The cost-effectiveness of repairing ruptured abdominal aortic aneurysms

BACKGROUND: Although advances in technology have reduced the operative risk of elective abdominal aortic aneurysm (AAA) repair, the surgical repair of ruptured AAAs is associated with a much poorer prognosis and a higher cost. Accordingly, it has been suggested that patients with predictably high rates of morbidity and mortality from ruptured AAA may not benefit from surgical intervention.Methods and Results: A cost-effectiveness analysis was performed with the use of a Markov decision-analytic model to compute long-term survival in quality-adjusted life years and lifetime costs for a hypothetical cohort of patients with ruptured AAAs managed with either a strategy of open surgical repair or no intervention. Probability estimates for the various outcomes were based on a review of the literature. Average costs of (1) the immediate hospitalization ($28,356) and (2) complications resulting from the procedure were based on the average use of resources as reported in the literature and from a hospital's cost accounting system. Our measure of outcome was the incremental cost-effectiveness ratio. For our base-case analysis, the repair of ruptured AAAs was cost-effective with an incremental cost-effectiveness ratio of $10,754. (Society is usually willing to pay for interventions with cost-effectiveness ratios of less than $60,000; for example, the costeffectiveness ratios for coronary artery bypass grafting and dialysis are $9500 and $54,400, respectively.) In sensitivity analyses, the cost-effectiveness of repairing ruptured AAAs was influenced only by alterations in the operative mortality. If the operative mortality exceeded 88%, repair of ruptured AAAs was no longer cost-effective. As an independent variable, increasing age had no substantial impact on the cost-effectiveness, although it is reported to be associated with increased operative mortality. It was necessary that the patient's cost of the initial hospitalization for ruptured AAA exceed $195,000 before repairing ruptured AAAs was no longer cost-effective. CONCLUSIONS: Our analysis suggests that despite the high cost and poor outcomes, the surgical repair of ruptured AAAs is still cost-effective when compared with no intervention. The cost of repairing ruptured AAAs falls within society's acceptable limits and therefore should not be a consideration in the management of patients with AAAs.     

Cost of endovascular versus open surgical repair of abdominal aortic aneurysms

BACKGROUND: Endovascular repair of abdominal aortic aneurysms (AAA) is a new minimally invasive method of aneurysm exclusion that has been adopted with increasing enthusiasm, and with acceptable clinical results. It is important, however, to assess new health-care technologies in terms of their economic as well as their clinical impact. The aim of the present study was to compare the total treatment costs for endovascular (EVR) and open surgical repair (OSR) for AAA. METHODS: A retrospective review of patient hospital and outpatient records for 62 patients undergoing either EVR (n = 31) or OSR (n = 31) was carried out between June 1996 and October 1999. Resource utilization was determined by a combination of patient clinical and financial accounting data. Costs were determined for preoperative assessment, inpatient hospital stay, cost of readmissions and follow up, and predicted lifetime follow-up costs. RESULTS: The two groups were well matched, with no significant difference with respect to age, gender, maximum aneurysm diameter or comorbid factors. Endovascular treatment resulted in a shorter intensive care unit (ICU) and hospital stay (mean: 0.07 vs 2.9 days, P < 0.001; mean: 6.0 vs 13.4 days, P < 0.001; respectively) and fewer postoperative complications (P = 0.003). The cost of hospitalization was less for EVR ($7614 vs $15092, P < 0.001), but this was offset by the more costly vascular prosthesis ($10284 vs $686). Costs were higher for the EVR group for preoperative assessment ($2328 vs $1540, P < 0.001) and follow up ($1284 vs $70, P < 0.001). Lifelong follow up could be expected to cost an additional $4120 per patient after EVR. Total lifetime treatment costs including costs associated with readmission for procedure-related complications were higher for EVR ($26909 vs $17650). CONCLUSION: Treatment costs for endovascular repair are higher than conventional surgical repair due to the cost of the vascular prosthesis and the greater requirement for radiological imaging studies.     

