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Background. Recently the United Network for Organ Sharing (UNOS) began a pilot study to evaluate prospectively the merits of an allocation of cadaveric kidneys based on broader classes of HLA antigens, called cross-reactive groups (CREG). The objectives of the pilot study consider patient outcomes, but not the potential economic impact of a CREG-based allocation. This study predicts the impact of a CREG-based local allocation of cadaveric kidneys on 3-year Medicare payments and graft survival. Methods. The UNOS renal transplant registry was merged to Medicare claims data for 1991‐1997 by the United States Renal Data System. Average accumulated Medicare payments and graft survival up to 3 years posttransplant for first cadaveric renal transplant recipients were stratified by cross-reactive group mismatch categories. The economic impact was defined as the difference in average 3-year costs per transplant between the current and proposed allocation algorithms. Average 3-year costs were computed as a weighted average of costs, where the weights were the actual and predicted distributions of transplants across cross-reactive group categories. Results. Results suggest that an organ allocation based on cross-reactive group matching criteria would result in a 3-year cost savings of $1,231 (2%) per transplant, and an average 3-year graft survival improvement of 0.6%. Conclusions. Cost savings and graft survival improvements can be expected if CREG criteria were to replace current criteria in the current allocation policy for cadaveric kidneys, although the savings appear to be smaller than may be achievable through expanded HLA matching. The role of tissue matching as a criterion for organ allocation is still a subject of debate. Several studies of the effect of

The potential economic effects of the allocation of cadaveric kidneys on the basis of tissue-matching criteria is controversial. We analyzed the economic costs associated with the transplantation of cadaveric kidneys with various numbers of HLA mismatches and examined the potential economic benefits of a local, as compared with a national, system designed to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantations.All data were supplied by the U.S. Renal Data System. Data on all payments made by Medicare from 1991 through 1997 for the care of recipients of a first cadaveric renal transplant were analyzed according to the number of HLA-A, B, and DR mismatches between donor and recipient and the duration of cold ischemia before transplantation.Average Medicare payments for renal transplant recipients in the three years after transplantation increased from 60,436 dollars per patient for fully HLA-matched kidneys (those with no HLA-A, B, or DR mismatches) to 80,807 dollars for kidneys with six HLA mismatches between donor and recipient, a difference of 34 percent (P0.001). By three years after transplantation, the average Medicare payments were 64,119 dollars for transplantations of kidneys with less than 12 hours of cold ischemia time and 74,997 dollars for those with more than 36 hours (P0.001). In simulations, the assignment of cadaveric kidneys to recipients by a method that minimized HLA mismatching within a local geographic area (i.e., within one of the approximately 50 organ-procurement organizations, which cover widely varying geographic areas) produced the largest cost savings (4,290 dollars per patient over a period of three years) and the largest improvements in the graft-survival rate (2.3 percent) when the potential costs of longer cold ischemia time were considered.Transplantation of better-matched cadaveric kidneys could have substantial economic advantages. In our simulations, HLA-based allocation of kidneys at the local level produced the largest estimated cost savings, when the duration of cold ischemia was taken into account. No additional savings were estimated to result from a national allocation program, because the additional costs of longer cold ischemia time were greater than the advantages of optimizing HLA matching.

While it is generally accepted that the decision to switch a drug from the prescription market to the over-the-counter (OTC) market is based on an optimization problem that firms are solving, no attempts have been made to formalize the problem. The purpose of this article is to present a model of prescription to OTC switching that helps explain the role of potential generic competition in a firm's decision to switch. In particular, we examine what market conditions are necessary for the threat of generic competition to induce switching.The model is game-theoretic, played between an incumbent firm and a potential generic entrant, and is solved for its subgame perfect equilibrium. The incumbent first decides whether to apply to the FDA to switch to the OTC market. If the incumbent declines, then the potential generic entrant has the opportunity to apply for the switch. The FDA then accepts or rejects the application, and the generic chooses whether to enter the market.In equilibrium, when applying to switch is costless, switching occurs if the probability that the application will be approved by the FDA is strictly positive and the OTC market is characterized by first-mover advantages. Adding a cost to the application process places restrictions on the probability of FDA approval to offset the cost of applying. The probability of approval must be sufficiently high to offset the cost of the application.The model shows that switching from the prescription to OTC market may occur as a response to potential generic competition. Firms switch because they know that if they do not, a generic may initiate a switch and become the first mover in the OTC market.

Improved mortality rates following pancreaticoduodenectomy by high-volume surgeons and hospitals have been well documented, but less is known about the impact of such volumes on length of stay and cost. This study uses data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) to examine the effect of surgeon and hospital volume on mortality, length of stay, and cost following pancreaticoduodenectomy while controlling for patient-specific factors. Data included 3,137 pancreaticoduodenectomies from the NIS performed between 2004 and 2008. Using logistic regression, the relationship between surgeon volume, hospital volume, and postoperative mortality, length of stay, and cost was estimated while accounting for patient factors. After controlling for patient characteristics, patients of high-volume surgeons at high-volume hospitals had a significantly lower risk of mortality compared to low-volume surgeons at low-volume hospitals (OR 0.32, p

