The cost‐effectiveness of patient‐controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain,who are subsequently admitted to hospital

The clinical effectiveness of patient‐controlled analgesia has been demonstrated in a variety of settings. However, patient‐controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost‐effectiveness of patient‐controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non‐traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost‐effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient‐controlled analgesia rather than standard care (the incremental cost‐effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non‐traumatic abdominal pain. Overall costs were higher with patient‐controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non‐traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.     

Cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in high‐risk intensive care unit patients: An economic analysis of a randomised controlled trial

Pressure ulcer incidence is high in intensive care units. This causes a serious financial burden to healthcare systems. We evaluated the cost‐effectiveness of multi‐layered silicone foam dressings for prevention of sacral and heel pressure ulcers in addition to standard prevention in high‐risk intensive care units patients. A randomised controlled trial to assess the efficacy of multi‐layered silicone foam dressings to prevent the development of pressure ulcers on heels and sacrum among 422 intensive care unit patients was conducted. Direct costs for preventive dressings in the intervention group and costs for treatment of incident pressure ulcers in both groups were measured using a bottom‐up approach. A cost‐effectiveness analysis by calculating the incremental cost‐effectiveness ratio using different assumptions was performed. Additional dressing and labour costs of €150.81 (€116.45 heels; €34.36 sacrum) per patient occurred in the intervention group. Treatment costs were €569.49 in the control group and €134.88 in the intervention group. The incremental cost‐effectiveness ratio was €1945.30 per PU avoided (€8144.72 on heels; €701.54 sacrum) in the intervention group. We conclude that application of preventive dressings is cost‐effective for the sacral area, but only marginal on heels for critically ill patients.     

Long‐term quality of life and cost‐effectiveness of treatment of partial thickness burns: A randomized controlled trial comparing enzyme alginogel vs silver sulfadiazine (FLAM study)

The clinical effectiveness and scar quality of the randomized controlled trial comparing enzyme alginogel with silver sulfadiazine (SSD) for treatment of partial thickness burns were previously reported. Enzyme alginogel did not lead to faster wound healing (primary outcome) or less scar formation. In the current study, the health‐related quality of life (HRQoL), costs, and cost‐effectiveness of enzyme alginogel compared with SSD in the treatment of partial thickness burns were studied. HRQoL was evaluated using the Burn Specific Health Scale‐Brief (BSHS‐B) and the EQ‐5D‐5L questionnaire 1 week before discharge and at 3, 6, and 12 months postburn. Costs were studied from a societal perspective (health care and nonhealth‐care costs) for a follow‐up period of 1 year. A cost‐effectiveness analysis was performed using cost‐effectiveness acceptability curves and comparing differences in societal costs and Quality Adjusted Life Years (QALYs) at 1 year postburn. Forty‐one patients were analyzed in the enzyme alginogel group and 48 patients in the SSD group. None of the domains of BSHS‐B showed a statistically significant difference between the treatment groups. Also, no statistically significant difference in QALYs was found between enzyme alginogel and SSD (difference ?0.03; 95% confidence interval [CI], ?0.09 to 0.03; P = .30). From both the health care and the societal perspective, the difference in costs between enzyme alginogel and SSD was not statistically significant: the difference in health‐care costs was €3210 (95% CI, €‐1247 to €7667; P = .47) and in societal costs was €3377 (95% CI €‐6229 to €12 982; P = .49). The nonsignificant differences in costs and quality‐adjusted life‐years in favor of SSD resulted in a low probability (<25%) that enzyme alginogel is cost‐effective compared to SSD. In conclusion, there were no significant differences in quality of life between both treatment groups. Enzyme alginogel is unlikely to be cost‐effective compared with SSD in the treatment of partial thickness burns.     

