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1.
World Neurosurg ; 152: e476-e483, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34098141

RESUMO

OBJECTIVE: No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. METHODS: In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. RESULTS: Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. CONCLUSIONS: These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.


Assuntos
Adenoma/economia , Adenoma/cirurgia , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/métodos , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/cirurgia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Osso Esfenoide/cirurgia , Adulto , Idoso , Controle de Custos , Custos e Análise de Custo , Cuidados Críticos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Procedimentos de Cirurgia Plástica , Estudos Retrospectivos , Sela Túrcica/cirurgia , Resultado do Tratamento
2.
Mayo Clin Proc ; 96(5): 1203-1217, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33840520

RESUMO

OBJECTIVE: To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. PATIENTS AND METHODS: A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. RESULTS: With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. CONCLUSION: Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.


Assuntos
Adenoma/diagnóstico , Colonoscopia/economia , Neoplasias Colorretais/diagnóstico , Análise Custo-Benefício , DNA/análise , Detecção Precoce de Câncer/métodos , Sangue Oculto , Adenoma/economia , Adenoma/etnologia , Adenoma/metabolismo , Adulto , Idoso , Alaska/epidemiologia , Biomarcadores/análise , Biomarcadores/metabolismo , Neoplasias Colorretais/economia , Neoplasias Colorretais/etnologia , Neoplasias Colorretais/metabolismo , Simulação por Computador , Detecção Precoce de Câncer/economia , Fezes/química , Feminino , Humanos , Incidência , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Cooperação do Paciente/estatística & dados numéricos , Anos de Vida Ajustados por Qualidade de Vida
3.
Am J Otolaryngol ; 42(3): 102907, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33460975

RESUMO

PURPOSE: To present the results of our implementation of a four-dimensional computed tomography- (4DCT) based parathyroid localization protocol for primary hyperparathyroidism at a safety net hospital. METHODS: We performed a retrospective review of all patients who underwent parathyroidectomy for primary hyperparathyroidism at Elmhurst Hospital Center from June 2016 - September 2019. Patients treated prior to the implementation of 4DCT during October 2018 served as historical controls for comparison. Imaging-related costs and hospital charges were obtained from the Radiology Department for each patient. RESULTS: Forty-two patients underwent parathyroid surgery during the study period. Twenty patients had undergone 4DCT while 22 had nuclear medicine studies with or without ultrasonography. The sensitivity and specificity of 4DCT was 90.4% and 100% respectively, compared to 63% and 93.7% for nuclear imaging studies and 41% and 95% for ultrasound. The mean number of glands explored was significantly less in the 4DCT group, 1.8 ± 1.19 versus 2.77 ± 1.26 (p = 0.01). There was no increase in infrastructure or personnel costs associated with 4DCT implementation. CONCLUSIONS: 4DCT represents an increasingly common imaging modality for pre-operative parathyroid localization. Here we demonstrate that 4DCT is associated with a reduction in the number of glands explored and enables minimally invasive parathyroid surgery. 4DCT is a cost-effective and clinically sound localization study for parathyroid localization in an urban safety-net hospital.


Assuntos
Adenoma/diagnóstico por imagem , Tomografia Computadorizada Quadridimensional/métodos , Glândulas Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/diagnóstico por imagem , Adenoma/economia , Adenoma/cirurgia , Adulto , Idoso , Análise Custo-Benefício , Feminino , Tomografia Computadorizada Quadridimensional/economia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/educação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Glândulas Paratireoides/cirurgia , Neoplasias das Paratireoides/economia , Neoplasias das Paratireoides/cirurgia , Paratireoidectomia/economia , Paratireoidectomia/métodos , Período Pré-Operatório , Adulto Jovem
4.
J Robot Surg ; 15(1): 115-123, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32367439

RESUMO

AIM: The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis. METHODS: This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective. RESULTS: Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group. CONCLUSION: Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.


Assuntos
Adenocarcinoma/economia , Adenocarcinoma/cirurgia , Adenoma/economia , Adenoma/cirurgia , Colectomia/economia , Colectomia/métodos , Neoplasias do Colo/economia , Neoplasias do Colo/cirurgia , Análise Custo-Benefício , Laparoscopia/economia , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pontuação de Propensão , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento
5.
J Gastroenterol Hepatol ; 36(1): 7-11, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33179322

RESUMO

Adoption of artificial intelligence (AI) in clinical medicine is revolutionizing daily practice. In the field of colonoscopy, major endoscopy manufacturers have already launched their own AI products on the market with regulatory approval in Europe and Asia. This commercialization is strongly supported by positive evidence that has been recently established through rigorously designed prospective trials and randomized controlled trials. According to some of the trials, AI tools possibly increase the adenoma detection rate by roughly 50% and contribute to a 7-20% reduction of colonoscopy-related costs. Given that reliable evidence is emerging, together with active commercialization, this seems to be a good time for us to review and discuss the current status of AI in colonoscopy from a clinical perspective. In this review, we introduce the advantages and possible drawbacks of AI tools and explore their future potential including the possibility of obtaining reimbursement.


