Cost consequences due to reduced ulcer healing times – analyses based on the Swedish Registry of Ulcer Treatment

Resource use and costs for topical treatment of hard‐to‐heal ulcers based on data from the Swedish Registry of Ulcer Treatment (RUT) were analysed in patients recorded in RUT as having healed between 2009 and 2012, in order to estimate potential cost savings from reductions in frequency of dressing changes and healing times. RUT is used to capture areas of improvement in ulcer care and to enable structured wound management by registering patients with hard‐to‐heal leg, foot and pressure ulcers. Patients included in the registry are treated in primary care, community care, private care, and inpatient hospital care. Cost calculations were based on resource use data on healing time and frequency of dressing changes in Swedish patients with hard‐to‐heal ulcers who healed between 2009 and 2012. Per‐patient treatment costs decreased from SEK38 223 in 2009 to SEK20 496 in 2012, mainly because of shorter healing times. Frequency of dressing changes was essentially the same during these years, varying from 1·4 to 1·6 per week. The total healing time was reduced by 38%. Treatment costs for the management of hard‐to‐heal ulcers can be reduced with well‐developed treatment strategies resulting in shortened healing times as shown in RUT.     

Free tissue transfer provides durable treatment for large nonhealing venous ulcers

BACKGROUND: Most venous ulcers (VUs) will heal with conventional treatment, which focuses on improving regional venous hemodynamics. This treatment, however, often fails to heal large, recurrent VUs that are associated with severe lipodermatosclerosis (LDS). These complicated ulcers may require correction of local venous hemodynamics and replacement of the surrounding LDS with healthy tissue. We report our experience managing 24 especially difficult VUs with debridement and free flap coverage. PATIENTS AND METHODS: Between 1987 and 1997, 25 free flap procedures were performed in 22 patients for 24 recalcitrant VUs. Ulcers had been present for a mean of 5.24 years and had failed to heal with conservative therapy and split-thickness skin grafts (STSGs) (mean, 2.2). Eleven patients (46%) had exposed bone, tendon, or joint. At operation the area of LDS was excised, and all perforating veins were ablated. The defects after excision ranged from 100 to 600 cm(2) (mean, 237 cm(2)). The free flap was inset within the defect and covered with an STSG. RESULTS: We healed all 24 ulcers with free tissue transfer (one patient required a second flap after the first failed). There were no deaths. Local complications that required repeat STSG occurred in three (13%) of the 24 successful flap transfers. Four other flaps had minor local complications that healed with local wound care. Follow-up was available for 21 of the 24 successful flap transfers. No recurrent ulcers were identified in the territory of the flap after a mean of 58 months, but three patients had new ulcers in the same leg after 6 to 77 months. Patients with severe complications were hospitalized longer than those with minor or no complications (45.7 vs 12.8 days, P <.01), and their hospital charges were greater ($76,681 vs $30,428, P <.01). CONCLUSION: Free tissue transfer can provide rapid healing and long-term relief from severe VUs that are unable to be treated with conventional therapy. This technique improves venous hemodynamics, removes all liposclerotic tissue, provides an abundant blood supply, and resolves the tissue-related components of chronic ulceration. Although further work is needed to determine the optimal indications, this technique provides a durable treatment for especially recalcitrant ulcers.     

A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses

BACKGROUND. Previous randomized studies of laparoscopic appendectomy produced conflicting recommendations, and the adequacy of sample sizes is generally unknown. We compared clinical and economic outcomes after laparoscopic and open appendectomy in a sample of predetermined statistical power. METHODS. A pre-study power analysis suggested that 200 randomized patients would yield 80% power to show a mean decrease of 1.3 days' hospitalization. One hundred ninety-eight patients with a preoperative diagnosis of acute appendicitis were randomized prospectively to laparoscopic or open appendectomy. Economic analysis included billed charges, total costs, direct costs, and indirect costs associated with treatment. RESULTS. Laparoscopic appendectomy took longer to perform than open appendectomy (median, 107 vs 91 minutes; P <.01) and was associated with fewer days to return to a general diet (mean, 1.6 versus 2.3 days; P <.01), a shorter duration of parenteral analgesia (mean, 1.6 versus 2.2 days; P <.01), fewer morphine-equivalent milligrams of parenteral narcotic (median, 14 mg versus 34 mg; P =.001), a shorter postoperative hospital stay (mean, 2.6 versus 3.4 days; P <.01), and earlier return to full activity (median, 14 versus 21 days; P <.02). However, operative morbidity and time to return to work were comparable. Billed charges and direct costs were not significantly different in the 2 groups ($7711 versus $7146 and $5357 versus $4945, respectively), but total costs (including indirect costs) of laparoscopic appendectomy were, on average, nearly $2400 less, given the shorter length of stay and abbreviated recuperative period ($11,577 versus $13,965). Subgroup analyses suggested the benefit of a laparoscopic approach for uncomplicated appendicitis and for patients with active lifestyles. CONCLUSIONS. While laparoscopic appendectomy is associated with statistically significant but clinically questionable advantages over open appendectomy, a laparoscopic approach is relatively less expensive. The estimated difference in total costs of treatment (direct and indirect costs) was at least $2000 in more than 60% of the bootstrapped iterations. The economic significance and implications favoring a laparoscopic approach cannot be ignored.     