Aim Elective laparoscopic colectomy (LC) has been shown to provide short-term results comparable with open colectomy (OC), but there is potential selection bias whereby LC patients may be healthier and therefore more likely to have a superior outcome. The aim of this study was to compare the incidence of postoperative complications between matched laparoscopic and open colectomy cohorts, while controlling for differences in comorbidity. Method A retrospective cohort study (2005–2010) using National Surgical Quality Improvement Program data was performed, identifying laparoscopic and open partial colectomy patients through common procedural terminology codes. Patient having rectal resection were excluded. The cohorts were matched 1:1 on a propensity score to control for observable selection bias due to patient characteristics, comparing overall complication rates, length of hospital stay (LOS), the incidence of superficial (S-SSI) surgical site infection, urinary tract infection (UTI) and deep-venous thrombosis (DVT). Results We analysed 37 249 patients. After propensity score matching the LC group had a significantly lower overall incidence of postoperative complications (29.1 vs 21.2%; P

Beneficial effects of marriage on cancer outcomes have been observed for many cancers, but oral cavity and pharyngeal cancers have never been examined.We used the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) Program linked with Medicare records to identify 9403 elderly patients (age ≥66 years) with oral cavity and pharyngeal cancers. We used a propensity score analysis to estimate differences in proportions (pd ) between married and unmarried patients on stage, treatment, and survival.For oral cavity cancers, a larger proportion of married patients presented with earlier stage (pd = 0.05; 95% confidence interval [CI], 0.02-0.08), were treated with surgery (pd = 0.06; 95% CI, 0.03-0.08), and survived 1 year (pd = 0.04; 95% CI, 0.01-0.06). Similar results were found for pharyngeal cancers for stage (pd = 0.04; 95% CI, 0.01-0.06), treatment with chemotherapy and radiation (pd = 0.04; 95% CI, 0.01-0.07), and 1-year survival (pd = 0.01; 95% CI, 0.08-0.16).Marriage is associated with earlier stage, aggressive treatment, and superior survival for patients with oral cavity and pharyngeal cancers.

Inflammatory bowel disease (IBD) patients are at increased risk for venous thromboembolism (VTE) compared to the general population. Practice guidelines recommend pharmacologic prophylaxis for IBD inpatients.Our aim was to determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC) inpatients at a tertiary referral center. We also assessed potential predictors of pharmacologic prophylaxis.We conducted a retrospective cohort study of 377 UC patients between January 1st, 2007 and December 31st, 2011. The medical record of each patient was examined to determine whether pharmacologic VTE prophylaxis was ordered and administered. We conducted multiple logistic regression to determine predictors of pharmacologic prophylaxis.The overall VTE pharmacologic prophylaxis rate was 67.6%. The rate of patients admitted to the medical service was 57.4% compared to 93.5% for those admitted to surgery. In medical patients who received pharmacologic VTE prophylaxis, 34.0% of ordered doses were not given compared to 17.4% of doses in surgical patients (P0.001). In the multiple logistic regression analysis, having an additional VTE risk factor (OR 2.46, 95% CI 1.41-4.30), extensive colitis (OR 2.26, 95% CI 1.32-3.87) or being admitted to a surgical service (OR 12.03, 95% CI 5.29-27.38) was associated with VTE pharmacologic prophylaxis.A substantial proportion of medical patients admitted with UC were not ordered for VTE pharmacologic prophylaxis despite current guidelines. Even in patients who were ordered for pharmacologic prophylaxis, one third of doses were not given. Inappropriate prophylaxis may lead to unnecessary morbidity and mortality.

Both type 1 diabetes mellitus and end-stage renal disease are associated with increased fracture risk, likely because of metabolic abnormalities that reduce bone strength. Simultaneous pancreas–kidney transplantation is a treatment of choice for patients with both disorders, yet the effects of simultaneous pancreas–kidney and kidney transplantation alone on post-transplantation fracture risk are unknown. From the United States Renal Data System, we identified 11,145 adults with type 1 diabetes undergoing transplantation, of whom 4933 had a simultaneous pancreas–kidney transplant and 6212 had a kidney-alone transplant between 2000 and 2006. Post-transplantation fractures resulting in hospitalization were identified from discharge codes. Time to first fracture was modeled and propensity score adjustment was used to balance covariates between groups. Fractures occurred in significantly fewer (4.7%) of pancreas–kidney compared with kidney-alone transplant (5.9%) cohorts. After gender stratification and adjustment for fracture covariates, pancreas–kidney transplantation was associated with a significant 31% reduction in fracture risk in men (hazard risk 0.69). Older age, white race, prior dialysis, and pre-transplantation fracture were also associated with increased fracture risk. Prospective studies are needed to determine the gender-specific mechanisms by which pancreas–kidney transplantation reduces fracture risk in men.

The purpose of this study was to examine the values, beliefs, and perceptions of end-of-life (EOL) care held by inmates caring for peers approaching end of life. The study is part of a broader participatory action research project to infuse enhanced EOL care into state prisons. Face-to-face interviews using a semi-structured discussion guide were conducted with 17 male prisoners who were providing care for peers with advanced chronic illness and approaching end of life. Qualitative data were analyzed using content and thematic analyses. Key themes were: getting involved; living the role; and transforming self through caring for others. As well, contextual features at the organizational, peer, and personal levels were identified that either facilitated or impeded inmate caregiving. Provision of enhanced EOL care by inmate peers shows promise for improving prison community relations and morale, reducing suffering, and demonstrating care and compassion within the harsh prison environment. This study provides clear evidence that providing compassionate care for dying peers may result in transformative experiences for inmate caregivers. Implications for correctional nursing practice include providing training for inmate caregivers, including them in team meetings, and implementing grief support programs. Also, upholding nursing’s code of ethics and watching for predatory behavior are critical. “Prisons in the United States contain an ever growing number of aging men and women who…are incontinent, forgetful, suffering chronic illnesses, extremely ill, and dying” (Human Rights Watch, 2012, p. 4)