Assuntos
Inteligência Artificial/tendências , Colonoscópios/tendências , Colonoscopia/métodos , Colonoscopia/tendências , Adenoma/diagnóstico , Adenoma/economia , Adenoma/cirurgia , Inteligência Artificial/economia , Colonoscópios/economia , Colonoscopia/economia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/economia , Neoplasias Colorretais/cirurgia , Análise Custo-Benefício/tendências , Humanos , Reembolso de Seguro de Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Transferência de Tecnologia
6.
Eur J Endocrinol ; 181(4): 375-387, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31340199

RESUMO

OBJECTIVE: Although widely advocated, applying Value Based Health Care (VBHC) in clinical practice is challenging. This study describes VBHC-based perioperative outcomes for patients with pituitary tumors up to 6 months postoperatively. METHODS: A total of 103 adult patients undergoing surgery were prospectively followed. Outcomes categorized according to the framework of VHBC included survival, degree of resection, endocrine remission, visual outcome (including self-perceived functioning), recovery of pituitary function, disease burden and health-related quality of life (HRQoL) at 6 months (Tier 1); time to recovery of disease burden, HRQoL, visual function (Tier 2); permanent hypopituitarism and accompanying hormone replacement (Tier 3). Generalized estimating equations (GEEs) analysis was performed to describe outcomes over time. RESULTS: Regarding Tier 1, there was no mortality, 72 patients (70%) had a complete resection, 31 of 45 patients (69%) with functioning tumors were in remission, 7 (12%, with preoperative deficits) had recovery of pituitary function and 45 of 47 (96%) had visual improvement. Disease burden and HRQoL improved in 36-45% at 6 months; however, there were significant differences between tumor types. Regarding Tier 2: disease burden, HRQoL and visual functioning improved within 6 weeks after surgery; however, recovery varied widely among tumor types (fastest in prolactinoma and non-functioning adenoma patients). Regarding Tier 3, 52 patients (50%) had persisting (tumor and treatment-induced) hypopituitarism. CONCLUSIONS: Though challenging, outcomes of a surgical intervention for patients with pituitary tumors can be reflected through a VBHC-based comprehensive outcome set that can distinguish outcomes among different patient groups with respect to tumor type.


Assuntos
Adenoma/economia , Adenoma/cirurgia , Assistência Perioperatória/economia , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/cirurgia , Seguro de Saúde Baseado em Valor/economia , Adenoma/diagnóstico , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/normas , Neoplasias Hipofisárias/diagnóstico , Estudos Prospectivos , Resultado do Tratamento
7.
Endocrine ; 64(2): 330-340, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30903570

RESUMO

PURPOSE: Non-functioning pituitary adenomas (NFPA) have a substantial impact on patients' health status, yet research on the extent of healthcare utilization and costs among these patients is scarce. The objective was to determine healthcare usage, associated costs, and their determinants among patients treated for an NFPA. METHODS: In a cross-sectional study, 167 patients treated for an NFPA completed four validated questionnaires. Annual healthcare utilization and associated costs were assessed through the medical consumption questionnaire (MTA iMCQ). In addition, the Leiden Bother and Needs Questionnaire for pituitary patients (LBNQ-Pituitary), Short Form-36 (SF-36), and EuroQol (EQ-5D) were administered. Furthermore, age, sex, endocrine status, treatment, and duration of follow-up were extracted from the medical records. Associations were analyzed using logistic/linear regression. RESULTS: Annual healthcare utilization included: consultation of an endocrinologist (95% of patients), neurosurgeon (14%), and/or ophthalmologist (58%). Fourteen percent of patients had ≥1 hospitalization(s) and 11% ≥1 emergency room visit(s). Mean overall annual healthcare costs were € 3040 (SD 6498), highest expenditures included medication (31%), inpatient care (28%), and specialist care (17%). Factors associated with higher healthcare utilization and costs were greater self-perceived disease bother and need for support, worse mental and physical health status, younger age, and living alone. CONCLUSION: Healthcare usage and costs among patients treated for an NFPA are substantial and were associated with self-perceived health status, disease bother, and healthcare needs rather than endocrine status, treatment, or duration of follow-up. These findings suggest that targeted interventions addressing disease bother and unmet needs in the chronic phase are needed.