Health care costs in a randomized trial of antimicrobial duration among cystic fibrosis patients with pulmonary exacerbations

BackgroundThe purpose of these analyses was to determine whether overall costs were reduced in cystic fibrosis (CF) patients experiencing pulmonary exacerbation (PEx) who received shorter versus longer durations of treatment.MethodsAmong people with CF experiencing PEx, we calculated 30-day inpatient, outpatient, emergency room, and medication costs and summed these to derive total costs in 2020 USD. Using the Kaplan-Meier sample average (KMSA) method, we calculated adjusted costs and differences in costs within two pairs of randomized groups: early robust responders (ERR) randomized to receive treatment for 10 days (ERR-10 days) or 14 days (ERR-14 days), and non-early robust responders (NERR) randomized to receive treatment for 14 days (NERR-14 days) or 21 days (NERR-21 days).ResultsPatients in the shorter treatment duration groups had shorter lengths of stay per hospitalization (mean ± standard deviation (SD) for ERR-10 days: 7.9 ± 3.0 days per hospitalization compared to 10.1 ± 4.2 days in ERR-14 days; for NERR-14 days: 8.7 ± 4.9 days per hospitalization compared to 9.6 ± 6.5 days in NERR-21 days). We found statistically significantly lower adjusted mean costs (95% confidence interval) among those who were randomized to receive shorter treatment durations (ERR-10 days: $60,800 ($59,150 - $62,430) vs $74,420 ($72,610 - $76,450) in ERR-14 days; NERR-14 days: $66,690 ($65,960-$67,400) versus $74,830 ($73,980-$75,650) in NERR-21 days).ConclusionsTied with earlier evidence that shorter treatment duration was not associated with worse clinical outcomes, our analyses indicate that treating with shorter antimicrobial durations can reduce costs without diminishing clinical outcomes.     

Analgesia for Labor Pain: A Cost Model

Background: Epidural analgesia and intravenous analgesia with opioids are two techniques for the relief of labor pain. The goal of this study was to develop a cost-identification model to quantify the costs (from society's perspective) of epidural analgesia compared with intravenous analgesia for labor pain. Because there is no valid method to assign a dollar value to differing levels of analgesia, the cost of each technique can be compared with the analgesic benefit (patient pain scores) of each technique.

Methods: The authors created a cost model for epidural and intravenous analgesia by reviewing the literature to determine the rates of associated clinical outcomes (benefit of each technique to produce analgesia) and complications (e.g., postdural puncture headache). The authors then analyzed data from their institution's cost-accounting system to determine the hospital cost for parturients admitted for delivery, estimated the cost of each complication, and performed a sensitivity analysis to evaluate the cost impact of changing key variables. A secondary analysis was performed assuming that the cost of nursing was fixed (did not change depending on the number of nursing interventions).

Results: If the cesarean section rate equals 20% for both intravenous and epidural analgesia, the additional expected cost per patient to society of epidural analgesia of labor pain ranges from $259 (assuming nursing costs in the labor and delivery suite do not vary with the number of nursing interventions) to $338 (assuming nursing costs do increase as the number of interventions increases) relative to the expected cost of intravenous analgesia for labor pain. This cost difference results from increased professional costs and complication costs associated with epidural analgesia.     

An innovative enterostomal therapy nurse model of community wound care delivery: a retrospective cost-effectiveness analysis.

