Cost-Effectiveness of Transcatheter Aortic Valve Implantation in Intermediate and Low Risk Severe Aortic Stenosis Patients in Singapore.

INTRODUCTION: Singapore has the world's second most efficient healthcare system while costing less than 5% GDP. It remains unclear whether transcatheter aortic valve implantation (TAVI) is cost-effective for treating intermediate-low risk severe aortic stenosis (AS) patients in a highly efficient healthcare system. MATERIALS AND METHODS: A two-phase economic model combining decision tree and Markov model was developed to assess the costs, effectiveness, and the incremental cost-effectiveness ratio (ICER) of transfemoral (TF) TAVI versus surgical aortic valve replacement (SAVR) in intermediate-low risk patients over an 8-year time horizon. Mortality and complications rates were based on PARTNER 2 trial cohort A and Singapore life table. Costs were mainly retrieved from Singapore National University Health System database. Health utility data were obtained from Singapore population based on the EuroQol-5D (EQ-5D). A variety of sensitivity analyses were conducted. RESULTS: In base case scenario, the incremental effectiveness of TF-TAVI versus SAVR was 0.19 QALYs. The ICER of TF-TAVI was S$33,833/QALY. When time horizon was reduced to 5 years, the ICER was S$60,825/QALY; when event rates from the propensity analysis was used, the ICER was S$21,732/QALY and S$44,598/QALY over 8-year and 5-year time horizons, respectively. At a willingness to pay threshold of S$73,167/QALY, TF-TAVI had a 98.19% probability of being cost-effective after 100,000 simulations. The model was the most sensitive to the costs of TF-TAVI procedure. CONCLUSION: TF-TAVI is a highly cost-effective option compared to SAVR for intermediate-low risk severe AS patients from a Singapore healthcare system perspective. Increased procedure experience, reduction in device cost, and technology advance may have further increased the cost-effectiveness of TF-TAVI per scenario analysis.

Comparison of postoperative cognitive decline in patients undergoing conventional vs miniaturized cardiopulmonary bypass: A randomized, controlled trial.

Background: Neurocognitive dysfunction is a common complication of coronary artery bypass grafting (CABG) with incidence of 19-38%. The miniaturized cardiopulmonary bypass (MCPB) system was developed to reduce hemodilution and inflammation and provides better cerebral protection than conventional cardiopulmonary bypass (CCPB). In a meta-analysis, MCPB was associated with a 10-fold reduction in the incidence of strokes. However, its effect on postoperative cognitive decline (POCD) is unknown. We assessed if MCPB decreases POCD after CABG and compared the risk factors. Methods: A total of 71 Asian patients presenting for elective CABG at a tertiary center were enrolled. They were randomly assigned to MCPB (n = 36) or CCPB group (n = 35) and followed up in a single-blinded, prospective, randomized controlled trial. The primary outcome was POCD as measured by the repeatable battery of neuropsychological status (RBANS). Inflammatory markers (tumor necrosis factor-alpha and interleukin-6), hematocrit levels, and neutron-specific enolase (NSE) levels were studied. Results: Overall, the incidence of POCD at 3 months was 50%, and this was not significantly different between both groups (51.4 vs 50.0%, P = 0.90). Having <6 years of formal education [risk ratio (RR) = 3.014, 95% confidence interval (CI) = 1.054-8.618, P = 0.040] was significantly associated with POCD in the CCPB group, while the lowest hematocrit during cardiopulmonary bypass was independently associated with POCD in the MCPB group (RR = 0.931, 95% CI = 0.868-0.998, P = 0.044). The postoperative inflammatory markers and NSE levels were similar between the two groups. Conclusions: This study shows that the MCPB was not superior to CCPB with cell salvage and biocompatible tubing with regard to the neurocognitive outcomes measured by the RBANS.

Time needed to resolve patient complaints and factors influencing it: a cohort study.

OBJECTIVE: There has been an increase in the number and complexity of patient complaints against healthcare institutions. An understanding of the resources needed in this area is important for proper planning. DESIGN: Cohort study. SETTING: A 1250-bed tertiary-care teaching hospital. PARTICIPANTS: All patient complaints received between 1 February 2014 and 31 January 2015 were prospectively included in this cohort study. MAIN OUTCOME MEASURES: The amount of time spent on the investigation and liaising with the complainant for each case was recorded. The complainant's personal details and characteristics were recorded anonymously. RESULTS: In total, 908 patient complaints were recorded from 801 individuals during the study period. Longer median person-hours were spent on managing complaints that were brought forward by men (1.48 h), those who were distant relatives of the patients (2.08 h), foreigners (1.58 h) and non-subsidised patients (1.83 h). Patient complaints falling into the categories of clinical domain (3.00 h) and patient rights (2.54 h), quality (3.00 h) and safety (2.83 h) required the longest median time to manage. Multiple logistic regression analysis revealed that the total amount of time spent on the complaints was predicted by the gender of the complainant, the relationship of the complainant with the patient, the subsidy status of the patient, the severity and the domain of the complaint. CONCLUSIONS: This study reported the time required to manage patient complaints in a larger tertiary-care academic medical centre. Predictors of the time spent on resolving patient complaints can be used as parameters for resource planning.

Resolution of ascending aortic dissection in a Stanford type A patient.

We observed an unusual natural course of a Stanford type A aortic dissection. The patient presented to the emergency department with an acute aortic dissection involving an ascending aorta and left-sided hemiparesis. The patient declined surgery and was managed conservatively. A follow-up scan after 1 month revealed that the patient had a complete spontaneous resolution of the dissection in the ascending aorta. Such a development is very rare and unexpected in patients with Stanford type A aortic dissection.

Endovascular management of traumatic thoracic aortic transection.

The conventional treatment of traumatic thoracic aortic transection is open surgical repair but it is associated with high rates of morbidity and mortality, particularly in patients with multiple injuries. We reviewed our experience of endovascular repair of traumatic thoracic aortic transection. Between March 2002 and December 2007, 7 patients (male 6, female 1; mean age 40 years) with multiple injuries secondary to blunt trauma underwent endovascular stenting. One patient required adjunctive surgery to facilitate endovascular stenting. Mean intensive care unit stay was 8.6 days (range, 3-16 days). Arterial access in all patients was obtained by femoral cut-down. The mean operating time was 122 min. Technical success was achieved in all cases. There was no mortality. One patient suffered a right parietal stroke, but none developed procedure-related paralysis. The mean follow-up period was 18.6 months (range, 6-48 months). There was no evidence of endoleak, stent migration, or late pseudoaneurysm formation on follow-up computed tomography. Endovascular stents can be used to treat traumatic thoracic aortic transection, with low rates of morbidity and mortality. Although early and midterm results are promising, the long-term durability of endovascular stenting for traumatic thoracic aortic transection remains unknown.