Assuntos
Adenoma/economia , Gastos em Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Neoplasias Hipofisárias/economia , Idoso , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
8.
Comput Math Methods Med ; 2019: 2476565, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30915155

RESUMO

INTRODUCTION: Colorectal cancer (CRC), if not detected early, can be costly and detrimental to one's health. Colonoscopy can identify CRC early as well as prevent the disease. The benefit of screening colonoscopy has been established, but the optimal frequency of follow-up colonoscopy is unknown and may vary based on findings from colonoscopy screening and patient age. METHODS: A partially observed Markov process (POMP) was used to simulate the effects of follow-up colonoscopy on the development of CRC. The POMP uses adenoma and CRC growth models to calculate the probability of a patient having colorectal adenomas and CRC. Then, based on mortality, quality of life, and the costs associated with diagnosis, treatment, and surveillance of colorectal cancer, the overall costs and increase in quality-adjusted life years (QALYs) are calculated for follow-up colonoscopy scenarios. RESULTS: At the $100,000/QALY gained threshold, only one follow-up colonoscopy is cost-effective only after screening at age 50 years. The optimal follow-up is 8.5 years, which gives 84.0 QALYs gained/10,000 persons. No follow-up colonoscopy was cost-effective at the $50,000 and $75,000/QALY gained thresholds. The intervals were insensitive to the findings at screening colonoscopy. CONCLUSION: Follow-up colonoscopy is cost-effective following screening at age 50 years but not if screening occurs later. Following screening at age 50 years, the optimal follow-up interval is close to the currently recommended 10 years for an average risk screening but does not vary by colonoscopy result.


Assuntos
Adenoma/diagnóstico por imagem , Neoplasias do Colo/diagnóstico por imagem , Colonoscopia/métodos , Análise Custo-Benefício , Detecção Precoce de Câncer/métodos , Adenoma/economia , Adenoma/mortalidade , Fatores Etários , Idoso , Algoritmos , Neoplasias do Colo/economia , Neoplasias do Colo/mortalidade , Colonoscopia/economia , Simulação por Computador , Detecção Precoce de Câncer/economia , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Masculino , Cadeias de Markov , Informática Médica/métodos , Pessoa de Meia-Idade , Probabilidade , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Reprodutibilidade dos Testes , Programa de SEER , Sensibilidade e Especificidade , Estados Unidos
9.
J Neurosurg ; 131(2): 507-516, 2018 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-30239321

RESUMO

OBJECTIVE: Efficient allocation of resources in the healthcare system enables providers to care for more and needier patients. Identifying drivers of total charges for transsphenoidal surgery (TSS) for pituitary tumors, which are poorly understood, represents an opportunity for neurosurgeons to reduce waste and provide higher-quality care for their patients. In this study the authors used a large, national database to build machine learning (ML) ensembles that directly predict total charges in this patient population. They then interrogated the ensembles to identify variables that predict high charges. METHODS: The authors created a training data set of 15,487 patients who underwent TSS between 2002 and 2011 and were registered in the National Inpatient Sample. Thirty-two ML algorithms were trained to predict total charges from 71 collected variables, and the most predictive algorithms combined to form an ensemble model. The model was internally and externally validated to demonstrate generalizability. Permutation importance and partial dependence analyses were performed to identify the strongest drivers of total charges. Given the overwhelming influence of length of stay (LOS), a second ensemble excluding LOS as a predictor was built to identify additional drivers of total charges. RESULTS: An ensemble model comprising 3 gradient boosted tree classifiers best predicted total charges (root mean square logarithmic error = 0.446; 95% CI 0.439-0.453; holdout = 0.455). LOS was by far the strongest predictor of total charges, increasing total predicted charges by approximately $5000 per day.In the absence of LOS, the strongest predictors of total charges were admission type, hospital region, race, any postoperative complication, and hospital ownership type. CONCLUSIONS: ML ensembles predict total charges for TSS with good fidelity. The authors identified extended LOS, nonelective admission type, non-Southern hospital region, minority race, postoperative complication, and private investor hospital ownership as drivers of total charges and potential targets for cost-lowering interventions.