PURPOSE: A Canadian specialty nursing association identified the necessity to examine the role and impact of enterostomal (ET) nursing in Canada. We completed a retrospective analysis of the cost-effectiveness and benefits of ET nurse-driven resources for the treatment of acute and chronic wounds in the community. DESIGN: This was a multicenter retrospective pragmatic chart audit of 3 models of nursing care utilizing 4 community nursing agencies and 1 specialty company owned and operated by ET nurses. An analysis was completed using quantitative methods to evaluate healing outcomes, nursing costs, and cost-effectiveness. MAIN OUTCOME MEASURES: Kaplan-Meier estimates were calculated to determine the average time to 100% healing of acute and chronic wounds and total nursing visit costs for treatment in a community setting. Average direct nursing costs related to management of each wound were determined by number of nursing visits and related reimbursement for each visit. A Monte Carlo simulation method was used to help account for costs and benefits in determination of cost-effectiveness between caring groups and the uncertainty from variation between patients and wounds. RESULTS: Three hundred sixty chronic wounds and 54 acute surgical wound charts were audited. Involvement of a registered nurse (RN) with ET or advanced wound ostomy skills (AWOS) in community-level chronic and acute wound care was associated with lower overall costs mainly due to reduced time to 100% closure of the wound and reduced number of nursing visits. The differences in health benefits and total costs of nursing care between the ET/AWOS and a hybrid group that includes interventions developed by an ET nurse and followed by general visiting nurses that could include both RNs and registered practical nurses is an expected reduction in healing times of 45 days and an expected cost difference of $5927.00 per chronic wound treated. When outcomes were broken into ET/AWOS involvement categories for treatment of chronic wounds, there was a significantly faster time to 100% closure at a lower mean cost as the ET/AWOS involvement increased in the case. For acute wound treatment, the differences in health benefits and total costs between the ET/AWOS and a hybrid nursing care model were an expected reduction in healing times of 95 days and an expected cost difference of $9578.00 per acute wound treated. Again, there was a significant difference in healing times and reduced mean cost as the ET/AWOS became more involved in the treatment. The financial benefit to the Ontario Ministry of Health and Long-Term Care is estimated to increase as the involvement of nurses with ET/AWOS specialty training increases. CONCLUSIONS: The greater the involvement both directly and indirectly of an ET/AWOS nurse in the management of wounds, the greater the savings and the shorter the healing times.     

Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom

The aim of this study was to estimate costs of treating venous leg ulcers in Sweden and the United Kingdom during 1 year and to quantify costs in different health states. The costs of treating four different types of venous leg ulcers were estimated for 52 weeks by a stochastic health economic model, which simulated resource use data obtained from prospectively collected patient data, expert panels in the two countries, and published scientific literature. The average cost of treating an ulcer varied between 1332 Euro and 2585 Euro in Sweden and from 814 Euro to 1994 Euro in the United Kingdom. Cost of treating large ulcers (>/= 10 cm(2)) of long duration (>/= 6 months) was highest in both countries. Frequency of dressing changes and duration of time for each dressing change were higher in Sweden than in the United Kingdom, resulting in higher total cost per patient in Sweden. An important factor for the total costs was time to heal. Other important variables influencing treatment costs were frequency and duration of dressing changes. Actions to reduce time used for dressing changes and the total time to healing are thus very important in reducing costs spent on treatment of venous leg ulcers in both countries.     

A real‐world experience with the bioactive human split thickness skin allograft for venous leg ulcers

