first 3 days: 344.5 versus 269.5, pâ¯<â¯0.05), and lower total and direct hospital costs ($2906 and $1865 respectively, pâ¯<â¯0.05). Although a shorter LOS in the LB group was not statistically significant (4.3 versus 5.1 days, pâ¯=â¯0.156), more patients in the LB group were discharged directly home than the control group (44.2% versus 28.4%, pâ¯<â¯0.05). There was no difference noted in overall adverse events including 30-day readmissions between the two groups. CONCLUSION: LB is a viable alternative for pain management in patients undergoing VATS-R. With recent scrutiny on healthcare costs and the opioid epidemic, these results are encouraging and should be further investigated.
Asunto(s)
Analgesia Epidural/economía , Anestésicos Locales/economía , Bupivacaína/uso terapéutico , Preparaciones de Acción Retardada/economía , Enfermedades Pulmonares/cirugía , Manejo del Dolor/economía , Dolor Postoperatorio/prevención & control , Cirugía Torácica Asistida por Video , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Liposomas , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios RetrospectivosRESUMEN
Aims: Post-surgical pain experienced by patients undergoing total knee arthroplasty (TKA) can be severe. Enhanced recovery after surgery programs incorporating multimodal analgesic regimens have evolved in an attempt to improve patient care while lowering overall costs. This study examined clinical and economic outcomes in hospitals using liposomal bupivacaine (LB) for pain control following TKA.Methods: This retrospective observational study utilized hospital chargemaster data from the Premier Healthcare Database from January 2011 through April 2017 for the 10 hospitals with the highest number of primary TKA procedures using LB. Within these hospitals, patients undergoing TKA who received LB were propensity-score matched in a 1:1 ratio to a control group not receiving LB. Outcomes included hospital length of stay (LOS), discharge status, 30-day same-hospital readmissions, total hospitalization costs, and opioid consumption; only patients with Medicare or commercial insurance as the primary payer for TKA were considered.Results: The study population included 20,907 Medicare-insured patients (LB = 10,411; control =10,496) and 12,505 patients with commercial insurance (LB = 6,242; control = 6,263). Overall, LOS was 0.6 days shorter with LB (p < 0.0001), and patients who received LB were 1.6-times more likely to be discharged home (p < 0.0001). Total hospitalization costs for the TKA procedure were lower with LB for patients with both Medicare (-$616; P < 0.0001) and commercial insurance (-$775; p < 0.0001). Opioid consumption was lower with LB in both payer populations (p < 0.0001). No significant differences for 30-day readmissions were found.Limitations: Costs were estimated using Premier charge-to-cost ratios and limited to goods and services recorded in the chargemaster. Findings from these 10 hospitals may not be representative of other US hospitals.Conclusions: In a sub-set of 10 US hospitals with the highest use of LB for TKA, LB use was associated with shorter hospital LOS, increased home discharge, lower total hospitalization costs, and decreased opioid use after TKA.
Asunto(s)
Anestésicos Locales/uso terapéutico , Artroplastia de Reemplazo de Rodilla/métodos , Bupivacaína/uso terapéutico , Precios de Hospital/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Bupivacaína/administración & dosificación , Bupivacaína/economía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Liposomas , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Postoperative pain control, short-term and long-term narcotic consumption, complication rates, and costs of indwelling interscalene catheter (ISC) were compared with a liposomal bupivacaine (LBC) mixture in patients undergoing primary total elbow arthroplasty. METHODS: Forty-four consecutive patients were identified, the first 28 with an ISC and the later 16 with intraoperative LBC injection that also included ketorolac and 0.5% bupivacaine. Medical records were reviewed for visual analog scale scores for pain, oral morphine equivalent (OME) use, complications, and facility charges. RESULTS: Average visual analog scale scores at 24 hours, 2 weeks, 6 weeks, and 12 weeks were not significantly different. Mean OME use was significantly greater in the LBC group at 24 hours but less at 12 weeks, although this difference was not statistically significant. Twelve anesthetic-related complications occurred in the ISC group (1 major and 11 minor); 10 patients (36%) had at least 1 complication. The major complication was respiratory failure requiring emergent tracheostomy. Minor complications included leaking pump/catheters, catheters inadvertently pulled out early, global hand paresthesias, forearm paresthesias, and pain at the catheter site. There were no anesthetic-related complications in the LBC group. The average charge for the LBC mixture was $327.10; charges for ISC, including equipment and anesthesia fees, were $1472.42. CONCLUSIONS: An LBC mixture provides similar pain relief with fewer complications at a lower cost than indwelling ISC after total elbow arthroplasty. Although the OME use in the LBC group was almost double that of the ISC group at 24 hours, there was no difference at later time points.