Assuntos
Adenoma/cirurgia , Custos e Análise de Custo/tendências , Custos de Cuidados de Saúde/tendências , Aprendizado de Máquina/tendências , Neoplasias Hipofisárias/cirurgia , Seio Esfenoidal/cirurgia , Adenoma/economia , Adenoma/epidemiologia , Adulto , Idoso , Custos e Análise de Custo/métodos , Bases de Dados Factuais/economia , Bases de Dados Factuais/tendências , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/epidemiologia , Estados Unidos/epidemiologia
10.
World Neurosurg ; 110: e496-e503, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29158096

RESUMO

BACKGROUND: Endoscopic transsphenoidal surgery (ETPS) has become increasingly popular for resection of pituitary tumors, whereas microscopic transsphenoidal surgery (MTPS) also remains a commonly used approach. The economic sustainability of new techniques and technologies is rarely evaluated in the neurosurgical skull base literature. The aim of this study was to determine the cost-effectiveness of ETPS compared with MTPS. METHODS: A Markov model was constructed to conduct a cost-utility analysis of ETPS versus MTPS from a single-payer health care perspective. Data were obtained from previously published outcomes studies. Costs were based on Medicare reimbursement rates, considering covariates such as complications, length of stay, and operative time. The base case adopted a 2-year follow-up period. Univariate and multivariate sensitivity analyses were conducted. RESULTS: On average, ETPS costs $143 less and generates 0.014 quality-adjusted life years (QALYs) compared with MTPS over 2 years. The incremental cost-effectiveness ratio (ICER) is -$10,214 per QALY, suggesting economic dominance. The QALY benefit increased to 0.105 when modeled to 10 years, suggesting that ETPS becomes even more favorable over time. CONCLUSIONS: ETPS appears to be cost-effective when compared with MTPS because the ICER falls below the commonly accepted $50,000 per QALY benchmark. Model limitations and assumptions affect the generalizability of the conclusion; however, ongoing efforts to improve rhinologic morbidity related to ETPS would appear to further augment the marginal cost savings and QALYs gained. Further research on the cost-effectiveness of ETPS using prospective data is warranted.


Assuntos
Adenoma/cirurgia , Análise Custo-Benefício , Microcirurgia/economia , Neuroendoscopia/economia , Neoplasias Hipofisárias/cirurgia , Adenoma/economia , Seguimentos , Custos de Cuidados de Saúde , Pessoal de Saúde/economia , Humanos , Tempo de Internação/economia , Cadeias de Markov , Medicare , Duração da Cirurgia , Neoplasias Hipofisárias/economia , Complicações Pós-Operatórias/economia , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
11.
Korean J Gastroenterol ; 69(5): 283-290, 2017 May 25.
Artigo em Inglês | MEDLINE | ID: mdl-28539033

RESUMO

BACKGROUND/AIMS: To date, the best therapeutic modality for gastric adenoma, especially low-grade adenoma, has not been established. The aim of this study was to assess the usefulness of argon plasma coagulation (APC) in treating gastric adenoma compared with endoscopic submucosal dissection (ESD). METHODS: We included 210 patients with gastric adenoma, who underwent treatment with either APC (97 patients) or ESD (113 patients). The clinical and pathologic characteristics, mean duration of hospital stay, complications, and recurrence rates between the two groups were compared. RESULTS: The mean adenoma size was 0.9 cm and 1.1 cm in the APC group and ESD group, respectively (p<0.001). The mean duration of hospital stay was significantly shorter in the APC group than in the ESD group (1.6 days vs. 5.8 days, p<0.001). Complications did not occur in the APC group. However, one case of perforation (0.9%) and 6 cases of bleeding (5.3%) occurred in the ESD group. The recurrence rates were 15.3% (15/97 patients) in the APC group and 3.5% (4/113 patients) in the ESD group (p=0.003). The proportion of hospitalization was less in the APC group (43.3%, 42/97) than in the ESD group (100.0%, 113/113) (p<0.001). Medical expense was less in the APC group (377,172 won) than in the ESD group (1,430,610 won) (p<0.001). CONCLUSIONS: The findings of this study suggest that APC is a safe treatment method for gastric adenoma without serious complications. However, regular endoscopic follow-up is necessary to detect any residual or recurrent lesions due to the relatively high rate of local recurrence after APC.