Pre‐operative anaemia,intra‐operative hepcidin concentration and acute kidney injury after cardiac surgery: a retrospective observational study

Acute kidney after cardiac surgery is more common in anaemic patients, whereas haemolysis during cardiopulmonary bypass may lead to iron‐induced renal injury. Hepcidin promotes iron sequestration by macrophages: hepcidin concentration is reduced by anaemia and increased by inflammation. We analysed the associations in 525 patients between pre‐operative anaemia (haemoglobin < 130 g.l^?1 in men and < 120 g.l^?1 in women), intra‐operative hepcidin concentration and acute kidney injury (dialysis or > 26.4 μmol.l^?1 or > 50% creatinine increase during the first two days after cardiac surgery. Rates of pre‐operative anaemia and postoperative kidney injury were 109/525 (21%) and 36/525 (7%), respectively. The median (IQR [range]) intra‐operative hepcidin concentration was 20 (10–33 [0–125]) μg.l^?1 and was lower in anaemic patients than those who were not: 15 (4–28 [0–125]) μg.l^?1 vs. 21 (12–33 [0–125]) μg.l^?1, respectively, p = 0.002. Four variables were independently associated with postoperative kidney injury, for which the beta‐coefficients (SE) were: minutes on cardiopulmonary bypass, 0.016 (0.004), p < 0.001; intra‐operative hepcidin concentration, 0.032 (0.008), p < 0.001; pre‐operative anaemia, 1.97 (0.56), p < 0.001; and Cleveland clinic risk score, 0.88 (0.35), p = 0.005. Contrary to generally increased rates of kidney injury in patients with higher hepcidin concentrations, rates of kidney injury in anaemic patients were lower in patients with higher hepcidin concentrations, beta‐coefficient (SE) ?0.037 (0.01), p = 0.007. In cardiac surgical patients the rate of postoperative acute kidney injury predicted by the Cleveland risk score might be adjusted for pre‐operative anaemia and intra‐operative cardiopulmonary bypass time and hepcidin concentration. Pre‐operative correction of anaemia, reduction in intra‐operative bypass time and modification of iron homeostasis and hepcidin concentration might reduce acute kidney injury.     

Real‐world data on healthcare resource consumption and costs before and after kidney transplantation

End‐stage renal disease (ESRD) is increasing worldwide as a consequence of population aging and increasing chronic illness. Treatment consists mostly of dialysis and kidney transplantation (KTx), and KTx offers advantages for life expectancy and long‐term cost reductions compared with dialysis. This study uses the administrative database of the Lombardy Region to analyze the costs of a cohort of patients with ESRD receiving KTx, covering a time period of 24 months before transplant to 12 months after. During 2011, 276 patients underwent kidney transplantation (8.7% preemptive and 91.3% non‐preemptive). In the period before transplantation, the main cost driver was dialysis (66.6% for the period from ?24 to ?12 months and 73.8% for the period from ?12 to 0 months), while in the 12 months after KTx, the most relevant cost was surgery. The total cost ?24 to ?12 months pre‐KTx was 35 049.2€; the cost ?12 to 0 months was 36 745.9€; and the cost 12 months after KTx was 43 805.8€. Non‐preemptive patients showed much higher costs both pre‐ and post‐KTx than preemptive patients. This study highlights how KTx modifies the resource consumption and costs composition of patients with ESRD vs those undergoing dialysis treatment and how KTx may be economically beneficial, especially preemptive intervention.     

Cost‐effectiveness analysis of antiviral treatment in liver transplant recipients with HCV infection

Within 5–10 years, 20–40% of hepatitis C virus (HCV)‐infected liver transplant recipients can be expected to develop cirrhosis. Here, cost‐effectiveness of antiviral therapy was assessed. A Markov model was developed to simulate disease progression and calculate outcome and costs of treatment. In the baseline analysis, Peg‐IFN/RBV treatment prevented organ loss/death, gained quality‐adjusted life‐years (QALYs) and undercut the limit of cost‐effectiveness of €50 000/QALY with an incremental cost‐effectiveness ratio of approximately €40 400/QALY and €21 000/QALY for HCV genotype 1 and 2/3 patients, respectively. Furthermore, sensitivity analysis testing modified model parameters according to extreme data described in the literature confirmed cost‐effectiveness for a lower or higher rate of fibrosis progression, increased non‐HCV‐related mortality, lower limits of utilities, a time horizon of 30 years, and additional costs in the year of death. On the other hand, cost‐effectiveness was lost for patients with genotype 1 in case of doubled antiviral or life‐time costs or an increased discount rate of 7%. New treatment strategies for HCV genotype 1 infected patients remained on the same level cost‐effective, if additional costs did not exceed €10 774 per 10% sustained virologic response gain. We conclude that Peg‐IFN/RBV treatment is cost‐effective post transplant. This may support treatment decision in individual cases.     