Data collected from standardized clinical practices can be valuable in evaluating the real‐world therapeutic benefit of skin substitutes in the treatment of venous leg ulcers (VLU). Utilizing such a dataset, this study aimed to validate the effectiveness of a bioactive human split‐thickness skin allograft for the treatment of VLU in the real‐world setting and to understand how certain variables impacted healing rates. From a pool of 1474 VLU treated with allograft, 862 ulcers in 742 patients were selected from a large wound EMR database and analyzed. All patients received standard wound care prior to allograft application. Impact of ulcer duration, number of applications, ulcer size, and time to application were analyzed. The VLU, on average, were of 189 days duration with a mean ulcer size of 19.3 cm². During treatment, 70.7% of wounds healed, with an average time to closure of 15 weeks (SD = 14.1 weeks). The percentage of VLU less than one‐year duration that healed was significantly higher (72.3%) than the percentage of VLU with duration of greater than 1 years (51.5%) ( χ² = 18.17 ; P < .001). Ulcers less than 10 cm² in size were more likely to heal (73.9%) than those larger than 10 cm² (67.9%) ( χ² = 8.65, P = .03). VLU receiving allograft within 90 days of initial presentation are 1.4 times more likely to heal vs those receiving their first BSA application after 90 days of standard of care (95% CI: [1.05, 1.86], P = .02). Allograft used in wound clinics healed a majority of refractory VLU, even in large ulcers of long duration, which are more difficult to heal. Smaller wound, size, and shorter wound duration were associated with greater likelihood of healing. VLUs treated earlier with allograft had better healing outcomes. Clinicians may consider more aggressive and timely treatment with allograft for refractory VLU.     

A prospective,randomised, controlled,multicentre clinical trial examining healing rates,safety and cost to closure of an acellular reticular allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers

Acellular dermal matrices can successfully heal wounds. This study's goal was to compare clinical outcomes of a novel, open‐structure human reticular acellular dermis matrix (HR‐ADM) to facilitate wound closure in non‐healing diabetic foot ulcers (DFUs) versus DFUs treated with standard of care (SOC). Following a 2‐week screening period in which DFUs were treated with offloading and moist wound care, patients were randomised to either SOC alone or HR‐ADM plus SOC applied weekly for up to 12 weeks. At 6 weeks, the primary outcome time, 65% of the HR‐ADM‐treated DFUs healed (13/20) compared with 5% (1/20) of DFUs that received SOC alone. At 12 weeks, the proportions of DFUs healed were 80% and 20%, respectively. Mean time to heal within 12 weeks was 40 days for the HR‐ADM group compared with 77 days for the SOC group. There was no incidence of increased adverse or serious adverse events between groups or any adverse events related to the graft. Mean and median graft costs to closure per healed wound in the HR‐ADM group were $1475 and $963, respectively. Weekly application of HR‐ADM is an effective intervention for promoting closure of non‐healing DFUs.     

A pilot multi‐centre prospective randomised controlled trial of RECELL for the treatment of venous leg ulcers

Venous leg ulcers (VLUs) have a significant impact on approximately 3% of the adult population worldwide, with a mean NHS wound care cost of £7600 per VLU over 12 months. The standard care for VLUs is compression therapy, with a significant number of ulcers failing to heal with this treatment, especially with wound size being a risk factor for non‐healing. This multicentre, prospective, randomised trial evaluated the safety and effectiveness of autologous skin cell suspension (ASCS) combined with compression therapy compared with standard compression alone (Control) for the treatment of VLUs. Incidence of complete wound closure at 14 weeks, donor site closure, pain, Health‐Related Quality of Life (HRQoL), satisfaction, and safety were assessed in 52 patients. At Week 14, VLUs treated with ASCS + compression had a statistically greater decrease in ulcer area compared with the Control (8.94 cm² versus 1.23 cm², P = .0143). This finding was largely driven by ulcers >10 to 80 cm² in size, as these ulcers had a higher mean percentage of reepithelialization at 14 weeks (ASCS + compression: 69.97% and Control: 11.07%, P = .0480). Additionally, subjects treated with ASCS + compression experienced a decrease in pain and an increase in HRQoL compared with the Control. This study indicates that application of ASCS + compression accelerates healing in large venous ulcers.     

Predictors of survival,healthcare resource utilization,and healthcare costs in veterans with non-metastatic castration-resistant prostate cancer