Assuntos
Adenoma/terapia , Coagulação com Plasma de Argônio , Neoplasias Gástricas/terapia , Adenoma/economia , Adenoma/patologia , Idoso , Coagulação com Plasma de Argônio/efeitos adversos , Ressecção Endoscópica de Mucosa , Feminino , Mucosa Gástrica/patologia , Gastroscopia , Hemorragia/etiologia , Hospitalização , Humanos , Perfuração Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estudos Retrospectivos , Neoplasias Gástricas/economia , Neoplasias Gástricas/patologia
12.
Cancer ; 123(9): 1516-1527, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28117881

RESUMO

BACKGROUND: Screening for colorectal cancer (CRC) has been successful in decreasing the incidence and mortality from CRC. Although new screening tests have become available, their relative impact on CRC outcomes remains unexplored. This study compares the outcomes of various screening strategies on CRC outcomes. METHODS: A Markov model representing the natural history of CRC was built and validated against empiric data from screening trials as well as the Microstimulation Screening Analysis (MISCAN) model. Thirteen screening strategies based on colonoscopy, sigmoidoscopy, computed tomographic colonography, as well as fecal immunochemical, occult blood, and stool DNA testing were compared with no screening. A simulated sample of the US general population ages 50 to 75 years with an average risk of CRC was followed for up to 35 years or until death. Effectiveness was measured by discounted life years gained and the number of CRCs prevented. Discounted costs and cost-effectiveness ratios were calculated. A discount rate of 3% was used in calculations. The study took a societal perspective. RESULTS: Colonoscopy emerged as the most effective screening strategy with the highest life years gained (0.022 life years) and CRCs prevented (n = 1068) and the lowest total costs ($2861). These values were 0.012 life years gained, 574 CRCs prevented, and a total cost of $3164, respectively, for FOBT; and 0.011 life years gained, 647 CRCs prevented, and a total cost of $4296, respectively, for DNA testing. Improved sensitivity or specificity of a screening test for CRC detection was not sufficient to close the outcomes gap compared with colonoscopy. CONCLUSIONS: Improvement in CRC-detection performance is not sufficient to improve screening outcomes. Special attention must be directed to detecting precancerous adenomas. Cancer 2017;123:1516-1527. © 2017 American Cancer Society.


Assuntos
Adenocarcinoma/diagnóstico , Adenoma/diagnóstico , Colonografia Tomográfica Computadorizada/métodos , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , DNA de Neoplasias/análise , Hemoglobinas/análise , Adenocarcinoma/economia , Adenoma/economia , Idoso , Colonografia Tomográfica Computadorizada/economia , Colonoscopia/economia , Neoplasias Colorretais/economia , Simulação por Computador , Análise Custo-Benefício , Detecção Precoce de Câncer , Fezes/química , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Sangue Oculto , Sigmoidoscopia/economia , Sigmoidoscopia/métodos
13.
Colorectal Dis ; 18(9): 842-5, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27207111

RESUMO

Colorectal cancer (CRC) develops from normal epithelium, through dysplastic adenoma to invasive carcinoma. In addition to familial adenomatous polyposis and Lynch syndrome, approximately 10-35% of CRCs are familial in nature. CRC screening and surveillance programmes are based on an understanding of the natural history of polyps and rely on the ability to remove premalignant lesions endoscopically before they are capable of developing invasion. There are, however, significant differences in these guidelines between the UK and the USA in relation to the weight attributed to a family history of polyps. Here, using publicly available national data sets, we show that these differences in guidelines unexpectedly generate inadequate screening recommendations for second-degree relatives of patients with CRC in the UK. We validate our simple mathematical modelling of the clinical problem on a regional data set as well as previously published study data to demonstrate the correct interpretation. We further discuss the implications of a family history of adenoma formation in the current climate of the Bowel Cancer Screening Programme and suggest a re-evaluation of the UK guidelines in the light of this developing issue.


Assuntos
Adenoma/diagnóstico , Carcinoma/diagnóstico , Pólipos do Colo/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/normas , Adenoma/economia , Adenoma/genética , Polipose Adenomatosa do Colo/genética , Carcinoma/economia , Carcinoma/genética , Pólipos do Colo/genética , Colonoscopia/economia , Neoplasias Colorretais/economia , Neoplasias Colorretais/genética , Neoplasias Colorretais Hereditárias sem Polipose/genética , Bases de Dados Factuais , Detecção Precoce de Câncer/economia , Predisposição Genética para Doença , Custos de Cuidados de Saúde , Humanos , Anamnese , Modelos Teóricos , Linhagem , Guias de Prática Clínica como Assunto , Medição de Risco , Medicina Estatal , Reino Unido
14.
Gastrointest Endosc ; 83(6): 1248-57, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26608129

RESUMO

BACKGROUND AND AIMS: Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS: A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS: LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS: Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.