Question Does selective decontamination of the digestive tract (SDD) of people in intensive care (ICU) reduce mortality and infection by drug-resistant bacteria? Study design Unblinded randomised controlled trial. Main results In the ICU, SDD lowered mortality compared with usual care (69 deaths vs. 107 deaths; RR 0.65 95% CI 0.49–0.85, p =0.002). SDD decreased overall hospital mortality compared with usual care (113 vs. 146; p =0.02). Acquired infections of resistant Gram-negative aerobic bacteria were lower for SDD compared with usual care (16% vs. 26%, RR 0.61, 95% CI 0.46–0.81). There were no differences in vancomycin-resistant enterococcus infections between groups ( p =1.0). No methicillin-resistant S. aureus were found in either group. The usual care unit was colonised with significantly more ceftazidime-resistant enterobacteriaceae compared with the SDD unit ( p Authors’ conclusions SDD decreased colonisation with vancomycin-resistant enterococcus, and reduced in-hospital mortality.

AIM: Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms. METHODS: A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children’s Eating Attitudes Test (ChEAT), Children’s Depression Inventory (CDI), and Revised Children’s Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects. RESULTS: The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p

123 Background: Standard of care for patients with advanced gastric cancer includes administration of adjuvant chemotherapy (ADJ); however, post-operative convalescence often prolongs the interval between surgery and chemotherapy. This study assesses the survival impact of timing of adjuvant chemotherapy in patients undergoing resection for gastric cancer. Methods: The 2003-2012 ACS NCDB was analyzed for patients treated with gastrectomy for cancer. Treatment groups were stratified by time to initiation of ADJ. The categories included: initiation of chemotherapy within 3 months post-operatively, after 3 months post-operatively, and surgery only. Univariate and multivariate analyses were performed. Results: Of 10,242 patients undergoing gastrectomy, 31% received ADJ and 69% underwent surgery only. Median time to receipt of chemotherapy was 52 days. The majority, 87%, received ADJ within 3 months. 13% received ADJ after 3 months. Patients who received ADJ earlier were more frequently younger, female, privately insured, with fewer comorbidities, treated in comprehensive community facilities, and more often with stages II and III disease. In multivariate analysis, patients who received ADJ had a 36% less hazard of death, both with administration within 3 months post-operatively and later, compared to surgery only patients (HR = 0.64, p < 0.0001, both). Among patients who received ADJ within 3 months and after, median time of survival was not different at a statistically significant level, when stratified by pathologic stage (see Table). Median time of survival was longer for both chemotherapy cohorts when compared with surgery only, specifically in patients with pathologic stage II, III, and III disease. Conclusions: Time to initiation of adjuvant therapy following surgery does not impact survival. With improved survival over surgery only, even delayed initiation of chemotherapy should be offered, when appropriate. [Table: see text]

122 Background: This study assesses the survival impact of perioperative chemotherapy, with further analysis of pathologic response to neoadjuvant chemotherapy (NAC), in patients undergoing gastrectomy for gastric cancer (GC) in a large US sample. Methods: Using the 2003-2012 ACS National Cancer Database, 16,128 patients underwent gastrectomy for cancer. Treatment groups were categorized as: NAC, adjuvant chemotherapy, and surgery only. Patients receiving NAC were further categorized as: down-staged, no response, and disease progression. Univariate and multivariate analyses were performed to estimate the impact of treatment on overall survival. Results: Of patients undergoing gastrectomy, 36.6% received NAC, 19.5% received adjuvant chemotherapy, and 43.9% underwent surgery only. Median time of survival was longer in patients with more advanced disease who underwent either NAC or adjuvant chemotherapy versus surgery alone (see Table). In multivariate analysis, patients who received NAC had 20% lower hazard of death than surgery only patients (HR = 0.80, p < 0.0001). Within the NAC cohort (N = 5,909), 47.7% were down-staged, 36.5% had no response, and 15.7% demonstrated disease progression. Having a pathologic response to NAC was associated with having private insurance (OR = 1.22, p < 0.0001), higher socioeconomic status (OR = 1.21, p = 0.003), treatment in the central US (p < 0.0001, both), and undergoing proximal gastrectomy (OR = 1.59, p < 0.0001). Among patients who received NAC, median time of survival was longer if NAC down-staged patients to stages 0 or 1, with no survival difference in advanced stage disease. Conclusions: Neoadjuvant chemotherapy elicits a survival benefit in patients with advanced GC. Pathologic response is achieved in nearly half of patients undergoing NAC and is associated with improved survival, although only when down-staging to early stage disease. [Table: see text] [Table: see text]