ObjectivesThe objective of this study was to evaluate the association of prostate-specific antigen doubling time (PSADT) with metastasis-free survival (MFS) and overall survival (OS), and to describe healthcare resource utilization (HRU) and costs among patients with non-metastatic castrate-resistant prostate cancer (nmCRPC) in the Veterans Health Administration setting.Methods and MaterialsPatients with nmCRPC were identified from the Veterans Health Administration electronic health record database (1/2007–8/2017). PSADT was categorized as <3 months, 3 to 9 months, 9 to 15 months, ≥15 months, and unknown. MFS and OS were assessed using multivariable Cox proportional hazards regression, including PSADT as a predictor. HRU and costs were described per-patient-per-year (PPPY).ResultsAmong 12,083 patients in the study, shorter PSADT was associated with shorter MFS and OS (PSADT <3 months vs. PSADT ≥15 months hazard ratio [HR] [95% confidence interval (CI)] = 0.307 [0.281, 0.335] and 0.371 [0.335, 0.410], respectively). Patients who developed metastasis had a 3-fold higher risk of death compared to those without metastasis (HR [95% CI] = 2.933 [2.763, 3.113]). Mean HRU increased following the onset of nmCRPC and metastatic castrate-resistant prostate cancer (mCRPC); mean inpatient stays more than doubled (0.2 vs. 0.5 and 0.6 vs. 2.8 PPPY, respectively). Similar increases in healthcare costs were observed; pharmacy costs more than tripled following nmCRPC ($2,074 vs. $6,839 PPPY). From nmCRPC to mCRPC, large increases were observed for inpatient costs ($7,257–$61,691), emergency room costs ($844–$1,958), and pharmacy costs ($4,115–$26,279) PPPY.ConclusionsIn Veterans with nmCRPC, shorter PSADT was significantly associated with shorter MFS and OS. Onset of nmCRPC and mCRPC was associated with substantial HRU and cost increases.     

愈创膏联合干细胞移植治疗重度压疮的临床研究

目的探讨愈创膏联合干细胞移植治疗对重度压疮创面愈合及神经生长因子表达的影响。方法选取健康外伤患者30例手术中废弃的正常皮肤及皮下软组织作为对照组,将60例重度压疮患者随机分为两组各30例。观察组应用愈创膏联合庆大霉素纱布常规换药,治疗组应用愈创膏联合脐血干细胞移植治疗。比较治疗组与观察组愈合时间,同时测定三组创面神经生长因子(NGF)含量。结果治疗组创面愈合时间显著短于观察组(P<0.01)。观察组与治疗组治疗前NGF含量显著低于对照组(均P<0.01)。治疗后观察组与治疗组局部NGF含量显著升高,后期治疗6 d达到高峰,10 d逐步趋于正常,治疗组治疗后期3 d、6 dNGF含量显著高于观察组(均P<0.01)。结论愈创膏联合干细胞治疗可加速重度压疮创面的愈合,提高创面组织神经生长因子表达。     

Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day

BACKGROUND: Earlier studies have reported that endovascular abdominal aortic aneurysm (EAAA) repair yields lower total profit margins than open AAA (OAAA) repair. This study compared EAAA versus OAAA based on contribution margin per day, which may better measure profitability of new clinical technologies. Contribution margin equals revenue less variable direct costs (VDCs). VDCs capture incremental resources tied directly to individual patients' activity (eg, invoice price of endograft device, nursing labor). Overhead costs factor into total margin, but not contribution margin. METHODS: The University of Michigan Health System's cost accounting system was used to extract fiscal year 2002-2003 information on revenue, total margin, contribution margin, and duration of stay for Medicare patients with principal diagnosis of AAA (ICD-9 code 441.4). RESULTS: OAAA had revenues of $37,137 per case versus $28,960 for EAAA, similar VDCs per case, and thus higher contribution margin per case ($24,404 for OAAA vs $13,911 for EAAA, P < .001). However, OAAA had significantly longer mean duration of stay per case (10.2 days vs 2.2 days, P < .001). Therefore, mean contribution margin per day was $2948 for OAAA, but $8569 for EAAA ( P < .001). CONCLUSIONS: On the basis of contribution margin per day, EAAA repair dominates OAAA repair. The shorter duration of stay with EAAA allows higher throughput, fuller overhead amortization, better use of scarce inpatient beds, and higher health system profits. Surgeons must understand overhead allocation to devices, especially when new technologies cut duration of stay markedly.     