The cost-effectiveness of early surgery versus watchful waiting in the management of small abdominal aortic aneurysms

Purpose: The purpose of this study was to compare the relative cost-effectiveness of two clinical strategies for managing 4 to 5 cm diameter abdominal aortic aneurysms (AAAs): early surgery (repair 4 cm AAA when diagnosed) versus watchful waiting (monitor AAA with ultrasound size measurements every 6 months and repair if the diameter reaches 5 cm).Methods: We used a Markov decision tree to compute the expected survival in quality-adjusted life years (QALYs) for each strategy, based on literature-derived estimates for the probabilities of different outcomes in this model. We determined hospital costs for patients undergoing elective and emergency AAA repair at our center. With standard methods of cost accounting, we then calculated the additional cost per year of life saved by early surgery compared with watchful waiting (cost-effectiveness ratio, dollars/QALY).Results: Mean hospital costs for elective and emergency AAA repair were $24,020 and $43,208, respectively (1992 dollars). For our base-case analysis (60-year-old men with 4 cm diameter AAAs, with 5% elective operative mortality rate and 3.3% annual rupture rate), early surgery improved survival by 0.34 QALYs compared with watchful waiting, at an incremental cost of $17,404/QALY. Increased elective surgical mortality rate, decreased AAA rupture risk, and increased patient age all reduced the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery.Conclusions: The cost effectiveness of early surgery for 4 cm diameter AAAs in carefully selected patients compares favorably with that of other commonly accepted preventive interventions such as hypertension screening and treatment. With an upper limit of $40,000/QALY as an "acceptable" cost-effectiveness ratio, early surgery appears to be justified for patients 70 years old or younger, if the AAA rupture risk is 3%/year or more and the elective operative mortality rate is 5% or less. Although not a substitute for clinical judgment, this cost-effectiveness analysis delineates the essential tradeoffs and uncertainties in treating patients with small AAAs. (J VASC SURG 1994;19:980–91.)     

Cost-effectiveness of surgery for small abdominal aortic aneurysms on the basis of data from the United Kingdom small aneurysm trial

PURPOSE: Although the United Kingdom small aneurysm trial reported no survival benefit for early operation in patients with small (4. 0-5.5 cm) abdominal aortic aneurysms (AAAs), the trial lacked statistical power to detect small but potentially meaningful gains in life expectancy, particularly for specific subgroups. We used decision analysis to better characterize the potential benefits and cost-effectiveness of early surgery. METHODS: We used a Markov model to assess the marginal cost-effectiveness (incremental cost per quality-adjusted life year [QALY] saved) of early surgery relative to surveillance for small AAAs, using data from the UK Trial. Subgroup analyses were performed by patient age and AAA diameter. Sensitivity analysis was used to evaluate the effect of elective operative mortality on cost-effectiveness. RESULTS: In our baseline analysis, early operations provided a small survival advantage (0.14 QALYs) at a small incremental cost of $1510. Thus, despite a small survival benefit, early surgery appeared cost-effective ($10, 800/QALY). The small cost differential resulted from the large proportion of patients who underwent surveillance, who eventually underwent AAA repair, and therefore incurred the cost of the surgical procedures. The survival advantage and cost-effectiveness of early operation increased with lower operative mortality, younger age, and larger AAA diameter. CONCLUSION: Despite the negative conclusions of the UK trial, early surgery may be cost-effective for patients with small AAAs, particularly younger patients (<72 years of age) with larger AAAs (> or = 4.5 cm). Because the gains in life expectancy are relatively small, however, clinical decision making should be strongly guided by patient preferences.     