367 Background: Pancreatic cancer carries a dismal prognosis, with surgical resection and adjuvant therapy offering the only hope for long-term survival. In recent years, neoadjuvant therapy (NAT) has been employed to optimize outcomes. This study evaluates the impact of NAT on survival in patients with resected stage I-III pancreatic cancer. Methods: The National Cancer Data Base (2003-2011) was analyzed for patients with clinical stage I-III resected carcinoma of the pancreas who underwent NAT or surgery first +/- adjuvant therapy. Univariate statistics were used to compare characteristics between groups. Analysis of variance and Kaplan Meier analyses were used to compare median survival for each clinical stage of disease. Multivariate analyses were performed using a Cox proportional hazards model. Results: 16,122 patients who underwent NAT and 16,869 patients who underwent surgery-first were included. Patients who underwent NAT tended to be younger, covered by private insurance, have a higher median income, greater comorbidities, higher clinical stage disease, and undergo a whipple. Additionally, NAT patients had a greater number of positive regional lymph nodes (9 vs. 6, respectively), although a similar number of nodes retrieved, and higher pathological stage disease. In patients with clinical stage I disease, adjuvant therapy was associated with improved median survival than NAT and surgery-alone (24.8, 18.5, 17.9 months, p < 0.0001, respectively). However, in stage II, adjuvant and NAT offered similar median survival, which was improved over surgery-alone (20.5, 20.1, and 12.4 months, p < 0.0001, respectively). In stage III, NAT had improved median survival than the other groups (19.6, 14.2, 8.6 months, p < 0.0001, respectively). In the multivariate survival analysis, patients who received NAT had a 22% lower hazard of mortality up to 5 years as compared to adjuvant therapy (p < 0.0001). Conclusions: Neoadjuvant therapy in advanced stage pancreatic cancer confers a survival benefit and may allow more patients to undergo surgery; NAT appears to offer similar survival as adjuvant therapy in early stage pancreatic cancer.

368 Background: Pancreatic cancer carries a grim prognosis. Surgical resection followed by adjuvant chemotherapy is standard of care, but little is known about the temporal relationship of chemotherapy initiation and survival. This study analyzed the impact of time to initiation of adjuvant chemotherapy on survival in patients with resected pancreatic cancer. Methods: The National Cancer Data Base (2003-2011) was retrospectively reviewed for patients with clinical stages 1-3 resected pancreatic carcinoma. Time to chemotherapy was stratified at the 12-week post-operative timepoint. Univariate statistics, Kaplan-Meier estimates, and Cox proportional hazard modeling were performed. Results: 5,205 patients who had undergone surgical resection alone, 3,144 patients who had undergone surgical resection and adjuvant chemotherapy initiated at or before 12 weeks, and 906 patients who had undergone surgical resection followed by adjuvant therapy started after 12 weeks were included. Patients who received chemotherapy > 12 weeks tended to be older, have more co-morbidities, receive treatment at academic centers, and undergo whipple procedures. In all pathologic disease stages, adjuvant chemotherapy conferred a significant survival benefit over surgical resection alone (p < 0.0001). However, there was no significant overall survival benefit for patients receiving adjuvant chemotherapy before 12 weeks as compared to after (p = 0.85). When stratified by pathological stage, there was still no significant survival benefit for earlier initiation of chemotherapy (£ vs. > 12 weeks): stage I, p = 0.16, stage II, p = 0.12, stage III, p = 0.38. After controlling for patient, disease, and surgery characteristics, patients who received adjuvant chemotherapy after 12 weeks had a 31% lower odds of mortality at 5 years, while those who initiated it before 12 weeks had a 34% lower odds (p < 0.0001, p < 0.0001 respectively), versus surgery-alone. Conclusions: Earlier initiation of adjuvant chemotherapy does not significantly impact long-term survival in patients with resected pancreatic cancer. However, because adjuvant chemotherapy confers a survival benefit, delayed chemotherapy should be offered when appropriate.

Aim It is unclear whether colectomy for fulminant Clostridium difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population. Method Selected studies from 1994–2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle–Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel–Haenszel method and fixed-effects modelling. Results Five hundred and ten patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery with medical therapy was 0.70 (0.49–0.99), suggesting that surgery provided a survival benefit. Conclusion Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C. difficile colitis.

Aim Previous reports describing Clostridium difficile colitis (CDC) developing after the closure of a loop ileostomy suggest it is severe. In this study the incidence of CDC following ileostomy closure and its effect on the postoperative outcome have been studied. Method Patients undergoing closure of loop ileostomy from 2004 to 2008 were analysed using the Nationwide Inpatient Sample. Patients who developed postoperative CDC (n = 217) were matched 10:1 to a propensityscore-matched cohort of patients without CDC (n = 13 245). Linear and logistic regression were used to examine the effect of CDC on hospital cost (US dollars), length of stay and mortality rates. Population resampling was performed using nearest neighbour bootstrapping to confirm the validity of the results. Results The incidence of CDC following ileostomy closure was 16 per 1000 patients. The mean length of stay was 11.5 days longer among CDC patients (P < 0.0001), with a greater cost of hospitalization of US$21 240 (P < 0.0001). There was no difference in mortality between the cohorts. Conclusion CDC following ileostomy closure is an uncommon, costly and morbid complication. Patients undergoing stoma closure are at high risk for an adverse outcome if they have CDC. Should it develop they should be aggressively treated.

Background: The objective was to determine whether motivation to change is significantly altered over the course of partial hospitalization in children and adolescents with eating disorders (EDs). Method: This study was a retrospective chart review of 30 sets of adolescents and their parents who completed the Motivational Stage of Change for Adolescents Recovering from an Eating Disorder (MSCARED) at both intake and discharge from partial hospitalization. The main outcome variables included change in stage of change (SOC) for patients and their parents. Secondary outcomes included correlations between SOC and other baseline variables, as well as changes in SOC and psychological test scores. Results: The SOC was significantly higher at discharge than at intake in both the patients and parents, but the two groups were not in agreement at discharge. The change in the SOC was correlated with change in Children’s Eating Attitudes Test scores. Assessment of decisional balance showed correlations with SOC. Age, change in weight, and psychiatric diagnoses did not correlate with initial SOC. Conclusion: The MSCARED may be a useful tool for monitoring young ED patients’ psychological improvements with day treatment. Initial SOC is not predictive of treatment outcomes.

