Which factors render cost-covering lump-sum charging difficult for the treatment of patients with acute leukemias?

BACKGROUND: Growing budget limitations and the planned charging subject to Diagnosis-Related Groups (DRG) points raise the question as to what costs are incurred by the induction therapy and early consolidation treatment of patients with acute myeloid leukemias (AML) and whether these can be compensated in a cost-covering manner by a system based on DRG points. PATIENTS AND METHODS: For 100 patients recruited within the framework of the "Kooperative AML-Studie 96" of the Süddeutsche Hämoblastosegruppe a process cost analysis was made between 1996 and 1999. All manpower and material costs incurred in the department itself and in the secondary services departments as well as the basic cost shares were recorded taking into due account the length of stay. The cost breakdown was effected based on a double induction therapy and one early consolidation treatment. RESULTS: It turns out that substantial differences exist between lower und upper limits of the length of stay and costs. For all three therapy blocks for patients up to 60 years the cost spread varies between 63 and 204 kDM with a median of 105 kDM, and for older patients between 55.6 and 146.6 kDM with a median of 87.6 kDM. On average, the costs subject to length of stay were roughly 70%. CONCLUSIONS: As the costs per case are subject to a spread and, for this relatively small group of patients, are extremely high, the fixing of a case-related lump sum is problematic, the more so as age of patient, comorbidity, type of therapy, ist outcome, and therapy-induced complications represent decisive influencing factors.

Dose-dependent effect of etoposide in combination with busulfan plus cyclophosphamide as conditioning for stem cell transplantation in patients with acute myeloid leukemia.

To evaluate the efficacy and toxicity of two different etoposide (VP-16) dosages (30 or 45 mg/kg) in combination with busulfan/cyclophosphamide as conditioning therapy followed by stem cell transplantation in acute myeloid leukemia (AML), 90 patients with AML received either 30 mg/kg (n = 60) or 45 mg/kg (n = 30) etoposide in combination with busulfan (16 mg/kg) and cyclophosphamide (120 mg/kg). The stem cell source was allogeneic related bone marrow (BM) (n = 53), allogeneic unrelated BM (n = 5), allogeneic unrelated peripheral blood (PBSC) (n = 2), syngeneic BM (n = 2), autologous BM purged (n = 9) or unpurged (n = 9), autologous PBSC (n = 10). Fifty-six patients (62%) were in first CR, 26 (29%) were > first CR, and eight (9%) were transplanted in relapse. Principal toxicities in both groups were mucositis and hepatotoxicity. Forty-five mg/kg etoposide resulted in greater hepatic toxicity (P = 0.03), and a higher incidence of VOD (23 vs 12%, P = 0.04) and acute GVHD grade III/IV (13 vs 5%, NS). The treatment-related mortality was 17% in the 30 mg/kg group and 33% in the 45 mg/kg group, mainly due to infections, intestinal pneumonia and GVHD. Hematological recovery of leukocytes 1/nl was comparable in both groups (17 vs 16 days). After a median follow-up of 16 months 19% in the 30 mg/kg group and 23% in the 45 mg/kg group relapsed. In patients who had undergone allogeneic related bone marrow transplantation in first CR no relapses occurred after a median follow-up of 3 years. For all patients the 3-year estimated disease-free survival was 62% in the 30 mg/kg group and 40% in the 45 mg/kg group (P = 0.03). For patients in first CR who underwent allogeneic related stem cell transplantation the 3 year disease-free survivals were 80% and 66%, respectively (P = 0.4). We conclude that etoposide 30 mg/kg or 45 mg/kg in combination with busulfan/cyclophosphamide is a highly active regimen for bone marrow transplantation of patients with AML with a low relapse rate. However, conditioning with 30 mg/kg rather than 45 mg/kg etoposide resulted in less toxicity and a better overall survival due to a lower transplant-related mortality. Bone Marrow Transplantation (2000) 26, 711-716.

Efficacy of further attempts to mobilize CD34+ peripheral stem cells with alternative procedures after primary failure.

19 patients who failed the target collection of at least 2.5 x 10(6) CD34+ cells/kg underwent further mobilization procedures either with granulocyte-colony-stimulating factor (G-CSF) alone after failure to chemotherapy plus G-CSF (group 1), or with chemotherapy plus G-CSF (group 2), or with high-dose G-CSF (24 microg/kg) alone (group 3) after failure to respond to standard dose of G-CSF (10 microg/kg) alone. In all groups, an increase in median CD34+ cell yield could be observed following alternative procedures (1.1- to 1.9 x 10(6) kg; p = 0.02). The highest increase in CD34+ cell harvest was achieved in group 1 (0.85 to 2.2 x 10(6) kg), followed by group 2 (1. 2 to 1.7) and group 3 (1.0 to 1.4), but without statistically significant difference between the mobilization technologies. All patients with more than 1.0 x 10(6) CD34+ cells/kg in the first apheresis procedure reached the overall target of 2.5 x 10(6) CD34+ cells/kg after a second or subsequent mobilization procedure. In contrast, only 3 of 8 patients (37%) with less than 1.0 x 10(6) CD34+ cells in the first harvest could reach the target of 2.5 x 10(6) CD34+ cells after further mobilization attempts.

[Leg positioning device for facilitating arthroscopy and arthrotomy of the knee joint]. / Beinlagerungsgerät zur Erleichterung von Arthroskopie und Arthrotomie am Kniegelenk.

The knee positioning device presented above fulfills all requirements to be met for positioning the leg for all procedures on the knee. Possible adjustments during the surgical procedure can be carried out by the operating surgeon or his assistant while maintaining the asepsis. It allows immediate arthrotomy after the diagnostic arthroscopy has been carried out without demanding a new sterile covering.