Mortality,Morbidity, and Costs of Ruptured and Elective Abdominal Aortic Aneurysm Repairs in Nova Scotia,Canada

Ruptured abdominal aortic aneurysms (RAAA) have a 78-94% mortality rate. If cost-effectiveness of screening programs for abdominal aortic aneurysms (AAA) are to be assessed, direct costs for RAAA repairs and elective AAA (EAAA) repairs are required. This study reports mortality, morbidity, and direct costs for RAAA and EAAA repairs in Nova Scotia in 1997-1998 and also compares Nova Scotia and U.S. costs. We performed a retrospective study of 41 consecutive RAAA and 48 randomly selected EAAA patients. Average total costs for RAAA repair were significantly greater than those for EAAA repair (direct costs: $15,854 vs. $9673; direct plus overhead costs: $18,899 vs. $12,324 [pricing in 1998 Canadian dollars]). Intensive care unit length of stay and blood product usage were the most substantial direct cost differentials ($3593 and $2106). Direct cost for preoperative testing and surveillance was greater in the EAAA group ($839 vs. $33). Estimates of U.S. in-hospital RAAA and EAAA repair costs are more than 1.5 times Nova Scotia costs. Direct in-hospital RAAA repair costs are $6181 more than EAAA repair costs. These in-hospital cost data are key cost elements required to assess the cost-effectiveness of various screening strategies for earlier detection and monitoring of AAA within high-risk populations in Canada. Further studies are required to estimate cost per quality-adjusted-life-year gained for various AAA screening and monitoring strategies in Canada.     

Benign superior vena cava syndrome: stenting is now the first line of treatment

BACKGROUND: Endovascular repair (EVR) is emerging as first-line treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remain scarce. The aims of this study were to assess the efficacy and durability of EVR and compare results of EVR with open surgical reconstruction (OSR). METHODS: Data from 70 consecutive patients undergoing treatment for benign SVC syndrome between November 1983 and November 2006 were retrospectively reviewed. RESULTS: There were 30 males and 40 females (mean age, 41 years; range, 5-75 years). Etiology included indwelling catheters or pacemaker wires in 35 patients, mediastinal fibrosis in 31, idiopathic thrombosis in 2, hypercoagulable disorder in 1, and postsurgical thrombosis in 1. In 42 patients, OSR was done through a median sternotomy: repair was with spiral saphenous vein in 22, expanded polytetrafluoroethylene (ePTFE) in 13, femoral vein grafts in 6, and human allograft in 1. Fifteen OSRs followed failed EVR interventions. EVR was attempted in 32 patients and was successful in 28 (88%): 19 had stenting, 14 had percutaneous transluminal balloon angioplasty (PTA), 2 had thrombolytic therapy with PTA, and 3 had stenting. All four technical failures subsequently underwent OSR. There were no early deaths in either group. Periprocedural morbidity was 19% after OSR and 4% in the EVR group. Six early surgical graft failures were successfully treated with surgical revision; one restenosis after EVR was restented. During a mean follow-up of 4.1 years (range, 0.1-17.5 years) after OSR, 11 patients underwent 18 secondary interventions. Mean follow-up after EVR was 2.2 years (range, 0.2-6.4 years), and nine patients underwent 21 secondary EVR interventions. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were, respectively, 45%, 68%, and 75% at 3 and 5 years. Primary, assisted primary and secondary patency rates after EVR were 44%, 96%, and 96% at 3 years. Assisted primary patency was significantly higher in vein grafts than in ePTFE grafts (P = .05). Assisted primary and secondary patency was significantly higher in patients undergoing stenting compared with PTA (P = .02). At last follow-up, 93% of patients in both OSR and EVR groups had significant relief from symptoms. CONCLUSIONS: OSR of benign SVC syndrome is effective, with durable long-term relief from symptoms. EVR is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions, and is an appropriate primary treatment for benign SVC syndrome. OSR remains an excellent choice for patients who are not suitable for EVR or in whom the EVR fails.     

Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis

BACKGROUND: Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. STUDY DESIGN: We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. RESULTS: At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. CONCLUSION: At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.     