As payment policies for surgical complications evolve, surgeons and hospitals need to understand the financial implications of postoperative events. Using data from the National Surgical Quality Improvement Program (NSQIP), the authors estimated mortality, length of stay (LOS), and total cost attributable to multiple postoperative events in general and vascular surgery patients. Data were collected using standard NSQIP practices at a single academic center between 2007 and 2009. LOS and costs were fit to linear regression models to determine the effect of 19 postoperative events in the setting of 1, 2, or 3+ events. Of 2250 patients sampled, 457 patients developed at least 1 postoperative event. LOS increased by 2.59, 5.18, and 10.99 days (P < .0001) for 1, 2, and 3+ postoperative events; excess costs were $6358, $12 802, and $42 790 (P < .0001), respectively. Multiple postoperative events have a synergistic effect on mortality, LOS, and the financial cost of patient care.

It is unknown how colorectal surgical outcomes in recipients of renal transplants (TXP) compare to the outcomes in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).Data from the Nationwide Inpatient Sample for 2004 to 2008 were reviewed. International Classification of Diseases (ICD-9) codes identified patients undergoing colorectal surgery who were stratified as having no kidney disease, CKD, ESRD, or TXP. The effects of renal status on mortality, length of hospital stay, and hospital costs were determined.A total of 171,133 patients were identified; 162,986 had no kidney disease, 3,686 had CKD, 1,296 had ESRD, and 3,765 had had TXP. The odds of death after surgery were 43% more likely for patients with CKD, 82% more likely for TXP, and 240% more likely for those with ESRD. TXP resulted in an additional length of hospital stay of 3.4 days, compared to 3.2 days for those with ESRD, and 1.1 days for those with CKD (P.0001). CKD added $4,223 in additional costs, TXP added $8,213, and ESRD added $12,821 (P.0001). TXP demonstrated odds of mortality between those of CKD and ESRD for cardiovascular complications (OR 2.47). Pulmonary complications resulted in the highest odds of mortality for TXP (OR 6.3).After TXP, patients undergoing colorectal surgery have mortality and costs between those of patients with CKD and ESRD, with pulmonary complications remaining high mortality events.

Donation after cardiac death (DCD) liver transplantation is increasing largely because of a shortage of organs. However, there are almost no data that have specifically assessed the impact of using DCD livers for HCV patients. We retrospectively studied adult primary DCD liver transplantation (630 HCV, 1164 non-HCV) and 54 129 donation after brain death (DBD) liver transplantation between 2002 and 2009 using the UNOS/OPTN database. With donation after brain death (DBD) livers, HCV recipients had significantly inferior graft survival compared to non-HCV recipients (p < 0.0001). Contrary to DBD donors, DCD livers used in HCV patients showed no difference in graft survival compared to non-HCV patients (p = 0.5170). Cox models showed DCD livers and HCV disease had poorer graft survival (HR = 1.80 and 1.28, p < 0.0001, respectively). However, the hazard ratio of DCD and HCV interaction was 0.80 (p = 0.02) and these results suggest that DCD livers on HCV disease do not fare worse than DCD livers on non-HCV disease. The graft survival of recent years (2006–2009) was significantly better than that in former years (2002–2005) (p = 0.0482). In conclusion, DCD liver transplantation for HCV disease showed satisfactory outcomes. DCD liver transplantation can be valuable option for HCV related end-stage liver disease.

Background: Hip fractures are common in the elderly, and patients with hip fractures frequently have comorbid illnesses. Little is known about the relationship between comorbid illness and hospital costs or length of stay following the treatment of hip fracture in the United States. We hypothesized that specific individual comorbid illnesses and multiple comorbid illnesses would be directly related to the hospitalization costs and the length of stay for older patients following hip fracture. Methods: With use of discharge data from the 2007 Nationwide Inpatient Sample, 32,440 patients who were fifty-five years or older with an isolated, closed hip fracture were identified. Using generalized linear models, we estimated the impact of comorbidities on hospitalization costs and length of stay, controlling for patient, hospital, and procedure characteristics. Results: Hypertension, deficiency anemias, and fluid and electrolyte disorders were the most common comorbidities. The patients had a mean of three comorbidities. Only 4.9% of patients presented without comorbidities. The average estimated cost in our reference patient was $13,805. The comorbidity with the largest increased hospitalization cost was weight loss or malnutrition, followed by pulmonary circulation disorders. Most other comorbidities significantly increased the cost of hospitalization. Compared with internal fixation of the hip fracture, hip arthroplasty increased hospitalization costs significantly. Conclusions: Comorbidities significantly affect the cost of hospitalization and length of stay following hip fracture in older Americans, even while controlling for other variables. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy. BACKGROUND The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear. METHODS A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters. RESULTS In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost ($311 vs $574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost ($1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM. CONCLUSIONS In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.

