Moriarty, James P.

AbstractBackgroundCompare the cost-effectiveness of 2 recombinant hepatitis B virus (HBV) vaccines in patients with inflammatory bowel disease (IBD).MethodsMarkov models were developed for 2 IBD cohorts: (1) 40-year-old patients prior to starting IBD treatment and (2) 40-year-old patients already receiving therapy. Cohort A received full vaccination series, cohort B had primary vaccine failure and received a vaccine booster. Two vaccines were compared: adjuvanted HEPLISAV-B and nonadjuvanted Engerix-B. Clinical probabilities of acute hepatitis, chronic hepatitis, cirrhosis, fulminant hepatic failure and death, treatment costs, and effectiveness estimates were obtained from published literature. A lifetime analysis and a US payer perspective were used. Probabilistic sensitivity analyses were performed for different hypothetical scenarios.ResultsAnalysis of cohort A showed moderate cost-effectiveness of HEPLISAV-B ($88,114 per quality-adjusted life year). Analysis of cohort B showed increased cost-effectiveness ($35,563 per quality-adjusted life year). Changing Engerix-B to HEPLISAV-B in a hypothetical group of 100,000 patients prevented 6 and 30 cases of acute hepatitis; and 4 and 5 cases of chronic hepatitis annually for cohorts A and B, respectively. It also prevented 1 and 2 cases of cirrhosis, and 1 and 2 deaths over 20 years for each cohort. Cost-effectiveness was determined by vaccination costs, patient age, and progression rate from chronic hepatitis to cirrhosis.ConclusionsHEPLISAV-B is cost-effective over Engerix-B in patients receiving immunosuppressive therapy for IBD. Benefits increase with population aging and lower costs of vaccines. We advocate measuring levels of HBV antibodies in patients with IBD and favor adjuvanted vaccines when vaccination is needed.

Importance: A postoperative video telemedicine follow-up program was introduced by the Mayo Clinic. An attempt was made to understand the potential cost savings to patients before contemplating full-scale expansion across all potentially eligible surgical patients and practices. Objective: The primary purpose was to estimate potential cost savings to patients with video telemedicine follow-up to home compared with face-to-face follow-up in a standard clinic setting. Design: The research was designed collaboratively by the Center for Connected Care and the surgical practice to address the question of estimated cost savings of postoperative video telemedicine visits. The intervention arm is the postoperative video telemedicine follow-up visit to home setting and the comparator is the face-to-face visit at Mayo Clinic. Setting: Large, integrated, academic multispecialty practice supporting patient care delivery, research, and education. Participants: The population under study comprised routine uncomplicated postoperative patients who underwent video telemedicine or face-to-face follow-up visits that fell within the 90-day global period across multiple (general, neurosurgery, plastic, thoracic, transplant, and urology) surgical specialties. Main Outcome(s) and Measure(s): Economic outcomes were cost of travel, accommodations, meals, and missed work. Additional outcomes included time expenditure and patient satisfaction. Cost/benefit analysis unit was US dollars (USD). All costs were inflated to 2018 USD, using the Gross Domestic Product Implicit price deflator. Results: Patients who utilized video telemedicine rather than face-to-face clinic visit for postoperative follow-up were estimated to save $888 per visit on average. More specifically, patients residing more than 1,635 miles round trip from clinic saved an estimated $1,501 per visit and patients not needing accommodation still saved an estimated $256 per visit. Patient satisfaction over video telemedicine postoperative follow-up visits remained high over the 6-year period of study. Conclusions and Relevance: The use of video telemedicine for routine uncomplicated postoperative follow-up visits to replace face-to-face follow-up visits has the potential to be financially advantageous for patients. Key points Question: For postoperative patients, what are the health economic outcomes associated with video telemedicine follow-up to home compared with face-to-face follow-up in a standard clinic setting? Findings: Video telemedicine offers a cost benefit for patients through avoidance of travel costs and missed work. Meaning: For uncomplicated routine postoperative follow-up visits, video telemedicine is a less costly alternative for most patients.