Rotator cuff repair: an analysis of utility scores and cost-effectiveness

More than 75,000 rotator cuff repairs are performed annually, yet cost-effectiveness data are unavailable. This study examines the cost utility of rotator cuff repair by relating surgical costs to increase in quality-adjusted life-years (QALYs). Eighty-seven patients were followed up prospectively for 1 year, during which cost and quality of life data were collected. Patient-based utility measures of quality of life (European Quality-of-Life measure [EuroQoL] and Health Utility Index [HUI]) were administered. Changes in these measures generated net QALYs. Finally, life expectancies were applied to generate a cost-effectiveness ratio, and subsequent 1-way sensitivity analyses varied costs, QALYs, and discount rates to determine which factors drive cost-effectiveness. Total costs averaged $10,605.20. Significant improvements were noted in health-related quality of life postoperatively. The estimated mean lifetime gain in QALYs from surgery was 0.81 by use of the HUI and 3.43 by use of the EuroQoL. This yielded cost-effectiveness ratios of $13,092.84/QALY by use of the HUI and $3,091.90/QALY by use of the EuroQoL. The cost-effectiveness of rotator cuff repair compares favorably with other common interventions in health care and reaches commonly accepted benchmarks for cost-effectiveness.     

Is carotid angioplasty and stenting more cost effective than carotid endarterectomy?

OBJECTIVE: Carotid angioplasty and stenting (CAS) has been advocated as a minimally invasive and inexpensive alternative to carotid endarterectomy (CEA). However, a precise comparative analysis of the immediate and long-term costs associated with these two procedures has not been performed. To accomplish this, a Markov decision analysis model was created to evaluate the relative cost effectiveness of these two interventions. METHODS: Procedural morbidity/mortality rate for CEA and costs (not charges) were derived from a retrospective review of consecutive patients treated at New York Presbyterian Hospital/Cornell (n = 447). Data for CAS were obtained from the literature. We incorporated into this model both the immediate procedural costs and the long-term cost of morbidities, such as stroke (major stroke in the first year = $52,019; in subsequent years = $27,336/y; minor stroke = $9419). We determined long-term survival rate in quality-adjusted life years and lifetime costs for a hypothetic cohort of 70-year-old patients undergoing either CEA or CAS. Our measure of outcome was the cost-effectiveness ratio. RESULTS: The immediate procedural costs of CEA and CAS were $7871 and $10,133 respectively. We assumed major plus minor stroke rates for CEA and CAS of 0.9% and 5%, respectively. We assumed a 30-day mortality rate of 0% for CEA and 1.2% for CAS. In our base case analysis, CEA was cost saving (lifetime savings = $7017/patient; increase in quality-adjusted life years saved = 0.16). Sensitivity analysis revealed major stroke and death rates as the major contributors to this differential in cost effectiveness. Procedural costs were less important, and minor stroke rates were least important. CAS became cost effective only if its major stroke and mortality rates were made equivalent to those of CEA. CONCLUSION: CEA is cost saving compared with CAS. This is related to the higher rate of stroke with CAS and the high cost of stents and protection devices. To be economically competitive, the mortality and major stroke rates of CAS must be at least equivalent if not less than those of CEA.     

Hospital resource use and costs among abdominal aortic aneurysm repair patients admitted to the intensive care unit

BackgroundAbdominal aortic aneurysm (AAA) repair is associated with significant morbidity and mortality. As a result, many of these patients are monitored postoperatively in the intensive care unit (ICU). However, little is known about resource utilization and costs associated with ICU admission in this population. We sought to evaluate predictors of total costs among patients admitted to the ICU after repair of nonruptured or ruptured AAA.MethodsWe retrospectively analyzed prospectively collected data (2011-2016) of ICU patients admitted after AAA repair. The primary outcome was total hospital costs. We used elastic net regression to identify pre-ICU admission predictors of hospitalization costs separately for nonruptured and ruptured AAA patients.ResultsWe included 552 patients in the analysis. Of these, 440 (79.7%) were admitted after repair of nonruptured AAA, and 112 (20.3%) were admitted after repair of ruptured AAA. The mean age of patients with nonruptured AAA was 74 (standard deviation, 9) years, and the mean age of patients with ruptured AAA was 70 (standard deviation, 8) years. Median total hospital cost (in Canadian dollars) was $21,555 (interquartile range, $17,798-$27,294) for patients with nonruptured AAA and $33,709 (interquartile range, $23,173-$53,913) for patients with ruptured AAA. Among both nonruptured and ruptured AAA patients, increasing age, illness severity, use of endovascular repair, history of chronic obstructive pulmonary disease, and excessive blood loss (≥4000 mL) were associated with increased costs, whereas having an anesthesiologist with vascular subspecialty training was associated with lower costs.ConclusionsPatient-, procedure-, and clinician-specific variables are associated with costs in patients admitted to the ICU after repair of AAA. These factors may be considered future targets in initiatives to improve cost-effectiveness in this population.     