Assuntos
Adenoma/cirurgia , Pólipos do Colo/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Custos de Cuidados de Saúde , Laparoscopia/métodos , Recidiva Local de Neoplasia/epidemiologia , Adenoma/economia , Pólipos do Colo/economia , Colonoscopia/economia , Colonoscopia/métodos , Análise Custo-Benefício , Custos e Análise de Custo , Técnicas de Apoio para a Decisão , Árvores de Decisões , Ressecção Endoscópica de Mucosa/economia , Humanos , Laparoscopia/economia , Cadeias de Markov , Recidiva Local de Neoplasia/economia , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
15.
J Endocrinol Invest ; 38(7): 717-23, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25783618

RESUMO

PURPOSE: This study aimed to estimate the cost effectiveness of two therapeutic schemes, including preoperative medical therapy and surgery as primary therapy. METHODS: A total of 168 acromegaly cases were retrospectively investigated for a comparative evaluation of surgery and preoperative medical therapy. A Markov model was developed to simulate treatment cost-effectiveness and progression of acromegaly. RESULTS: Overall effectiveness of preoperative medical therapy was significantly higher than surgery in acromegalic patients with macroadenoma. In addition, life expectancy, and cost per life-year gained were slightly higher in the preoperative medical therapy group than in the initial surgery group when patients received surgery as a secondary treatment. Interestingly, preoperative medical therapy achieved a significant increase in life expectancy and reduced cost for patients who received long-term medical therapy as secondary treatment. CONCLUSIONS: In acromegalic patients with macroadenoma, the cost-effectiveness analysis revealed more satisfactory outcomes in preoperative therapy, compared with primary surgery.


Assuntos
Adenoma , Análise Custo-Benefício , Avaliação de Resultados em Cuidados de Saúde , Neoplasias Hipofisárias , Acromegalia/tratamento farmacológico , Acromegalia/economia , Acromegalia/cirurgia , Adenoma/tratamento farmacológico , Adenoma/economia , Adenoma/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/economia , Neoplasias Hipofisárias/tratamento farmacológico , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/cirurgia , Estudos Retrospectivos
16.
J Neurosurg ; 121(1): 84-90, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24724857

RESUMO

UNLABELLED: OBJECT.: An increasingly important measure in the health care field is utilization of hospital resources, particularly in the context of emerging surgical techniques. Despite the recent widespread adoption of the endoscopic transsphenoidal approach for pituitary lesion surgery, the health care resources utilized with this approach have not been compared with those utilized with the traditional microscopic approach. The purpose of this study was to determine the drivers of resource utilization by comparing hospital charges for patients with pituitary tumors who had undergone either endoscopic or microscopic transsphenoidal surgery. METHODS: A complete accounting of all hospital charges for 166 patients prospectively enrolled in a surgical quality-of-life study at a single pituitary center during October 2011-June 2013 was undertaken. Patients were assigned to surgical technique group according to surgeon preference and then managed according to a standard postoperative institutional set of orders. Individual line-item charges were assigned to categories (such as pharmacy, imaging, surgical, laboratory, room, pathology, and recovery unit), and univariate and multivariate statistical analyses were conducted. RESULTS: Of the 166 patients, 99 underwent microscopic surgery and 67 underwent endoscopic surgery. Baseline demographic descriptors and tumor characteristics did not differ significantly. Mean total hospital charges were $74,703 ± $15,142 and $72,311 ± $16,576 for microscopic and endoscopic surgery patients, respectively (p = 0.33). Furthermore, other than for pathology, charge categories did not differ significantly between groups. A 2-step multivariate regression model revealed that length of stay was the most influential variable, followed by a diagnosis of Cushing's disease, and then by endoscopic surgical technique. The model accounts for 42% of the variance in hospital charges. CONCLUSIONS: Study findings suggest that adoption of the endoscopic transsphenoidal technique for pituitary lesions does not adversely affect utilization of resources for inpatients. The primary drivers of hospital charges, in order of importance, were length of stay, a diagnosis of Cushing's disease, and, to a lesser extent, use of the endoscopic technique. This study also highlights the influence of individual surgeon practice patterns on resource utilization.


Assuntos
Adenoma/cirurgia , Recursos em Saúde/estatística & dados numéricos , Pacientes Internados , Procedimentos Neurocirúrgicos/economia , Hipófise/cirurgia , Neoplasias Hipofisárias/cirurgia , Osso Esfenoide/cirurgia , Adenoma/economia , Adenoma/patologia , Adulto , Idoso , Feminino , Recursos em Saúde/economia , Preços Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Hipófise/patologia , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/patologia , Resultado do Tratamento
17.
Neurosurg Focus ; 37(5): E7, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26223274