Asunto(s)
Analgésicos no Narcóticos/administración & dosificación , Anestésicos Locales/administración & dosificación , Artroplastia de Reemplazo de Codo , Bupivacaína/administración & dosificación , Ketorolaco/administración & dosificación , Anciano , Analgésicos no Narcóticos/efectos adversos , Analgésicos no Narcóticos/economía , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/efectos adversos , Anestésicos Locales/economía , Bupivacaína/efectos adversos , Bupivacaína/economía , Catéteres de Permanencia , Combinación de Medicamentos , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Humanos , Inyecciones , Ketorolaco/efectos adversos , Ketorolaco/economía , Masculino , Morfina/uso terapéutico , Dolor Postoperatorio/prevención & control , Estudios Retrospectivos , Escala Visual AnalógicaRESUMEN
BACKGROUND: Evidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection. METHODS: The HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants' 'average' follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial. DISCUSSION: To ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections. TRIAL REGISTRATION: ISRCTN: 50550256 , 28th July 2015.
Asunto(s)
Anestésicos Locales/economía , Análisis Costo-Beneficio/métodos , Glucocorticoides/economía , Osteoartritis de la Cadera/tratamiento farmacológico , Osteoartritis de la Cadera/economía , Ultrasonografía Intervencional/economía , Corticoesteroides/administración & dosificación , Corticoesteroides/economía , Adulto , Anciano , Anciano de 80 o más Años , Anestésicos Locales/administración & dosificación , Femenino , Estudios de Seguimiento , Glucocorticoides/administración & dosificación , Humanos , Inyecciones Intraarticulares/economía , Inyecciones Intraarticulares/métodos , Lidocaína/administración & dosificación , Lidocaína/economía , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/diagnóstico por imagen , Dimensión del Dolor/efectos de los fármacos , Dimensión del Dolor/economía , Dimensión del Dolor/métodos , Método Simple Ciego , Resultado del Tratamiento , Triamcinolona Acetonida/administración & dosificación , Triamcinolona Acetonida/economía , Ultrasonografía Intervencional/métodosRESUMEN
Effective postsurgical analgesia is a critical aspect of patient recovery. The goal of this prospective, randomized, controlled, blinded study was to examine the effect that liposomal bupivacaine delivered by means of a transversus abdominis plane block has on pain control in women undergoing unilateral deep inferior epigastric perforator flap reconstruction. Institutional review board approval was granted for this prospective study. Patients were eligible if they were undergoing unilateral, delayed deep inferior epigastric perforator flap reconstruction. Patients were randomized to one of three groups: liposomal bupivacaine transversus abdominis plane block, or bupivacaine pain pump. Charts were reviewed for demographics, length of stay, and postoperative narcotic use. There were eight patients in the liposomal bupivacaine and bupivacaine transversus abdominis plane block groups and five patients in the pain pump group. A retrospective cohort of six patients who did not receive any intervention was included. Patients who received a liposomal bupivacaine transversus abdominis plane block used statistically significantly less intravenous and total postoperative narcotics in milligrams and milligrams per kilogram per day compared with all other cohorts. They were able to get out of bed at an earlier time point. Overall hospital costs were similar among the groups. This is the first study to investigate liposomal bupivacaine delivered as a transversus abdominis plane block in a prospective, randomized, blinded study in women undergoing unilateral, delayed, abdominally based autologous breast reconstruction. The authors were able to demonstrate a significant reduction in intravenous and total narcotic use when a liposomal bupivacaine transversus abdominis plane block was used. Future studies are needed to prospectively investigate the effect that liposomal bupivacaine would have on immediate and bilateral reconstructions.