Cost‐effectiveness of treating vascular leg ulcers with UrgoStart® and UrgoCell® Contact

Although chronic wounds have a high socio‐economic impact, data on comparative effectiveness of treatments are rare. UrgoStart^® is a hydroactive dressing containing a nano‐oligosaccharide factor (NOSF). This study aimed at evaluating the cost‐effectiveness of this NOSF‐containing wound dressing in vascular leg ulcers compared with a similar neutral foam dressing (UrgoCell^® Contact) without NOSF. Cost‐effectiveness analysis from the perspective of the German statutory health care system was performed using a decision tree model for a period of 8 weeks. Cost and outcome data were derived from the clinical study ‘Challenge’ suggesting a response rate (≥40% wound size reduction) of UrgoStart^® of 65·6% versus 39·4% for the comparator. In the treatment model, effect‐adjusted costs of €849·86 were generated after 8 weeks for treatment with UrgoStart^® versus €1335·51 for the comparator resulting in an effect‐adjusted cost advantage of €485·64 for UrgoStart^®. In linear sensitivity analyses, the outcomes were stable for varying assumptions on prices and response rates. In an 8‐week period of treatment for vascular leg ulcers, UrgoStart^® shows superior cost‐effectiveness when compared with the similar neutral foam dressing without any active component (NOSF). As demonstrated within a randomised, double‐blind clinical trial, UrgoStart^® is also more effective in wound area reduction than the neutral foam dressing. Wound healing was not addressed in this clinical trial. Follow‐up data of 12 months to allow for reulceration assessment were not generated.     

Implementation of a new strategy to improve the peri‐operative management of neuromuscular blockade and its effects on postoperative pulmonary complications

Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra‐operative documentation of train‐of‐four measurement before administration of neostigmine. We conducted a pre‐specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity‐matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre‐intervention and 568 (6.3%) of 9088 cases post‐intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61–0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93–0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87–0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity‐matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra‐operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.     

Cost‐Effectiveness of New Direct‐Acting Antivirals to Prevent Post–Liver Transplant Recurrent Hepatitis

Preliminary studies on HCV‐cirrhotics listed for transplant suggest that sofosbuvir in combination with ribavirin is very effective in promoting viral clearance and preventing disease recurrence. Unfortunately, the high cost of such treatment (€46 500 per 12 weeks of treatment) makes its cost‐effectiveness questionable. A semi‐Markov model was developed to assess the cost‐effectiveness of sofosbuvir/ribavirin treatment in cirrhotic patients without HCC (HCV‐CIRRH) and with HCC (HCV‐HCC) listed for transplant. In the base‐case analysis, the incremental cost‐effectiveness ratio for 24 weeks of sofosbuvir/ribavirin was €44 875 per quality‐adjusted life‐year gained in HCV‐CIRRH and €60 380 in HCV‐HCC patients. Both results were above the willingness to pay threshold of €37 000 per quality‐adjusted life‐year. Our data also show that in order to remain cost‐effective (with a 24‐week treatment), any novel interferon‐free treatment endowed with ideal efficacy should cost less than €67 224 or €95 712 in HCV‐cirrhotics with and without HCC, respectively. The results shows that sofosbuvir/ribavirin therapy, given to patients listed for transplant, is not cost‐effective at current prices despite being very effective, and new, more effective treatments will have little economic margins to remain cost‐effective. New interferon‐free combinations have the potential to revolutionize the treatment and prognosis of HCV‐positive patients listed for transplant; however, without sustainable prices, this revolution is unlikely to happen.     

Cost‐of‐illness of chronic leg ulcers in Germany

Chronic wounds are important because of their frequency, their chronicity and high costs of treatment. However, there are few primary data on the cost‐of‐illness in Germany. The aim was to determine the cost‐of‐illness of venous leg ulcers (VLU) in Germany. Prospective cost‐of‐illness study was performed in 23 specialised wound centres throughout Germany. Direct, medical, non medical and indirect costs to the patient, statutory health insurers and society were documented. Thereover, health‐related quality of life (QoL) was recorded as intangible costs using the Freiburg quality of life assessment for wounds (FLQA‐w, Augustin). A total of 218 patients (62.1% female) were recruited consecutively. Mean age was 69.8 ± 12.0 years. The mean total cost of the ulcer per year and patient was € 9569, [ € 8658.10 (92%) direct and € 911.20 (8%) indirect costs]. Of the direct costs, € 7630.70 was accounted for by the statutory health insurance and € 1027.40 by the patient. Major cost factors were inpatient costs, outpatient care and non drug treatments. QoL was strikingly reduced in most patients. In Germany, VLU are associated with high direct and indirect costs. As a consequence, there is a need for early and qualified disease management. Deeper‐going cost‐of‐illness‐studies and cost‐benefit analyses are necessary if management of chronic wounds is to be improved.     