To determine whether Medicare's decision to cover routine administration of erythropoietin stimulating agents (ESAs) to treat anemia of end-stage renal disease (ESRD) has been a cost-effective policy relative to standard of care at the time.The authors used summary statistics from the actual cohort of ESRD patients receiving ESAs between 1995 and 2004 to create a simulated patient cohort, which was compared with a comparable simulated cohort assumed to rely solely on blood transfusions. Outcomes modeled from the Medicare perspective included estimated treatment costs, life-years gained, and quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratio (ICER) was calculated relative to the hypothetical reference case of no ESA use in the transfusion cohort. Sensitivity of the results to model assumptions was tested using one-way and probabilistic sensitivity analyses.Estimated total costs incurred by the ESRD population were $155.47B for the cohort receiving ESAs and $155.22B for the cohort receiving routine blood transfusions. Estimated QALYs were 2.56M and 2.29M, respectively, for the two groups. The ICER of ESAs compared to routine blood transfusions was estimated as $873 per QALY gained. The model was sensitive to a number of parameters according to one-way and probabilistic sensitivity analyses.This model was counter-factual as the actual comparison group, whose anemia was managed via transfusion and iron supplements, rapidly disappeared following introduction of ESAs. In addition, a large number of model parameters were obtained from observational studies due to the lack of randomized trial evidence in the literature.This study indicates that Medicare's coverage of ESAs appears to have been cost effective based on commonly accepted levels of willingness-to-pay. The ESRD population achieved substantial clinical benefit at a reasonable cost to society.

Objective To compare office-based care (OBC) with a care model using a home nursing visit (HNV) as the initial postdischarge encounter for “well” breastfeeding newborns and mothers. Design Randomized controlled trial. Setting A single academic hospital. Participants A total of 1154 postpartum mothers intending to breastfeed and their 1169 newborns of at least 34 weeks' gestation. Interventions Home nursing visits were scheduled no later than 2 days after discharge; OBC timing was physician determined. Outcome Measures Mothers completed telephone surveys at 2 weeks, 2 months, and 6 months. The primary outcome was unplanned health care utilization for mothers and newborns within 2 weeks of delivery. Other newborn outcomes were proportion seen within 2 days after discharge and breastfeeding duration. Maternal mental health, parenting competence, and satisfaction with care outcomes were assessed. Analyses followed an intent-to-treat paradigm. Results At 2 weeks, hospital readmissions and emergency department visits were uncommon, and there were no study group differences in these outcomes or with unplanned outpatient visit frequency. Newborns in the HNV group were seen no more than 2 days after discharge more commonly than those in the OBC group (85.9% vs 78.8%) (P = .002) and were more likely to be breastfeeding at 2 weeks (92.3% vs 88.6%) (P = .04) and 2 months (72.1% vs 66.4%) (P = .05) but not 6 months. No group differences were detected for maternal mental health or satisfaction with care, but HNV group mothers had a greater parenting sense of competence (P Conclusions Home nursing visits are a safe and effective alternative to OBC for the initial outpatient encounter after maternity/nursery discharge with similar patterns of unplanned health care utilization and modest breastfeeding and parenting benefits. Trial Registration clinicaltrials.gov Identifier: NCT00360204

Background Reasons for race and gender differences in controlling elevated low density lipoprotein (LDL) cholesterol may be related to variations in prescribed lipid-lowering therapy. We examined the effect of lipid-lowering drug treatment and potency on time until LDL control for black and white women and men with a baseline elevated LDL. Methods We studied 3,484 older hypertensive patients with dyslipidemia in 6 primary care practices over a 4-year timeframe. Potency of lipid-lowering drugs calculated for each treated day and summed to assess total potency for at least 6 and up to 24 months. Cox models of time to LDL control within two years and logistic regression models of control within 6 months by race-gender adjust for: demographics, clinical, health care delivery, primary/specialty care, LDL measurement, and drug potency. Results Time to LDL control decreased as lipid-lowering drug potency increased (P < 0.001). Black women (N = 1,440) received the highest potency therapy (P < 0.001) yet were less likely to achieve LDL control than white men (N = 717) (fully adjusted hazard ratio [HR] 0.66 [95% CI 0.56-0.78]). Black men (N = 666) and white women (N = 661) also had lower adjusted HRs of LDL control (0.82 [95% CI 0.69, 0.98] and 0.75 [95% CI 0.64-0.88], respectively) than white men. Logistic regression models of LDL control by 6 months and other sensitivity models affirmed these results. Conclusions Black women and, to a lesser extent, black men and white women were less likely to achieve LDL control than white men after accounting for lipid-lowering drug potency as well as diverse patient and provider factors. Future work should focus on the contributions of medication adherence and response to treatment to these clinically important differences.

Catheter-related bloodstream infections (CRBSIs) are frequently observed in the intensive care unit (ICU) and are a serious cause of morbidity and mortality in the United States. This article summarizes what is currently known about the cost of CRBSIs in the ICU setting. The cost of CRBSIs is between $33,000 and $44,000 in the general adult ICU, between $54,000 and $75,000 in the adult surgical ICU, and approximately $49,000 in the pediatric ICU. Finally, CRBSIs are associated with reimbursement that is more than $26,000 less than costs. Hospital and clinical decision makers should be aware of the high cost of CRBSIs in the ICU, the relatively poor reimbursement, and the implied high value of prevention efforts.