Comparison of minimal incision aortic surgery with endovascular aortic repair

BACKGROUND: Enthusiasm for endovascular aortic repair (EVAR) has been tempered by midterm outcomes that raise valid concern about long-term durability. METHODS: This article compares outcome data from a prospective nonrandomized comparison of a less-invasive open surgical repair technique-minimal incision aortic surgery (MIAS)-and EVAR. RESULTS: MIAS and EVAR had comparable intensive care unit stays (1 day or less), quick return to general dietary feeding (2 days), and comparable hospital length of stay (4.8 days [3.4 days for uncomplicated cases MIAS] and 2.0 days for EVAR). Overall morbidity and mortality for MIAS and EVAR were comparable (18% versus 27%). MIAS was more cost effective than EVAR (net revenue MIAS = +8,445 US dollars, EVAR -7,263 US dollars). CONCLUSIONS: MIAS is a safe, cost-effective alternative to endovascular aortic repair.     

Laparoscopic totally extraperitoneal versus open preperitoneal mesh repair for inguinal hernia recurrence: a decision analysis based on net health benefits

Background

The aim of this study is to evaluate the most cost-effective treatment strategy using preperitoneal mesh for patients with recurrent inguinal hernia. Currently, the issue of cost-effectiveness is entirely unresolved.

Methods

A decision analysis was carried out based on the results of a systematic literature review of articles concerning recurrent inguinal hernia repair that were published between 1979 and 2011. A virtual cohort was programmed to undergo three different treatment procedures: (1) laparoscopic totally extraperitoneal hernia repair (TEP), (2) open preperitoneal mesh repair according to Stoppa, and (3) open preperitoneal mesh repair according to Nyhus. We carried out a base-case analysis and varied all variables over a broad range of reasonable hypotheses in multiple one-way and two-way sensitivity analyses.

Results

The average cost-effectiveness ratio of Nyhus, Stoppa, and TEP per quality-adjusted life year was US $ ($)1,942, $1,948, and $2,011, respectively. In terms of the incremental cost-effectiveness ratio (ICER), Stoppa was dominated. The choice between TEP or Nyhus procedure depends on the combination of a specific center’s rates of recurrence and morbidity as disclosed by three-way sensitivity analysis.

Conclusions

Nyhus and TEP repairs are possible optimal choices depending primarily on the institution’s rates of recurrence and morbidity. Based on our net benefit-related decision analysis, a hypothetical “fixed budget trade-off” suggests potential annual incremental health system cost savings of $200,000 attained by shifting care for 1,000 patients from TEP to Nyhus repair (depending on clinical end-points, which is a decisive factor).     

A cost-effectiveness analysis of standard versus endovascular abdominal aortic aneurysm repair.

