Point of care rapid diagnostic tests (RDTs) have demonstrated accurate and timely diagnosis across decentralized settings, broadening patient access in remote locations and improving pathways to diagnosis. This study aimed to synthesize published and other literature on the clinical, societal, and economic value of RDTs for infectious disease across Asia, Africa, and Latin America. A systematic literature review (SLR) was conducted using PubMed and Embase for publications dated 2017 to 2021 in accordance with PRISMA guidelines using RDT and infectious disease search terms. This SLR was supplemented by targeted searches to evaluate guidelines and recommendations for RDTs from non-governmental organizations or other bodies (e.g. WHO). Of the 616 articles identified in the systematic search, 128 were selected for full-text review, and 63 were included across the targeted and systematic review. Studies spanned 28 countries and 6 infectious diseases. Outcomes were clinical (e.g., patient outcomes), societal (e.g., reduced patient/clinician burden), and economic (e.g., cost savings). Of the 15 studies that reported RDT time to results, 10 reported results in under 1 hour which can lead to testing/treating more patients. Five studies showed that RDTs led to faster time to treatment for multiple disease areas compared to treatment initiated based on centralized laboratory testing, which can reduce the spread of infectious diseases. RDTs can reduce clinical and economic costs for misdiagnosis by reducing unnecessary treatment, including antibiotics that lead to resistance in select populations. Additionally, 11 studies reported high RDT usability for patients and/or clinicians. Point of care RDTs with high demonstrated accuracy provide for timely and cost-effective diagnosis across decentralized settings, even in remote areas of emerging markets. This allows for quicker treatment and can improve clinical outcomes. Further work is needed to translate existing evidence into population-level studies/models to determine the holistic impact of RDT implementation.

An increase in the incidence of FNF in Japan, most of which will require surgical treatment, would add significant burden to the healthcare system. This study describes patient characteristics, complications, LOS and healthcare expenditures associated with FNF surgical fixation in Japan. Patients ≥18 years old with a primary diagnosis of FNF receiving surgical fixation between 2008-2017 were identified using the Medical Data Vision Co. Ltd. database. Surgical fixations of interest included Cannulated Cancellous Screws (CCS), Dynamic Hips Screw (DHS), Hook Pin (HP) or Hook Pin with plate (HPL). Baseline characteristics, complications, readmissions, implant revisions, LOS and healthcare expenditures were extracted. Descriptive statistics were calculated to assess these endpoints. 8,044 patients (mean age 77.0±12.9; 76.2% female) met inclusion criteria. FNF fixation with HP (45.8%) was most common, followed by CCS (34.1%), DHS (11.4%) and HPL (8.7%). The most frequent inpatient complication was blood loss requiring transfusion (7.9% CCS, 21.2% DHS, 7.4% HP and 8.2% HPL). Median (IQR; day) LOS from surgery was CCS 21 (15, 34); DHS 28 (18, 48); HP 24 (16, 39); HPL 22 (16, 35.5). The median (IQR) inpatient healthcare expenditures were ¥1,171,759 (928,632, 1,703,036) for CCS, ¥1,600,066 (1,219,870, 2,525,716) for DHS, ¥1,505,947 (1,206,093, 2,132,549) for HP and ¥1,636,166 (1,384,697, 2,337,470) for HPL. 12-month follow-up period, readmission (6.6% in CCS, 3.7% in DHS, 6.3% in HP, 5.6% in HPL) and revision rates (2.7% in CCS, 1.5% in DHS, 2.7% in HP, 4.0% in HPL) were observed by fixation type. This study highlighted shorter LOS with less invasive fixation approaches (CSS, HP and HPL) and lower incidence of readmission & revision for DHS patients in a sample of FNF patients. Future research on patient factors and fixation methods that influence healthcare resource utilization in FNF treatment is necessary to address the burden in Japan.