Objective.Electronic measures of surgical site infections (SSIs) are being used more frequently in place of labor-intensive measures. This study compares performance characteristics of 2 electronic measures of SSIs with a clinical measure and studies the implications of using electronic measures to estimate risk factors and costs of SSIs among surgery patients.Methods.Data included 1,066 general and vascular surgery patients at a single academic center between 2007 and 2008. Clinical data were from the National Surgical Quality Improvement Program (NSQIP) database, which includes a nurse-derived measure of SSI. We compared the NSQIP SSI measure with 2 electronic measures of SSI: MedMined Nosocomial Infection Marker (NIM) and International Classification of Diseases, Ninth Revision (ICD-9) coding for SSIs. We compared infection rates for each measure, estimated sensitivity and specificity of electronic measures, compared effects of SSI measures on risk factors for mortality using logistic regression, and compared estimated costs of SSIs for measures using linear regression.Results.SSIs were observed in 8.8% of patients according to the NSQIP definition, 2.6% of patients according to the NIM definition, and 5.8% according to the ICD-9 definition. Logistic regression for each SSI measure revealed large differences in estimated risk factors. NIM and ICD-9 measures overestimated the cost of SSIs by 134% and 33%, respectively.Conclusions.Caution should be taken when relying on electronic measures for SSI surveillance and when estimating risk and costs attributable to SSIs. Electronic measures are convenient, but in this data set they did not correlate well with a clinical measure of infection.

Thyroid cancer, the most common endocrine cancer, is on the rise. It is less common in the African American (AA) population in the United States. Few studies have looked at outcome disparities for different patient populations, particularly those involving race.Using data from the SEER registry, we sought to determine whether five-year survival differed significantly between AA and White patients and, whether differences were due to patient or disease characteristics.Retrospective cohort analysis. Univariate comparisons were made using Student-t tests for continuous variables, chi-square tests for categorical variables. Survivor functions were estimated using Kaplan-Meier curves, and comparisons were made by log rank tests.26,902 patients (25,210 White and 1,692 AA) were diagnosed with thyroid cancer between 1992 and 2006.Five-year survival defined as time from diagnosis to death from cancer within five years.AA had a significantly lower rate of five-year survival compared to Whites (96.5% vs 97.4%, P = .006). AA patients were 2.3 times more likely to be diagnosed with anaplastic disease (Risk ratio [RRI = 2.33 (95% CI: 1.52-3.58), P = .0001), and were also nearly 80% more likely to be diagnosed with follicular disease (RR = 1.78 [95% CI: 1.59-1.99], P.0001). They were nearly twice as likely to have larger tumors (or = 4 cm) than White patients (RR = 1.94 [95% CI: 1.78-2.12], P.0001).AA had poorer survival from thyroid cancer relative to White patients; this difference may be explained by differences in disease characteristics such as a relatively higher rate of anaplastic thyroid cancer, follicular cancer and larger tumors at presentation.

Although much has been written about excess cost and duration of stay (DOS) associated with surgical site infections (SSIs) after cardiothoracic surgery, less has been reported after vascular and general surgery. We used data from the National Surgical Quality Improvement Program (NSQIP) to estimate the total cost and DOS associated with SSIs in patients undergoing general and vascular surgery.Using standard NSQIP practices, data were collected on patients undergoing general and vascular surgery at a single academic center between 2007 and 2009 and were merged with fully loaded operating costs obtained from the hospital accounting database. Logistic regression was used to determine which patient and preoperative variables influenced the occurrence of SSIs. After adjusting for patient characteristics, costs and DOS were fit to linear regression models to determine the effect of SSIs.Of the 2,250 general and vascular surgery patients sampled, SSIs were observed in 186 inpatients. Predisposing factors of SSIs were male sex, insulin-dependent diabetes, steroid use, wound classification, and operative time (P.05). After adjusting for those characteristics, the total excess cost and DOS attributable to SSIs were $10,497 (P.0001) and 4.3 days (P.0001), respectively.SSIs complicating general and vascular surgical procedures share many risk factors with SSIs after cardiothoracic surgery. Although the excess costs and DOS associated with SSIs after general and vascular surgery are somewhat less, they still represent substantial financial and opportunity costs to hospitals and suggest, along with the implications for patient care, a continuing need for cost-effective quality improvement and programs of infection prevention.

• To evaluate epidemiological and survival patterns of upper-tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population-based database.• Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10-year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes.•In total, 13,800 SEER-registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100,000 person-years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P0.001), whereas local tumours declined from 50.4% to 23.6% (P0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P0.001), male gender (P0.001), black non-Hispanic race (P0.001), bilateral UTUC (P = 0.001) and regional/distant disease (P0.001) were all associated with poorer survival outcomes.• The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross-sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.

Marital status has been associated with outcomes in several cancer sites including breast cancer in the literature, but little is known about colon cancer, the fourth most common cancer in the US.A total of 127,753 patients with colon cancer were identified who were diagnosed between 1992 and 2006 in the US Surveillance, Epidemiology and End Results (SEER) Program. Marital status consisted of married, single, separated/divorced and widowed. Chi-square tests were used to examine the association between marital status and other variables. The Kaplan-Meier method was used to estimate survival curves. Cox proportional hazards models were fit to estimate the effect of marital status on survival.Married patients were more likely to be diagnosed at an earlier stage (and for men also at an older age) compared with single and separated/divorced patients, and more likely to receive surgical treatment than all other marital groups (all p0.0001). The five-year survival rate for the single was six percentage points lower than the married for both men and women. After controlling for age, race, cancer stage and surgery receipt, married patients had a significantly lower risk of death from cancer (for men, HR: 0.86, CI: 0.82-0.90; for women, HR: 0.87, CI: 0.83-0.91) compared with the single. Within the same cancer stage, the survival differences between the single and the married were strongest for localized and regional stages, which had overall middle-range survival rates compared to in situ or distant stage so that support from marriage could make a big difference.Marriage was associated with better outcomes of colon cancer for both men and women, and being single was associated with lower survival rate from colon cancer.