The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial

The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248–577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186–474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.     

Intravenous dexamethasone for prophylaxis of postoperative nausea and vomiting after administration of long‐acting neuraxial opioids: a systematic review and meta‐analysis

Long‐acting neuraxial opioids provide excellent analgesia after surgery, but are associated with higher rates of postoperative nausea and vomiting. Dexamethasone effectively prevents postoperative nausea and vomiting after general anaesthesia, but its value in patients receiving long‐acting neuraxial opioids is undetermined. Therefore, the objective of this meta‐analysis was to assess the prophylactic anti‐emetic efficacy of intravenous (i.v.) dexamethasone in this population. The study methodology followed the PRISMA statement guidelines. The primary outcome was the need for rescue anti‐emetics during the first 24 postoperative hours, analysed according to the dose of dexamethasone (low‐dose 2.5–5.0 mg; intermediate dose 6.0–10.0 mg), timing of administration (beginning or end of surgery) and route of long‐acting opioid administration (intrathecal or epidural). Additionally, the rates of complications (restlessness, infection, hyperglycaemia) were sought. Thirteen trials were identified, representing a total of 1111 patients. When compared with placebo, intravenous dexamethasone reduced the need for rescue anti‐emetics (risk ratio (95%CI) 0.44 (0.35–0.56); I² = 43%; p < 0.00001; quality of GRADE evidence: moderate), without differences between dexamethasone doses (p for sub‐group difference = 0.67), timing of administration (p for sub‐group difference = 0.32) or route of long‐acting opioid (p for sub‐group difference = 0.10). No patients developed infection or restlessness among trials that sought these complications. No trial measured blood glucose levels. In conclusion, there is enough evidence to state that intravenous dexamethasone provides effective anti‐emetic prophylaxis during the first 24 postoperative hours in patients who receive long‐acting neuraxial opioids.     

Cost‐effectiveness of pretransplant sofosbuvir for preventing recurrent hepatitis C virus infection after liver transplantation

There are reports of pretransplant sofosbuvir (SOF) plus ribavirin being effective in preventing recurrent hepatitis C virus (HCV) infection after liver transplantation (LT). The aim of this study was to assess the cost‐effectiveness of this strategy in the area served by the North Italy Transplant program. We retrospectively assessed the impact of HCV infection on post‐LT survival in 2376 consecutive adult patients (MELD ≤ 25, unknown genotype, period 2004–2009) and the prevalence costs of conventional standard of care (SOC) antiviral therapy (pegylated interferon plus ribavirin) after LT. A Markov model was developed to compare two strategies: 12–24 weeks of SOF+ ribavirin for pre‐LT anti‐HCV treatment versus on‐demand post‐LT SOC antiviral therapy. Among the 1794 patients undergoing LT, 860 (48%) were HCV+ and 50% of them were given SOC therapy after LT (mean cost of drugs and adverse effect management = 14 421€ per patient). HCV etiology had a strong impact on post‐LT survival (hazard ratio = 1.59, 95% CI = 1.22–2.09, P = 0.0007). After Monte Carlo simulation, pre‐LT SOF therapy showed a median survival benefit of 1.5 quality‐adjusted life years and an Incremental cost‐effectiveness ratio (ICER) of 30 663€/QALY, proving cost‐effective in our particular Italian scenario. The costs of SOF therapy, sustained viral response rate 12 weeks after LT, and recipient's age were the main ICER predictors at multivariate analysis. This study proposes a dynamic model based on real‐life data from northern Italy for adjusting the costs of pre‐LT direct‐acting antiviral therapies to the actual sustained virological response reached after LT.     