To assess the usability of an early digital platform (tablet application + wearable activity tracker) designed to enhance recovery for elderly patients undergoing TKA surgery during hospitalization. Adult Japanese patients scheduled to undergo unilateral, primary TKA were prospectively recruited at a single center between September 2018 and July 2019 in Japan, following ethics approval. Following informed consent, patients were assigned 2:1 to the digital group (standard of care [SOC] + digital platform [DP]) versus SOC alone. Self-knowledge and adoption were evaluated before and after surgery. Patients and physicians were interviewed to understand their perspectives on the usability of the DP. Nine patients in the DP group (mean age 68.2 years; 55.6% female) and five patients (70.6 years; 100% female) in the SOC group completed the study. At baseline, 13/14 (90%) patients in both groups reported that they lacked enough information about rehabilitation to manage their post-surgical condition. Similarly, all patients lacked pre-operative knowledge about important complications associated with TKA. After surgery, 6/9 (67%) patients attributed improved ability to self-manage their condition to the DP. Forty-four percent of DP patients felt that the application improved their ability to communicate with their doctor. 4/9 (44%) patients indicated that they would continue using the DP on their personal device upon discharge. Usability issues included those related to font size, data entry, device navigation. Thus, while 8/9 (89%) of patients would recommend the DP to others, 5/9 (55%) of these would do so only with improved usability. Physicians mentioned the DP could save consultation time as it provided valuable health education for patients. This small pilot study found the DP may improve self-efficacy and communication with doctors during hospitalization after TKA, albeit with improvements required to improve usability. It also may reduce physician consultation time related to patient education.

As demand for TKA in Australia has seen steady growth over the past decade, there is increasing interest in optimizing the post-acute care to reduce hospitalization duration and overall financial burden. Post-operative recovery is influenced by many factors, such as management protocols, patient characteristics or implant design. This study aims to describe the real-world hospital LOS, discharge status and DR of TKA patients at an acute hospital and assess factors that influence them. A retrospective review of adult TKA patients at Mater Miscericordiae hospital between January 2013 and December 2017. Baseline demographic, clinical events and implant information were captured. Data is summarised using descriptive statistics. Generalised Linear Models were used to assess the influence of implant and patient demographics on study endpoints. Results from 173 patients (mean age 70.4 years; 63.6% female; 59% obese, 94.2% ASA II-III) showed a mean LOS of 5.3 (95% CI 5.0-5.6). 67.1% of the patients were discharged home without home care support. Mean days to achieve DR was 4.1 (95% CI 3.8 - 5.6). Study endpoints were observed to be influenced by gender, obesity, ASA and implant design. Patients with Attune implants (N=68) were associated with statistically significant reduction in: a) adjusted mean LOS (p<0.05), b) proportion of patients discharged home without home care support (p<0.01) and c) days to achieve DR (p<0.01) when compared to PFC Sigma (N=105). All patients achieved DR before actual discharge. Only 22% of patients were discharged on the same day they achieved DR. Patient characteristics and implant design influenced LOS, discharge destination and DR. While the mean LOS was within the national reported average, patients could achieve DR on average 1.5 days earlier. Better alignment between DR and actual discharge can have a significantly positive impact on healthcare economics by directly reducing episode of care costs.

The volume of Total Hip Arthroplasty (THA) procedures for patients with hip diseases has increased in Japan in the past decades, thus adding to the strained national socio-economic environment. However, nationwide information about patient epidemiology, medical resource utilization and cost for THA in Japan is still incomplete, because of inherent limitations of the databases analyzed. This study seeks to identify the epidemiology and economic burden of THA through evaluating a population-based claims database against published literature. A retrospective cohort analysis of the Japan Medical Data Center payer-based insurance claim database (JMDC) included 2783 patients ≥ 18 years old with THA (standardized procedure name=arthroplasty (hip)) between January 2009 and March 2018. For the 394 patients with more than one THA, the first procedure was selected as the index procedure for analysis. Baseline demographics, clinical characteristics, length of stay (LOS), and healthcare costs were extracted from the database. Descriptive statistics were calculated to assess the endpoints. Mean (SD) age in the cohort was 56.9 (7.99) years and 23.9% of patients were male. 86% patients had a diagnosis of osteoarthritis, and the second most common diagnosis was osteonecrosis for 12.5% of patients. Mean (SD) LOS for the index hospitalization was 15.8 (7.37) days, mean (SD) total cost for the index hospitalization was ¥1,927,205 (389,375). A review of relevant literature shows a range of LOS between 28.6 and 58.7 days, and total cost between ¥2,170,000 and ¥2,632,000. Despite differences in patient populations and large variabilities in data, cost of care observed was consistent with the literature. As expected, the JMDC database showed younger (34.3% patients ≥60 years old) patients undergoing THA, and shorter LOS. JMDC provides another reliable datasource, with existing literature, to better inform health policy decision-making, adding to our overall understanding of the epidemiology and economic burden of THA in Japan.