Background: The three-dimensional vault geometry beneath the glenoid face reduces to a narrow width in many individuals, creating a risk of perforation of the glenoid component pegs or keel in total shoulder arthroplasty. The purpose of this study was to introduce the concept of a centerline of the glenoid vault determined by computed optimization and to compare this centerline geometry against two existing surgical methods for orienting the glenoid component. Methods: Thirty-four subject-specific computer models of three-dimensional scapular geometry were created from computed tomography scans. The glenoid vault centerline was calculated by slicing the vault into a series of cross sections, determining the center of each section, and fitting a centerline with use of optimization. Vault centerline orientations were compared with the drill-line orientations determined by two surgical techniques, the face plane technique, which drills perpendicular to the glenoid face, and the neutralization technique, which drills parallel to the scapular body resulting in 0° of glenoid version. Distances between the drill lines and the vault wall, throughout the vault depth, were also calculated. Results: The vault centerline intersected the articular surface of the glenoid at an intersubject average (and standard deviation) of 1.1 ± 0.8 mm posterior to the glenoid face center point. In comparison with the neutralization direction, the centerline was oriented an average of 9.4° ± 5.1° posteriorly and the face plane perpendicular direction was oriented an average of 7.3° ± 4.0° posteriorly. Minimum distances between the centerline and the vault wall averaged 5.1 mm (minimum, 2.6 mm), whereas they averaged 4.4 mm (minimum, 1.0 to 1.4 mm) for the center peg drill lines of both surgical techniques. Conclusions: The normal glenoid vault centerline is directed from lateral-posterior to medial-anterior, and it crosses, on the average, close to the glenoid face center. The neutralization direction, on the average, anteverts the glenoid relative to the vault centerline and the face plane perpendicular. Relationships between these directions vary across the subjects. Clinical Relevance: The vault centerline represents optimal containment of the glenoid central peg within the vault. This study provides an understanding of the location of this centerline relative to scapular landmarks and relative to the drill directions from two existing surgical techniques.

Cost-effectiveness analyses of asthma controller regimens for adults exist, but similar evaluations exclusively for children are few.We sought to compare the cost-effectiveness of 2 commonly used asthma controllers, fluticasone and montelukast, with data from the Pediatric Asthma Controller Trial.We compared the cost-effectiveness of low-dose fluticasone with that of montelukast in a randomized, controlled, multicenter clinical trial in children with mild-to-moderate persistent asthma. Analyses were also conducted on subgroups based on phenotypic factors. Effectiveness measures included (1) the number of asthma-control days, (2) the percentage of participants with an increase over baseline of FEV(1) of 12% or greater, and (3) the number of exacerbations avoided. Costs were analyzed from both a US health care payer's perspective and a societal perspective.For all cost-effectiveness measures studied, fluticasone cost less and was more effective than montelukast. For example, fluticasone treatment cost $430 less in mean direct cost (P.01) and resulted in 40 more asthma-control days (P.01) during the 48-week study period. Considering sampling uncertainty, fluticasone cost less and was more effective at least 95% of the time. For the high exhaled nitric oxide (eNO) phenotypic subgroup (eNO ≥25 ppb) and more responsive PC(20) subgroup (PC(20)2 mg/mL), fluticasone was cost-effective compared with montelukast for all cost-effectiveness measures, whereas not all the effectiveness measures were statistically different for the other 2 phenotypic subgroups.For children with mild-to-moderate persistent asthma, low-dose fluticasone had lower cost and higher effectiveness compared with montelukast, especially in those with more airway inflammation, as indicated by increased levels of eNO and more responsivity to methacholine.

OBJECTIVE: Despite data suggesting that routine urine screening for chronic kidney disease (CKD) has low diagnostic yield and the American Academy of Pediatrics 2007 recommendation to discontinue this screening, pediatricians may not have recognized this change. Because the new recommendation marks a major alteration in the practice guidelines, we sought to evaluate the cost-effectiveness of dipstick urinalysis for detection of CKD from the primary care practitioner's perspective. METHODS: Decision analysis was used to model a screening dipstick urinalysis strategy relative to a no-screening strategy. Data on the incidence of hematuria and proteinuria in children were derived from published reports of large cohorts of school-aged children. Direct costs were estimated from the perspective of the primary care practitioner. The measure of effectiveness was the rate of diagnoses of CKD. Cost-effectiveness was evaluated by using an incremental cost-effectiveness ratio. RESULTS: Expected costs and effectiveness for the no-screening strategy were $0 because no resources were used and no cases of CKD were diagnosed. The screening strategy involved a cost per dipstick of $3.05. Accounting for both true-positive and false-positive initial screens, 14.2% of the patients required a second dipstick as per typical clinical care, bringing the expected cost of the screening strategy to $3.47 per patient. In the screening strategy, 1 case of CKD was diagnosed per 800 screened, and the incremental cost-effectiveness ratio was $2779.50 per case diagnosed. CONCLUSIONS: Urine dipstick is inexpensive, but it is a poor screening test for CKD and a cost-ineffective procedure for the primary care provider. These data support the change in the American Academy of Pediatrics guidelines on the use of screening dipstick urinalysis. Clinicians must consider the cost-effectiveness of preventive care procedures to make better use of available resources.