OBJECTIVE: To compare endovascular and standard open repair of abdominal aortic aneurysms in terms of initial in-hospital costs and the costs of secondary interventions and surveillance. DESIGN: A retrospective study. SETTING: A university-affiliated tertiary care medical centre. PATIENTS: Seven patients who underwent elective endovascular (EV) repair of an abdominal aortic aneurysm in 1998 and 31 patients anatomically suitable for endovascular repair who underwent standard (STAN) elective repair. Follow-up ranged from 2 to 14 months. INTERVENTIONS: Elective repair of an abdominal aortic aneurysm with use of the standard technique or endovascular technology. OUTCOME MEASURES: Costs common to both groups were not determined. Costs were determined for total hospital stay, preoperative or postoperative embolization, grafts, additional endovascular equipment, and follow-up computed tomography. RESULTS: Groups were similar with respect to demographic data and aneurysm size (EV = 6.23 cm v. STAN = 6.05 cm). All patients were in American Society of Anesthesiologists class III or IV. Vanguar bifurcated grafts and extensions were used in the EV group. The total cost for both groups in Canadian dollars included: cost of stay (EV, 5.6 d, $2092.63 v. STAN, 10.7 d, $4449.19; p = 0.009); cost of embolization (EV, n = 3; $900/procedure); cost of follow-up CT (EV, 5.4 per patient; $450/CT); cost of grafts (EV = $8571.43, STAN = $374); additional radiologic equipment costs (EV = $1475). The mean total cost differed significantly between the 2 groups (EV = $14,967.63 v. STAN = $4823.19; p = 0.004). The additional cost associated with a reduction in hospital stay was calculated by determining the incremental cost-effectiveness ratio (ICER, difference in mean costs/difference in mean length of stay = $1604.51). CONCLUSIONS: Endovascular repair continues to be more expensive than standard open repair determined according to procedural and follow-up costs. The technology is still in the developmental stage, but as it evolves and follow-up protocols are streamlined, it is hoped that there will be an eventual reduction in the costs associated with the endovascular procedure.     

A cost analysis of surgery for ruptured abdominal aortic aneurysm.

OBJECTIVE: This study compares our costs of salvaging patients with ruptured abdominal aortic aneurysms (AAA) with the costs for unruptured AAAs. METHODS: Details of all AAAs presenting over 18 months were obtained. Costs of repair were carefully calculated for each case and were based upon ITU and ward stay and the use of theatre, radiology and pathology services. We compared the costs in unruptured AAAs with both uncomplicated ruptures and ruptures with one or more system failure. RESULTS: The mortality rate for ruptures undergoing repair was 18% and for elective repairs was 1.6%. The median cost for uncomplicated ruptures was 6427 Pounds (range 2012-13,756 Pounds). For 12 complicated ruptures, it was 20,075 Pounds (range 13,864-166,446 Pounds), and for 63 unruptured AAAs, was 4762 Pounds (range 2925-47,499 Pounds). CONCLUSION: Relatively low operative mortality rates for ruptured AAA repair can be achieved but this comes at substantial cost. On average, a ruptured AAA requiring system support costs four times as much as an elective repair.     

Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden

The aim of this study was to determine the threshold of fracture probability at which interventions became cost-effective in men and women, based on data from Sweden. We modeled the effects of a treatment costing $500 per year given for 5 years that decreased the risk of all osteoporotic fractures by 35% followed by a waning of effect for a further 5 years. Sensitivity analyses included a range of effectiveness (10-50%) and a range of intervention costs ($200–500/year). Data on costs and risks were from Sweden. Costs included direct costs, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of approximately $45,000/QALY gained was used. Cost of added years was included in a sensitivity analysis. With the base case ($500 per year; 35% efficacy) treatment in women was cost-effective with a 10-year hip fracture probability that ranged from 1.2% at the age of 50 years to 7.4% at the age of 80 years. Similar results were observed in men except that the threshold for cost-effectiveness was higher at younger ages than in women (2.0 vs 1.2%, respectively, at the age of 50 years). Intervention thresholds were sensitive to the assumed effectiveness and intervention cost. The exclusion of osteoporotic fractures other than hip fracture significantly increased the cost-effectiveness ratio because of the substantial morbidity from such other fractures, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be targeted cost-effectively to individuals at moderately increased fracture risk.     

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older

Background

This study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old.

Visceral ischemia and organ dysfunction after thoracoabdominal aortic aneurysm repair. A clinical and cost analysis.