Asunto(s)
Anestésicos Locales/administración & dosificación , Neoplasias de la Mama/cirugía , Bupivacaína/administración & dosificación , Mamoplastia/métodos , Dolor Postoperatorio/prevención & control , Colgajo Perforante , Músculos Abdominales/inervación , Anestésicos Locales/economía , Bupivacaína/análogos & derivados , Bupivacaína/economía , Costos de los Medicamentos , Femenino , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Liposomas , Persona de Mediana Edad , Narcóticos/administración & dosificación , Bloqueo Nervioso/métodos , Dimensión del Dolor , Dolor Postoperatorio/economía , Cuidados Posoperatorios/métodos , Náusea y Vómito Posoperatorios/inducido químicamente , Estudios ProspectivosRESUMEN
PURPOSE: Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments. METHODS: Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution's information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant's surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type). RESULTS: Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers' compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively. CONCLUSIONS: Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room). CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reductions for CTR surgery.
Asunto(s)
Síndrome del Túnel Carpiano/economía , Síndrome del Túnel Carpiano/cirugía , Descompresión Quirúrgica/economía , Procedimientos Quirúrgicos Ambulatorios/economía , Anestesia General/economía , Anestésicos Locales/economía , Anestésicos Locales/uso terapéutico , Costos y Análisis de Costo , Descompresión Quirúrgica/métodos , Endoscopía/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/economía , Quirófanos/economía , Estudios Retrospectivos , Estados UnidosAsunto(s)
Anestesia Local/economía , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Procedimientos Quirúrgicos Cardíacos/economía , Cateterismo Periférico/métodos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/economía , Anestesia Local/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Catéteres , Análisis Costo-Beneficio , Costos de Hospital , Humanos , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/economía , Esternotomía , EsternónAsunto(s)
Anestésicos Locales/provisión & distribución , Epinefrina/provisión & distribución , Lidocaína/provisión & distribución , Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Composición de Medicamentos , Industria Farmacéutica/economía , Industria Farmacéutica/organización & administración , Embalaje de Medicamentos , Almacenaje de Medicamentos , Epinefrina/administración & dosificación , Epinefrina/economía , Humanos , Lidocaína/administración & dosificación , Lidocaína/economía , Maniobras Políticas , Estados Unidos , United States Department of Veterans Affairs/normasRESUMEN
We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.
Asunto(s)
Anestésicos Locales/administración & dosificación , Anestésicos Locales/economía , Bolsa Sinovial/efectos de los fármacos , Bursitis/tratamiento farmacológico , Bursitis/economía , Costos de los Medicamentos , Glucocorticoides/administración & dosificación , Glucocorticoides/economía , Lidocaína/administración & dosificación , Lidocaína/economía , Metilprednisolona/administración & dosificación , Metilprednisolona/economía , Ultrasonografía Intervencional/economía , Adulto , Anciano , Puntos Anatómicos de Referencia , Anestésicos Locales/efectos adversos , Bolsa Sinovial/diagnóstico por imagen , Bolsa Sinovial/fisiopatología , Bursitis/diagnóstico por imagen , Bursitis/fisiopatología , Análisis Costo-Beneficio , Diseño de Equipo , Femenino , Fémur , Glucocorticoides/efectos adversos , Humanos , Inyecciones Intralesiones , Lidocaína/efectos adversos , Masculino , Metilprednisolona/efectos adversos , Persona de Mediana Edad , Agujas/economía , Dimensión del Dolor , Palpación/economía , Datos Preliminares , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional/efectos adversos , Estados UnidosRESUMEN
BACKGROUND: The pilot study is designed to investigate the effect of continuous thoracic sympathetic block (TSB) on cardiac function, reconstruction, and hemodynamic parameters in patients with heart failure resulting from valvular heart disease. METHOD: The cardiac function parameters, including left ventricle ejection fraction (LVEF), left ventricle end-diastole diameter (LVEDD), fractional shortening (FS), and N-terminal prohormone of brain natriuretic peptide (NT-proBNP), were measured in 19 patients before and after TSB treatment. The patients were also classified on the basis of NYHA classification system. RESULTS: 4 weeks of TSB administration improved cardiac function in 18 of 19 patients (94.74%). The patients' LVEF, LVEDD, and NT-proBNP were all improved significantly after treatment. CONCLUSIONS: The favorable clinical outcome of TSB administration suggests an alternative treatment for the patients with heart failure caused by valvular dysfunctions.