Significance Statement Efficacy of rituximab (RTX) in ANCA-associated vasculitis (AAV) in patients with severe renal involvement (eGFR<30 ml/min per 1.73 m 2 ) has not been addressed in clinical trials. This observational study did not find statistically significant differences between RTX and cyclophosphamide (CYC) for remission-induction therapy or any apparent benefit from the addition of plasma exchange (PLEX) to standard remission-induction therapy for patients with AAV and severe renal involvement. Although our analyses suggest that the benefits and risks of these therapeutic choices (RTX versus CYC with and without PLEX) are balanced, a randomized, controlled trial is needed to confirm these findings. Background Treatment of patients with ANCA-associated vasculitis (AAV) and severe renal involvement is not established. We describe outcomes in response to rituximab (RTX) versus cyclophosphamide (CYC) and plasma exchange (PLEX). Methods A retrospective cohort study of MPO- or PR3-ANCA–positive patients with AAV (MPA and GPA) and severe kidney disease (eGFR <30 ml/min per 1.73 m 2 ). Remission, relapse, ESKD and death after remission-induction with CYC or RTX, with or without the use of PLEX, were compared. Results Of 467 patients with active renal involvement, 251 had severe kidney disease. Patients received CYC ( n =161) or RTX ( n =64) for remission-induction, and 51 were also treated with PLEX. Predictors for ESKD and/or death at 18 months were eGFR <15 ml/min per 1.73 m 2 at diagnosis (IRR 3.09 [95% CI 1.49 to 6.40], P =0.002), renal recovery (IRR 0.27 [95% CI 0.12 to 0.64], P =0.003) and renal remission at 6 months (IRR 0.40 [95% CI 0.18 to 0.90], P =0.027). RTX was comparable to CYC in remission-induction (BVAS/WG=0) at 6 months (IRR 1.37 [95% CI 0.91 to 2.08], P =0.132). Addition of PLEX showed no benefit on remission-induction at 6 months (IRR 0.73 [95% CI 0.44 to 1.22], P =0.230), the rate of ESKD and/or death at 18 months (IRR 1.05 [95% CI 0.51 to 2.18], P =0.891), progression to ESKD (IRR 1.06 [95% CI 0.50 to 2.25], P =0.887), and survival at 24 months (IRR 0.54 [95% CI 0.16 to 1.85], P =0.330). Conclusions The apparent benefits and risks of using CYC or RTX for the treatment of patients with AAV and severe kidney disease are balanced. The addition of PLEX to standard remission-induction therapy showed no benefit in our cohort. A randomized controlled trial is the only satisfactory means to evaluate efficacy of remission-induction treatments in AAV with severe renal involvement.

Background: The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied. Methods: We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed. Results: Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non–ST-segment–elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [ P <0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population. Conclusions: AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.

ObjectivesIdentify predictors of high‐cost otolaryngology care.Study DesignCross‐sectional.SettingTertiary academic multispecialty hospital.Subjects/MethodsAll patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. “Outliers” were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status.ResultsIn total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers.ConclusionThis is the first large‐scale study of high‐cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high‐cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.

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Introduction Safe management of warfarin in the inpatient setting can be challenging. At the Mayo Clinic hospitals in Rochester, Minnesota, we set out to improve the safety of warfarin management among surgical and non-surgical inpatients. Methods A multidisciplinary team designed a pharmacist-managed warfarin protocol (PMWP) which designated warfarin dosing to inpatient pharmacists with guidance from computerised dosing algorithms. Ordering this protocol was ultimately designed as an ‘opt out’ practice. The primary improvement measure was frequency of international normalised ratio (INR) greater than 5; secondary measures included adoption rate of the protocol, a counterbalance INR metric (INR <1.7 three days after first inpatient warfarin dose), and complication rates, including bleeding and thrombosis events. An interrupted time series analysis was conducted to compare outcomes. Results Among over 50 000 inpatient warfarin recipients, the PMWP was adopted for the majority of both surgical and non-surgical inpatients during the study period (1 January 2005 to 31 December 2011). The primary improvement measure decreased from 5.6% to 3.4% for medical patients and from 5.2% to 2.4% for surgical patients during the preimplementation and postimplementation periods, respectively. The INR counterbalance measure did not change. Postoperative bleeding decreased from 13.5% to 11.1% among surgical patients, but bleeding was unchanged among medical patients. Conclusion Our PMWP led to achievement of improved INR control for inpatient warfarin recipients and to less near-term bleeding among higher risk, surgical patients.