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AIMS: To establish the resource and cost savings from the early use of transjugular intrahepatic portosystemic shunts (TIPS) procedures with ePTFE covered stent-grafts configured for TIPS (SG) compared to endoscopic procedures and pharmaceuticals in high risk patients (Child–Pugh class B/C) with acute variceal bleeding.
BACKGROUND: Endoscopic therapies are currently the primary treatment for bleeding varices, with TIPS used when endoscopic treatment fails or when patients are not amenable to endoscopic intervention. Trials have shown clinical benefit (lower mortality, fewer re-bleeds and lower hepatic encephalopathy (HE)) from the earlier use of TIPS in patients with persistent bleeding. There are currently no published cost-effectiveness analyses of this earlier use.
METHODS: A Markov economic model was developed to measure the incremental resources and costs of early TIPS with SG, compared to endoscopic band ligation (EBL) plus pharmaceuticals, with TIPS as rescue therapy. Clinical data came mainly from published studies including an RCT (Garcia-Pagan 2010), whilst healthcare costs were from UK national databases. Events & costs were modelled over two years.
RESULTS: Using early TIPS with SG compared to EBL plus pharmaceuticals was estimated to save £1,655 per patient over 2 years. The total treatment costs were £6,455 for TIPS and £8,110 for EBL, providing a net saving of £1,655 per patient. Early TIPS and subsequent re-interventions cost £4,332 more than the EBL arm. However, savings were accrued from fewer EBL procedures and pharmaceuticals (saving £3,223); fewer episodes of recurrent bleeding (saving £2,475) and reduced rate of severe HE (saving £290). Modelling 100 patients, mortality was reduced in the early TIPS arm, 28 patients compared to 63 in the EBL plus pharmaceuticals arm. Sensitivity analyses showed the results were sensitive to device costs, frequency of EBL procedures and the relative rates of severe HE per patient. Using TIPS with SG earlier to manage variceal bleeding was cost saving under all sensitivity analyses.
CONCLUSION: The model showed that early utilisation of TIPS with ePTFE covered stent-grafts configured for TIPS was cost saving and improved survival compared to EBL and pharmaceuticals for high risk patients (Child–Pugh class B/C) with acute variceal bleeding.
RATIONALE, AIMS, OBJECTIVES: Demand for both Emergency Department (ED) and radiology services continues to increase across the UK while simultaneously, healthcare organisations are being asked to evaluate the quality of care provided and constrain service costs. National guidance on radiograph reporting times recommends ED radiographs are reported on day of patient attendance but in practice, delays in reporting persist. This study considers whether a radiographer led immediate reporting service for ED referrals could provide a cost-effective service improvement solution.
METHODS: A pragmatic multi-centre randomised controlled trial was undertaken. 1502 patients were recruited and randomly assigned to an immediate or delayed reporting arm and treated according to group assignment. Patient health gain was measured in terms of change in utilities derived from EQ-5D responses at baseline and 8 week follow-up. Resources used and the costs of an immediate reporting service were analysed at the patient level and compared to standard reporting practices.
RESULTS: 1688 radiographic examinations were performed (1502 patients). 79 discordant radiographic interpretations were identified (n = 79/1688; 4.7%). Interpretive errors were significantly reduced within immediate reporting arm. No significant difference was noted in the relative improvement in patient perceived health status between the 2 arms of the study. The average cost saving per patient in the immediate reporting arm was £23.40.
CONCLUSIONS: Radiographer led immediate reporting of ED radiographs is a cost-effective service development and its universal introduction could make a significant contribution to the current drive to increase service productivity within current budget constraints.
PURPOSE: To describe a systematic review of population-based prevalence studies of visual impairment (VI) and blindness worldwide over the past 32 years that informs the Global Burden of Diseases, Injuries and Risk Factors Study.
METHODS: A systematic review (Stage 1) of medical literature from 1 January 1980 to 31 January 2012 identified indexed articles containing data on incidence, prevalence and causes of blindness and VI. Only cross-sectional population-based representative studies were selected from which to extract data for a database of age- and sex-specific data of prevalence of four distance and one near vision loss categories (presenting and best-corrected). Unpublished data and data from studies using rapid assessment methodology were later added (Stage 2).
RESULTS: Stage 1 identified 14,908 references, of which 204 articles met the inclusion criteria. Stage 2 added unpublished data from 44 rapid assessment studies and four other surveys. This resulted in a final dataset of 252 articles of 243 studies, of which 238 (98%) reported distance vision loss categories. A total of 37 studies of the final dataset reported prevalence of mild VI and four reported near VI.
CONCLUSION: We report a comprehensive systematic review of over 30 years of VI/blindness studies. While there has been an increase in population-based studies conducted in the 2000s compared to previous decades, there is limited information from certain regions (eg, Central Africa and Central and Eastern Europe, and the Caribbean and Latin America), and younger age groups, and minimal data regarding prevalence of near vision and mild distance VI.
Graft-versus-host disease (GvHD) is a common complication following haematopoietic stem cell transplant but little is published about the impact of this condition on hospital readmission rates. We report a retrospective analysis of readmission rates and associated costs in 187 consecutive allogeneic transplant patients to assess the impact of GvHD. The overall readmission rate was higher in patients with GvHD (86% (101/118) vs. 59% (41/69), p < 0.001). The readmission rate was higher both in the first 100 d from transplant (p = 0.02) and in the first year following transplant (p < 0.001). 151/455 (33%) of all readmission episodes occurred within 100 d of transplant. The mean number of inpatient days was significantly higher in patients with grade III/IV acute GvHD (101 d) compared with those with grade I/II GvHD (70 d; p = 0.003). The mean cost of readmission was higher in patients with GvHD (£28 860) than in non-GvHD patients (£13 405; p = 0.002) and in patients with grade III/IV GvHD (£40 012) compared with those patients with grade I/II GvHD (£24 560; p = 0.038). Survival was higher in those with grade I/II GvHD (55%) compared to grade III/IV GvHD (14%; p < 0.001). This study shows the high economic burden and poor overall survival associated with grade III/IV GvHD.
Systematic reviews (SR) are an evidence synthesis approach that provides robust and transparent answers toclearly formulated questions. Originally developed for use in clinical practice, SRs have wider applicability,including food and feed safety risk assessment. EFSA has implemented the use of SRs, and this documentcontributes to the further development of this in-house capacity. Since the publication of the document"Application of Systematic Review Methodology to Food and Feed Safety Assessments to Support DecisionMaking", which mainly focuses on interventions and exposures (PECO/PICO), little has changed in this arena.Fast increasing fields of application include chemical and environmental risk assessment, and analysingenvironmental management interventions. Considering time constraints at EFSA, the use of SRs should bepursued thoughtfully. Important are the use of explicit systematic methods aimed at minimising bias andmaximising transparency in order to produce the most reliable findings that can be used to inform decisionmaking. Participants of the training courses indicated SRs should be a priority for controversial topics (whichmight be subject to greater scrutiny by external parties, including the public, and thereby would benefit frommaximum transparency) or topics for which there was disagreement amongst experts. Some areas addressed byEFSA have considerable potential impact, for example related to public health or animal trade, and these topicscould be prioritised for SR. Under severe time constraints, a full SR may not be possible, but a rapid review canbe considered. However rapid reviews are not a substitute for systematic reviews. Adoption of rapid reviewsexchanges one set of concerns (time and resources contracts) for another (lack of robustness andcomprehensiveness). In the view of the Consortium, the continuation of training opportunities is important.Appropriate commissioning of SR expertise is an important step in establishing the role of the methodology in EFSA risk assessments.
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