OBJECTIVE: Repair of thoracoabdominal aortic aneurysms (TAAAs) is associated with significant postoperative morbidity and mortality. Reperfusion of acutely ischemic abdominal viscera in animals leads to release of multiple factors that cause local and distant organ damage, and similar phenomena occurring in humans after TAAA repair could contribute to the high morbidity/mortality and cost associated with this procedure. METHODS: Twenty-nine patients undergoing elective TAAA repair were studied prospectively. Preoperative organ dysfunction and intraoperative risk factors (cross-clamp time, blood loss, operative time) were assessed and compared with postoperative organ dysfunction (defined as: pulmonary, positive pressure ventilation for > 7 days; renal, increase in serum creatinine > 2.0 mg/dL over baseline; hepatic, lactate dehydrogenase > 500 international units and total bilirubin > 3.0 mg/dL or serum transaminase level > 200 international units; hematopoietic, platelet count > 50 K or leukocyte count > 4.5 K, mortality, and costs. RESULTS: No relationship between preoperative organ dysfunction, blood loss, or operative time and postoperative organ dysfunction or mortality was seen; however, cross-clamp times > 40 minutes were associated with a significantly greater incidence of pulmonary (59%), renal (47%), hepatic (35%), and hematopoietic (47%) dysfunction. In addition, multiple-organ dysfunction (> 2 organ systems) was more common after > 40 minutes of visceral ischemia and led to significantly greater overall hospital ($88,465 + $76,155 vs. $41,782 + $31,244) and intensive care unit ($26,726 + $28,256 vs. $11,234 + $12,146) costs (p < 0.01, Mann-Whitney U test). Mortality associated with leukopenia was 67% compared with 4% without leukopenia (p < 0.01). CONCLUSION: Increasing durations of acute visceral ischemia led to significant multiple organ dysfunction after TAAA repair. Methods of limiting visceral ischemia or the systemic effects of visceral ischemia may decrease both the morbidity and mortality and the overall hospital cost associated with this procedure.     

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

Background

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15–20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs.

Methods

Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included.

Results

All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6–54.2). Mean survival time was 51.4 months (95% CI: 48.6–54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025–1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225–4.553; P = .010) were substantially associated with in-hospital complications.

Conclusions

Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

     

Economic comparison of methods of wound closure: wound closure strips vs. sutures and wound adhesives

Our objective was to review and assess the treatment of low-tension wounds and evaluate the cost-effectiveness of wound closure methods. We used a health economic model to estimate cost/closure of adhesive wound closure strips, tissue adhesives and sutures. The model incorporated cost-driving variables: application time, costs and the likelihood and costs of dehiscence and infection. The model was populated with variable estimates derived from the literature. Cost estimates and cosmetic results were compared. Parameter values were estimated using national healthcare and labour statistics. Sensitivity analyses were used to verify the results. Our analysis suggests that adhesive wound closure strips had the lowest average cost per laceration ($7.54), the lowest cost per infected laceration ($53.40) and the lowest cost per laceration with dehiscence ($25.40). The costs for sutures were $24.11, $69.91 and $41.91, respectively; the costs for tissue adhesives were $28.77, $74.68 and $46.68, respectively. The cosmetic outcome for all three treatments was equivalent. We conclude adhesive wound closure strips were both a cost-saving and a cost-effective alternative to sutures and tissue adhesives in the closure of low-tension lacerations.     

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??Role and status of open surgery in the development of vascular surgery XIN Shi-jie, LIN Ruo-ran. Department of Vascular Surgery,the First Hospital of China Medical University??Shenyang 110001??China
Corresponding author: XIN Shi-jie??E-mail??xinshijie1963@aliyun.com
Abstract The morbidity of vascular disease is increasing daily?? while endovascular repair??EVR?? technique is becoming riper than before. It leads to most of the patients choose EVR instead of open surgical repair??OSR???? which can also obtain satisfactory therapeutic effects. In addition?? the phenomenon of the vascular surgeon neglect and forgot OSR should draw everyone’s attention. Overall?? OSR technique is essential grounding of each vascular surgeon.