Laparoscopic appendectomy in children: use of the endoloop vs the endostapler

HYPOTHESIS: Two techniques are used for laparoscopic appendectomy (LA): division of the mesoappendix with the harmonic scalpel and ligation of the appendix with an endoloop (EL), or division of the mesoappendix and appendix with an endostapler (ES). Using an ES is a cost-effective technique that provides an outcome benefit in children who require appendectomy. DESIGN: Case series. SETTING: Academic, tertiary care children's hospital. PATIENTS: Seventy-five children who underwent LA from January 1, 2002, to March 31, 2004. INTERVENTION: Laparoscopic appendectomy. MAIN OUTCOME MEASURES: Age, diagnosis, length of stay, surgical time, total operating room time, complications, and instrumentation costs were compared between the EL and ES groups. RESULTS: There was no significant difference in age, length of stay, perforated, gangrenous, or acute appendicitis diagnoses, or complications between the groups. The surgical time and total operating room time for LA in children in the ES group were significantly shorter than in children in the EL group by 15% and 17%, respectively (P<.05). The disposable equipment costs for LA were $201 per case in the ES group vs $400 per case in the EL group. The mean 14.9-minute increase in total operating room time in children in the EL group resulted in $373 of additional operating room and anesthesia costs. The decreased disposable equipment costs and shorter surgical time of LA in the ES group led to cost savings of $572 per case as compared with children who underwent LA with an EL. CONCLUSIONS: There is no significant difference in outcome between children who undergo LA with an EL or with an ES. However, this study supports the use of the ES for LA as a more cost-effective technique that is associated with reduced surgical time.     

Validation of venous leg ulcer guidelines in the United States and United Kingdom

BACKGROUND: Venous leg ulcers account for 85% of all lower-extremity ulcers, with treatment costs of 3 billion dollars and loss of 2 million workdays per year. The purpose of this study was to validate the clinical efficacy and cost effectiveness of multidisciplinary guidelines for the diagnosis and treatment of venous leg ulcers. METHODS: Eighty (40 retrospective, 40 prospective) patients from the United States and United Kingdom were enrolled. RESULTS: United States patients were 6.5 times and United Kingdom 2 times more likely to heal if a guideline was followed (P <0.001). A significant decrease was noted in healing time for both the United States and United Kingdom (P <0.01), and the median cost decreased significantly when the guideline was followed (P <0.01). CONCLUSIONS: Implementation of a guideline for diagnosis and treatment of venous leg ulcers resulted in improvement in diagnosis, decrease in healing time, and an increase in healing rates resulting in lower costs.     

Breast conservation therapy confers survival and distant recurrence advantage over mastectomy for stage II Triple Negative Breast cancer

IntroductionRecent studies suggest survival benefit of breast conservation over mastectomy. We evaluated distant recurrence (DR) rates after breast-conservation therapy (BCT) versus mastectomy in our community-based cancer institute.MethodsA retrospective review of patients undergoing treatment of Stage 0–3 breast cancer from January, 2002 to December, 2011 was performed. We evaluated outcomes between those having BCT versus mastectomy.ResultsWe reviewed 4876 patients. There was no significant difference in DR between patients undergoing BCT versus mastectomy in DCIS (n = 904; BCS 521, mastectomy 383; DR = 1/521 vs 1/383; p = 0.09), Stage I (n = 2202; BCT 1505, mastectomy 697; DR = 6/1505 vs 17/697; p = 0.98) or Stage III cancer (n = 417; BCT 87, mastectomy 330; DR = 17/87 vs 59/330; p = 0.50). There was significantly less DR in Stage II patients (n = 1353) undergoing BCT vs mastectomy (32/645 vs 64/708; p = 0.003). Subgroup analysis of Stage II TNBC (n = 198) subgroup analysis showed 104 mastectomy and 94 BCT patients. Those in the BCT group had significantly lower rates of DR (6/94 vs 16/104; p= 0.03) and significantly higher survival (81/94 vs 69/104; p = 0.007) than those undergoing mastectomy. Of Stage II TNBC patients with DR there was no difference in age, lymph node status or tumor size (p > 0.05 for all) in BCT versus mastectomy groups; there was a significant difference in radiation status (94/94 vs. 28/104; p < 0.0001). Radiation was associated with worse outcomes in the mastectomy group (HR 2.32; p = 0.04).ConclusionsWe found significantly less DR in Stage II patients undergoing BCT vs mastectomy. This benefit includes a survival advantage in patients with TNBC undergoing BCT. We could not identify an explanatory factor. Until the difference is understood eligible patients with TNBC should be encouraged to undergo BCT.     