A randomised,controlled trial evaluating a low cost, 3D‐printed bronchoscopy simulator

Low‐fidelity, simulation‐based psychomotor skills training is a valuable first step in the educational approach to mastering complex procedural skills. We developed a cost‐effective bronchial tree simulator based on a human thorax computed tomography scan using rapid‐prototyping (3D‐print) technology. This randomised, single‐blind study evaluated how realistic our 3D‐printed simulator would mimic human anatomy compared with commercially available bronchial tree simulators (Laerdal^® Airway Management Trainer with Bronchial Tree and AirSim Advance Bronchi, Stavanger, Norway). Thirty experienced anaesthetists and respiratory physicians used a fibreoptic bronchoscope to rate each simulator on a visual analogue scale (VAS) (0 mm = completely unrealistic anatomy, 100 mm = indistinguishable from real patient) for: localisation of the right upper lobe bronchial lumen; placement of a bronchial blocker in the left main bronchus; aspiration of fluid from the right lower lobe; and overall realism. The 3D‐printed simulator was rated most realistic for the localisation of the right upper lobe bronchial lumen (p = 0.002), but no differences were found in placement of a bronchial blocker or for aspiration of fluid (p = 0.792 and p = 0.057) compared with using the commercially available simulators. Overall, the 3D‐printed simulator was rated most realistic (p = 0.021). Given the substantially lower costs for the 3D‐printed simulator (£85 (€100/US$110) compared with > ~ £2000 (€2350/US$2590) for the commercially available simulators), our 3D‐printed simulator provides an inexpensive alternative for learning bronchoscopy skills, and offers the possibility of practising procedures on patient‐specific models before attempting them in clinical practice.     

Assessment of vacuum‐assisted closure therapy on the wound healing process in cardiac surgery

Postoperative deep sternal wound infection (DSWI) is a serious complication in cardiac surgery (1–5% of patients) with high mortality and morbidity rates. Vacuum‐assisted closure (VAC) therapy has shown promising results in terms of wound healing process, postoperative hospital length of stay and lower in‐hospital costs. The aim of our retrospective study is to report the outcome of patients with DSWI treated with VAC therapy and to assess the effect of contributory risk factors. Data of 52 patients who have been treated with VAC therapy in a single institution (study period: September 2003–March 2012) were collected electronically through PAtient Tracking System PATS and statistically analysed using SPSS version 20. Of the 52 patients (35 M: 17 F), 88·5% (n = 46) were solely treated with VAC therapy and 11·5% (n = 6) had additional plastic surgical intervention. Follow‐up was complete (mean 33·8 months) with an overall mortality rate of 26·9% (n = 14) of whom 50% (n = 7) died in hospital. No death was related to VAC complications. Patient outcomes were affected by pre‐operative, intra‐operative and postoperative risk factors. Logistic EUROscore, postoperative hospital length of stay, advanced age, chronic obstructive pulmonary disease (COPD) and long‐term corticosteroid treatment appear to be significant contributing factors in the long‐term survival of patients treated with VAC therapy.     

Cost‐of‐illness of leg ulcers in the community

Leg ulcer management is complex, time‐consuming and of high socio‐economic importance. Data on cost‐of‐illness in leg ulcer care are sparse. The objective of this study was to evaluate the cost‐of‐illness in leg ulcer treatment in the metropolitan area of Hamburg. About 147 institutions involved in wound care participated in a cross‐sectional study. Patients consecutively recruited underwent a standardised interview and clinical examination. Main economic outcomes were direct, indirect and intangible costs from a societal perspective. Five hundred and two patients with a mean age of 71 years and mean wound duration of 9 years were enrolled. Annual total costs summed up to a mean of 9060€ /patient/year (8288€ direct, 772€ indirect costs). Direct costs carried by statutory health insurances amounted to 7680€ , patients themselves paid on average 607€. Leg ulcer is associated with high costs for health insurances, patients and the society. Exploratory predictor analyses suggest that early, interprofessional disease‐management could lower treatment costs.     

The relationship between pre‐operative hypertension and intra‐operative haemodynamic changes known to be associated with postoperative morbidity

Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri‐operative risk factor. However, hypertension may predispose to peri‐operative haemodynamic changes known to be associated with peri‐operative morbidity and mortality, such as intra‐operative hypotension and tachycardia. The objective of this study was to determine whether pre‐operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri‐operative outcomes. We performed a five‐day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non‐cardiac, non‐obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra‐operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra‐operative tachycardia (heart rate> 100 beats.min^?1) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre‐operative hypertension and peri‐operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.     