RESUMO

OBJECT: Knowledge of the costs incurred through the delivery of neurosurgical care has been lagging, making it challenging to design impactful cost-containment initiatives. In this report, the authors describe a detailed cost analysis for pituitary surgery episodes of care and demonstrate the importance of such analyses in helping to identify high-impact cost activities and drive value-based care. METHODS: This was a retrospective study of consecutively treated patients undergoing an endoscopic endonasal procedure for the resection of a pituitary adenoma after implementation and maturation of quality-improvement initiatives and the implementation of cost-containment initiatives. RESULTS: The cost data pertaining to 27 patients were reviewed. The 2 most expensive cost activities during the index hospitalization were the total operating room (OR) and total bed-assignment costs. Together, these activities represented more than 60% of the cost of hospitalization. Although value-improvement initiatives contributed to the reduction of variation in the total cost of hospitalization, specific cost activities remained relatively variable, namely the following: 1) OR charged supplies, 2) postoperative imaging, and 3) use of intraoperative neuromonitoring. These activities, however, each contributed to less than 10% of the cost of hospitalization. Bed assignment was the fourth most variable cost activity. Cost related to readmission/reoperation represented less than 5% of the total cost of the surgical episode of care. CONCLUSIONS: After completing a detailed assessment of costs incurred throughout the management of patients undergoing pituitary surgery, high-yield opportunities for cost containment should be identified among the most expensive activities and/or those with the highest variation. Strategies for safely reducing the use of the targeted resources, and related costs incurred, should be developed by the multidisciplinary team providing care for this patient population.


Assuntos
Adenoma/economia , Hospitalização/economia , Neuroendoscopia/economia , Neoplasias Hipofisárias/economia , Neoplasias Hipofisárias/cirurgia , Adenoma/cirurgia , Adolescente , Adulto , Idoso , Controle de Custos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/economia , Papel do Médico , Estudos Retrospectivos , Adulto Jovem
18.
JAMA Surg ; 148(6): 500-3, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23575888

RESUMO

IMPORTANCE: Dynamic computed tomography (CT) is emerging as a first-line alternative to sestamibi scintigraphy for preoperative localization of parathyroid lesions. In recent years, there has been increased concern over the impact of radiation exposure from medical imaging, as well as on the cost of diagnostic medical procedures. An ideal diagnostic procedure would be cost effective while minimizing hazardous exposures and complication rates. OBJECTIVE: To compare the radiation dose and financial cost of dynamic CT with sestamibi scintigraphy. DESIGN, SETTING, AND PATIENTS: A retrospective review of 263 patients at a large, urban, tertiary referral center who underwent either dynamic parathyroid CT or sestamibi scintigraphy for any etiology of hyperparathyroidism from 2006 through 2010. MAIN OUTCOMES AND MEASURES: The 2 primary study outcomes were radiation exposure measured in millisieverts (mSv) and medical charges for the respective diagnostic procedures. The study was conducted with the hypothesis that dynamic parathyroid CT would have slightly greater radiation exposure with similar cost to sestamibi scintigraphy. RESULTS: Dynamic parathyroid CT and sestamibi scintigraphy delivered mean radiation doses of 5.56 and 3.33 mSv, respectively (P < .05). Charges totaled $1296 for thin-cut dynamic parathyroid CT and a mean of $1112 for sestamibi scintigraphy, depending on the type and amount of radiotracer injected. Although multiphase CT scanning took less than 5 minutes, sestamibi scintigraphy lasted a mean time of 306 minutes. A total of 62 of 119 patients (52%) in the CT group have undergone operative treatment to date, whereas all patients in the sestamibi arm underwent operative treatment of their hyperparathyroidism. Of the patients who underwent a surgical procedure, CT correctly identified the side of the parathyroid adenoma in 54 of 62 patients (87%), while sestamibi scintigraphy only correctly lateralized 90 of 122 adenomas (74%) as confirmed by exploratory surgery, intraoperative parathyroid hormone levels, and pathologic features. A dynamic parathyroid CT correctly predicted multiglandular disease in 1 of 7 patients (14%), while sestamibi scintigraphy correctly predicted multiglandular disease in 8 of 23 patients (35%). CONCLUSIONS AND RELEVANCE: In patients who underwent directed parathyroid surgery, dynamic CT is comparable to sestamibi scintigraphy in patients with hyperparathyroidism. Although CT delivers a higher dose of radiation, the average background radiation exposure in the United States is 3 mSv/y, and added exposures of less than 15 mSv are considered low risk for carcinogenesis. Overall, dynamic parathyroid CT is a safe, cost-effective alternative to sestamibi scintigraphy.