A prospective,randomised comparative study of weekly versus biweekly application of dehydrated human amnion/chorion membrane allograft in the management of diabetic foot ulcers

The aim of this study is to determine if weekly application of dehydrated human amnion/chorion membrane allograft reduce time to heal more effectively than biweekly application for treatment of diabetic foot ulcers. This was an institutional review board‐approved, registered, prospective, randomised, comparative, non‐blinded, single‐centre clinical trial. Patients with non‐infected ulcers of ≥ 4 weeks duration were included for the study. They were randomised to receive weekly or biweekly application of allograft in addition to a non‐adherent, moist dressing with compressive wrapping. All wounds were offloaded. The primary study outcome was mean time to healing. Overall, during the 12‐week study period, 92·5% (37/40) ulcers completely healed. Mean time to complete healing was 4·1 ± 2·9 versus 2·4 ± 1·8 weeks (P = 0·039) in the biweekly versus weekly groups, respectively. Complete healing occurred in 50% versus 90% by 4 weeks in the biweekly and weekly groups, respectively (P = 0·014). Number of grafts applied to healed wounds was similar at 2·4 ± 1·5 and 2·3 ± 1·8 for biweekly versus weekly groups, respectively (P = 0·841). These results validate previous studies showing that the allograft is an effective treatment for diabetic ulcers and show that wounds treated with weekly application heal more rapidly than with biweekly application. More rapid healing may decrease clinical operational costs and prevent long‐term medical complications.     

Analgesia for labor pain: a cost model

BACKGROUND: Epidural analgesia and intravenous analgesia with opioids are two techniques for the relief of labor pain. The goal of this study was to develop a cost-identification model to quantify the costs (from society's perspective) of epidural analgesia compared with intravenous analgesia for labor pain. Because there is no valid method to assign a dollar value to differing levels of analgesia, the cost of each technique can be compared with the analgesic benefit (patient pain scores) of each technique. METHODS: The authors created a cost model for epidural and intravenous analgesia by reviewing the literature to determine the rates of associated clinical outcomes (benefit of each technique to produce analgesia) and complications (e.g., postdural puncture headache). The authors then analyzed data from their institution's cost-accounting system to determine the hospital cost for parturients admitted for delivery, estimated the cost of each complication, and performed a sensitivity analysis to evaluate the cost impact of changing key variables. A secondary analysis was performed assuming that the cost of nursing was fixed (did not change depending on the number of nursing interventions). RESULTS: If the cesarean section rate equals 20% for both intravenous and epidural analgesia, the additional expected cost per patient to society of epidural analgesia of labor pain ranges from $259 (assuming nursing costs in the labor and delivery suite do not vary with the number of nursing interventions) to $338 (assuming nursing costs do increase as the number of interventions increases) relative to the expected cost of intravenous analgesia for labor pain. This cost difference results from increased professional costs and complication costs associated with epidural analgesia. CONCLUSIONS: Epidural analgesia is more costly than intravenous analgesia. How the cost of the anesthesiologist and nursing care is calculated affects how much more costly epidural analgesia is relative to intravenous analgesia. Published studies have determined that epidural analgesia provides relief of labor pain superior to intravenous analgesia, quantified in one study as 40 mm better on a 100-mm scale during the first stage of labor and 29 mm better during the second stage of labor. Patients, physicians, and society need to weigh the value of improved pain relief from epidural analgesia versus the increased cost of epidural analgesia.     

Alternative delivery system for controlled drugs in the surgical intensive care unit

Faced with a serious shortage of qualified nurses for critically ill patients, methods to reduce the time required to deliver care without sacrificing quality are needed. A non-electronic device designed as a patient-controlled analgesic (PCA) was evaluated as a nurse-controlled device (NCA). Twenty-five intubated patients received morphine sulfate (MS) with the nurse-controlled device (NCA) and 12 by standard IV push policy. The average nursing time for narcotic dosing with the standard policy was 5 minutes/unit dose. A total of 1,183 NCA doses were given over 77 patient days. The average doses per patient day were 15 (2-38). The average nursing time was 22 seconds/NCA dose. The NCA saved 85 nursing minutes/patient day. Annual nursing labor costs were reduced by $77,000.00 with NCA. Total costs for standard IV push narcotic use were $36.43/patient day versus $35.45/patient day for NCA. Using this protocol, the NCA system saved $8,500.00 annually. By increasing the duration of PCA use to 72 hours, the annual savings would become $49,500.00. These data indicate that a simple NCA can deliver controlled drugs rapidly and safely, save valuable nursing time, and decrease the cost of ICU care.