Association between peri‐operative angiotensin‐converting enzyme inhibitors and angiotensin‐2 receptor blockers and acute kidney injury in major elective non‐cardiac surgery: a multicentre,prospective cohort study

The peri‐operative use of angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri‐operative period. This study aimed to investigate if withholding angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers peri‐operatively reduces the risk of acute kidney injury following major non‐cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi‐level models were used to account for centre‐level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republic of Ireland. From this population, 573 (60.4%) patients had their angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers withheld during the peri‐operative period. One hundred and seventy‐five (18.4%) patients developed acute kidney injury; there was no difference in the incidence of acute kidney injury between patients who had their angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers continued or withheld (107 (18.7%) vs. 68 (18.1%), respectively; p = 0.914). Following propensity matching, withholding angiotensin‐converting enzyme inhibitors or angiotensin‐2 receptor blockers did not demonstrate a protective effect against the development of postoperative acute kidney injury (OR (95%CI) 0.89 (0.58–1.34); p = 0.567).     

Bioavailability and costs of once‐daily and twice‐daily tacrolimus formulations in de novo kidney transplantation

The use of once‐daily tacrolimus in de novo kidney transplantation is increasingly common. Therefore, we were interested in bioavailability aspects of novel once‐daily tacrolimus (LCPT, Envarsus) and once‐daily tacrolimus extended‐release formulation (ER‐Tac, Advagraf) compared with twice‐daily immediate‐release tacrolimus (IR‐Tac, Prograf). Furthermore, we calculated the costs. Kidney allograft recipients on tacrolimus‐based immunosuppression within 2 clinical trials were included in a single‐center analysis. The tacrolimus formulations were compared with respect to daily doses, doses per body weight, trough levels, and concentration‐dose (C/D) ratio over 12 months. Intrapatient variability in trough levels and C/D ratios after 3 months was calculated. For the calculation of tacrolimus costs, German list prices were used. Eighty patients (21 with LCPT, 23 with IR‐Tac, and 36 with ER‐Tac) were analyzed. Pharmacokinetic comparisons revealed significantly higher bioavailability of LCPT at all visits. The variability of trough levels and C/D ratios in general was high and highest in LCPT patients. Different dose requirements translated into different costs. Median treatment costs during the first year were 7.825€ (IQR 6.195‐8.892€) for LCPT, 9.813€ (IQR 7.630‐16.832€) for IR‐Tac, and 9.838€ (IQR 7.503‐ 13.541€) for ER‐Tac (Kruskal‐Wallis test, P = .003). The 3 tacrolimus formulations exhibit different dose requirements, exposure, and costs in favor of LCPT.     

Assessment of the financial implications for laparoscopic liver surgery: a single-centre UK cost analysis for minor and major hepatectomy

Background

Laparoscopic hepatectomy is progressively gaining popularity. However, it is still unclear whether the laparoscopic approach offers cost advantages compared with the open approach, especially when major hepatectomies are required. Data providing useful insights into the costs of the laparoscopic approach for clinicians and hospitals are needed. The aim of this study is to assess the financial implications of the laparoscopic approach for two standardized minor and major hepatectomies: left lateral sectionectomy and right hepatectomy.

Methods

A cost comparison analysis of patients undergoing laparoscopic right hepatectomy (LRH) and laparoscopic left lateral sectionectomy (LLLS) versus the open counterparts was performed. Data considered for the comparison analysis were operative costs (theatre cost, consumables and surgeon/anaesthetic labour cost), postoperative costs (hospital stay, complication management and readmissions) and overall costs.

Results

A total of 149 patients were included: 38 patients underwent LRH and 46 open right hepatectomy (ORH); 46 patients underwent LLLS and 19 open left lateral sectionectomy (OLLS). For LRH the mean operative, postoperative and overall costs were £10,181, £4,037 and £14,218; for ORH the mean operative, postoperative and overall costs were £6,483 (p < 0.0001), £10,304 (p < 0.0001) and £16,787 (p = 0.886). Regarding LLLS, the mean operative, postoperative and overall costs were £5,460, £2,599 and £8,059; for OLLS the mean operative, postoperative and overall costs were £5,841 (p = 0.874), £5,796 (p < 0.0001) and £11,637 (p = 0.0001).

Conclusion

Our data support the cost advantage of the laparoscopic approach for left lateral sectionectomy and the cost neutrality for right hepatectomy.