Assuntos
Adenoma/diagnóstico por imagem , Neoplasias das Paratireoides/diagnóstico por imagem , Compostos Radiofarmacêuticos , Tecnécio Tc 99m Sestamibi , Tomografia Computadorizada por Raios X/economia , Adenoma/economia , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Feminino , Humanos , Hiperparatireoidismo/cirurgia , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/cirurgia , Neoplasias das Paratireoides/economia , Cuidados Pré-Operatórios , Doses de Radiação , Cintilografia , Compostos Radiofarmacêuticos/economia , Estudos Retrospectivos , Tecnécio Tc 99m Sestamibi/economia , Tomografia Computadorizada por Raios X/métodos
19.
Ned Tijdschr Geneeskd ; 157(16): A6330, 2013.
Artigo em Holandês | MEDLINE | ID: mdl-23594877

RESUMO

The Dutch National Institute for Public Health and the Environment (RIVM) awarded the immunochemical faecal occult blood test (IFOBT) to FOB Gold of Sentinel following a European call for tenders. The contract-awarding procedure included the application of quality knock-out criteria, which were met by two suppliers. The decisive factor was the best price/quality ratio. A recent review indicated that, at present, no single IFOBT is better than any other. The decision to opt for a test manufactured by a different supplier than was used in the previous screening pilots made it necessary to re-determine the cut-off value. This value has now been set (88 ng/ml) and is confirmed by a laboratory test. Colonoscopy-related capacity planning, as well as its diagnostic yield, depends on numerous factors; therefore, the RIVM is currently monitoring the referral percentage and number of adenomas detected and is collaborating on quality terms. Any necessary adjustments are to be made during the introduction of the screening test.


Assuntos
Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/normas , Sangue Oculto , Adenoma/diagnóstico , Adenoma/economia , Adenoma/prevenção & controle , Colonoscopia , Neoplasias Colorretais/economia , Neoplasias Colorretais/prevenção & controle , Análise Custo-Benefício , Humanos , Programas de Rastreamento/métodos
20.
Trials ; 14: 74, 2013 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-23497601

RESUMO

BACKGROUND: Colorectal cancer (CRC) is the most frequent cancer in Europe. Randomized clinical trials demonstrated that screening with fecal occult blood test (FOBT) reduces mortality from CRC. Accordingly, the European Community currently recommends population-based screening with FOBT. Other screening tests, such as computed tomography colonography (CTC) and optical colonoscopy (OC), are highly accurate for examining the entire colon for adenomas and CRC. Acceptability represents a critical determinant of the impact of a screening program. We designed a randomized controlled trial to compare participation rate and diagnostic yield of FOBT, CTC with computer-aided diagnosis, and OC as primary tests for population-based screening. METHODS/DESIGN: A total of 14,000 subjects aged 55 to 64 years, living in the Florence district and never screened for CRC, will be randomized in three arms: group 1 (5,000 persons) invited to undergo CTC (divided into: subgroup 1A with reduced cathartic preparation and subgroup 1B with standard bowel preparation); group 2 (8,000 persons) invited to undergo a biannual FOBT for three rounds; and group 3 (1,000 persons) invited to undergo OC. Subjects of each group will be invited by mail to undergo the selected test. All subjects with a positive FOBT or CTC test (that is, mass or at least one polyp ≥ 6 mm) will be invited to undergo a second-level OC. Primary objectives of the study are to compare the participation rate to FOBT, CTC and OC; to compare the detection rate for cancer or advanced adenomas of CTC versus three rounds of biannual FOBT; to evaluate referral rate for OC induced by primary CTC versus three rounds of FOBT; and to estimate costs of the three screening strategies. A secondary objective of the study is to create a biological bank of blood and stool specimens from subjects undergoing CTC and OC. DISCUSSION: This study will provide information about participation/acceptability, diagnostic yield and costs of screening with CTC in comparison with the recommended test (FOBT) and OC. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01651624.


Assuntos
Adenoma/diagnóstico , Colonografia Tomográfica Computadorizada , Colonoscopia , Neoplasias Colorretais/diagnóstico , Programas de Rastreamento/métodos , Sangue Oculto , Projetos de Pesquisa , Adenoma/diagnóstico por imagem , Adenoma/economia , Adenoma/patologia , Adenoma/terapia , Bancos de Espécimes Biológicos , Protocolos Clínicos , Colonografia Tomográfica Computadorizada/economia , Colonoscopia/economia , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/economia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Custos e Análise de Custo , Custos de Cuidados de Saúde , Humanos , Itália , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Valor Preditivo dos Testes , Prognóstico , Interpretação de Imagem Radiográfica Assistida por Computador , Encaminhamento e Consulta
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