Belinda Udeh

Effects of volatile anesthetic choice on hospital length-of-stay: a retrospective study and a prospective trial.

Background:Volatile anesthetic prices differ substantially. But differences in drug-acquisition cost would be inconsequential if hospitalization were prolonged by more soluble anesthetics. The authors tested the hypothesis that the duration of hospitalization is prolonged with isoflurane anesthesia. Methods:Initially, the authors queried their electronic records and used propensity matching to generate homogeneous sets of adults having inpatient noncardiac surgery who were given desflurane, sevoflurane, and isoflurane. The authors then conducted a prospective alternating intervention trial in which adults (mostly having colorectal surgery) were assigned to isoflurane or sevoflurane, based on protocol. Results:In the retrospective analysis, 2,898 matched triplets were identified among 43,352 adults, each containing one patient receiving isoflurane, desflurane, and sevoflurane, respectively. The adjusted geometric mean (95% CI) hospital length-of-stay for the isoflurane cases was 2.85 days (2.78–2.93); this was longer than that observed for both desflurane (2.64 [2.57–2.72]; P < 0.001) and sevoflurane (2.55 [2.48–2.62]; P < 0.001). In the prospective trial (N = 1,584 operations), no difference was found; the adjusted ratio of means (95% CI) of hospital length-of-stay in patients receiving isoflurane versus sevoflurane was 0.98 (0.88–1.10), P = 0.77, with adjusted geometric means (95% CI) estimated at 4.1 (3.8–4.4) and 4.2 days (3.8–4.5), respectively. Conclusions:Results of the propensity-matched retrospective analysis suggested that avoiding isoflurane significantly reduced the duration of hospitalization. In contrast, length-of-stay was comparable in our prospective trial. Volatile anesthetic choice should not be based on concerns about the duration of hospitalization. These studies illustrate the importance of following even the best retrospective analysis with a prospective trial.

Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation.

RATIONALE Prognostic models can inform management decisions for patients requiring prolonged mechanical ventilation. The Prolonged Mechanical Ventilation Prognostic model (ProVent) score was developed to predict 1-year mortality in these patients. External evaluation of such models is needed before they are adopted for routine use. OBJECTIVES The goal was to perform an independent external validation of the modified ProVent score and assess for spectrum extension at 14 days of mechanical ventilation. METHODS This was a retrospective cohort analysis of patients who received prolonged mechanical ventilation at the University of Iowa Hospitals. Patients who received 14 or more days of mechanical ventilation were identified from a database. Manual review of their medical records was performed to abstract relevant data including the four model variables at Days 14 and 21 of mechanical ventilation. Vital status at 1 year was checked in the medical records or the social security death index. Logistic regressions examined the associations between the different variables and mortality. Model performance at 14 to 20 days and 21+ days was assessed for discrimination by calculating the area under the receiver operating characteristic curve, and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. MEASUREMENTS AND MAIN RESULTS A total of 180 patients (21+ d) and 218 patients (14-20 d) were included. Overall, 75% were surgical patients. One-year mortality was 51% for 21+ days and 32% for 14 to 20 days of mechanical ventilation. Age greater than 65 years was the strongest predictor of mortality at 1 year in all cohorts. There was no significant difference between predicted and observed mortality rates for patients stratified by ProVent score. There was near-perfect specificity for mortality in the groups with higher ProVent scores. Areas under the curve were 0.69 and 0.75 for the 21+ days and the 14 to 20 days cohorts respectively. P values for the Hosmer-Lemeshow statistics were 0.24 for 21+ days and 0.22 for 14 to 20 days. CONCLUSIONS The modified ProVent model was accurate in our cohort. This supports its geographic and temporal generalizability. It can also accurately identify patients at risk of 1-year mortality at Day 14 of mechanical ventilation, but additional confirmation is required. Further studies should explore the implications of adopting the model into routine use.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management

STUDY OBJECTIVE Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN Retrospective cost effectiveness analysis. SETTING Operating room. PATIENTS We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of

The apples and oranges of cost-effectiveness: a rejoinder.

150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of

473: COST-EFFECTIVENESS OF 6 TREATMENTS FOR PRIMARY CLOSTRIDIUM DIFFICILE INFECTION IN AN ICU POPULATION

10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

Economic Trends From 2003 to 2010 for Perioperative Myocardial Infarction: A Retrospective, Cohort Study

A recent CCJM commentary used straw men to indict cost-effectiveness research.