As demand for TKA in Australia is steadily growing over the past decade, there is increasing interest in optimizing the post-acute care to reduce hospitalization and overall financial burden. Post-operative recovery is influenced by many factors, such as management protocols or patient characteristics. Hence, this study aims to describe the real-world hospital LOS and discharge disposition of TKA patients at an acute hospital. This retrospective cohort study included 106 out of 121 unilateral primary TKA patients (diagnosis for gonarthrosis, ICD-10-AM) between January 2013 and December 2015. Primary and secondary outcomes were LOS, discharge readiness and destination respectively. Baseline demographic, clinical events and implant type data were captured. Descriptive analyses are reported with means and standard deviations for continuous variables and frequency and percentage for categorical variables. The difference in actual LOS and discharge readiness was examined for factors that may affect this outcome. Provisional results from 106 TKA patients (median age 69.2 years; 65% female; 82% obese, 94.4% ASA II-III) showed a mean LOS of 6.0 days (SD: 2.8, 95% CI 5.5-6.6). 98% of the patients were discharged home with or without home care support. 31.1% of patients had rehabilitation. All patients achieved discharge readiness before actual discharge. Only 18% of patients were discharged on the same day they achieved discharge readiness. Analysis shows significantly longer days for actual discharge for patients having clinical events, such as transfusion or other procedures. Our real-world study showed that while the hospital displayed a mean LOS within the national reported average, patients could achieve discharge readiness 1.5 days earlier. However, patient clinical events could induce delays in actual discharge. Alongside fast-track programs to optimize patient care path and costs, these findings can potentially help healthcare providers to further enhance recovery and potentially reduce LOS according to patient profiles.

To investigate the cost-effectiveness of using an innovative gradually reducing femoral radius design implant (GRAD) vs. a class of metal-backed implants (SOC) for patients with osteoarthritis who require a total knee arthroplasty (TKA) in both the public and private sectors in India. A Markov model was developed to compare the costs and outcomes of using GRAD vs. SOC over a 10-year time horizon in both the public and private sectors in India. The health states included were full benefit after primary TKA, limited benefit after primary TKA, primary TKA failure, full benefit after revision TKA, limited benefit after revision TKA and failure of revision TKA. The model assessed both direct and indirect costs such as cost of implant, surgery, hospitalisation, follow-up visits and productivity loss. One-way sensitivity analysis and probabilistic sensitivity analysis tested the robustness of the base case incremental cost-effectiveness ratio. Provisional results show that after 10 years the expected difference in the total cost of using GRAD vs a SOC per patient is (-₹4,170 or -₹7,224) in the public and private sectors respectively. The increment in quality-adjusted life years (QALYs) per patient is (0.0072 or 0.0068) for the public and private sectors respectively. Therefore using the innovative design implant is the economically dominant strategy as it produces more QALYs at a lower cost than SOC. The model results were most sensitive to the cost of the surgery, the probability of knee survivorship, and the discount rates. Provisional results indicate that using the innovative gradually reducing femoral radius design implant in Indian patients undergoing a TKA is cost-effective in both the public and private sectors compared to class of metal-backed implants and is therefore likely to result in better allocation of resources for the Indian healthcare system.

To evaluate the impact of re-usable surgical instruments management on the cost of performing Total Knee Arthroplasty (TKA) at a Japanese general hospital, in terms of time, personnel and financial resources. A detailed process map was developed for the re-usable surgical instruments management cycle at our study site, from the time surgery was scheduled until instruments were used in the Operating Theatre (OT), to post-operative return to storage. The prospective study (conducted 1/7/2017-30/9/2017) included time-in-motion direct observations of 15 TKAs, supplemented by literature and 21 interviews with hospital staff. Time-Driven Activity Based Costing (TDABC) methodology was used to identify who performed each step, its duration, and associated costs. Personnel costs for each phase of instrument management were measured based on job category labour rates. To support a 117 minute surgery, instruments were processed over a 6 day span behind the scenes, taking a total of 1,129 minutes from scheduling each TKA to return of instruments to storage. The hospital required at least 6 types of staff to manage re-usable surgical instruments: doctors, OT nurses, scrub nurses, central supply nurse assistants, medical office assistants, and medical engineers. This labour cost amounted to ¥65,027, which was nearly on par with mobilizing the entire surgical team for the TKA procedure (¥80,792). Hospital cost was split across pre-surgery (18%), surgery (73%), and post-surgery (9%). The surgical instruments management process and their influence on the overall cost of the TKA procedure has been brought to light for the first time in Japan. This exploratory study has identified important opportunities for the hospital to improve efficiency, especially for this relatively complex process requiring a high burden of support activities from skilled hospital staff.

To map the clinical pathway and calculate the true cost of performing TKA surgery from the hospital perspective. Inpatient pathways from pre-operative admission to discharge were prospectively mapped for 14 TKA cases at a tertiary medical center in Japan. Study patients (aged > 15 years) underwent elective surgery (K-code: K082 1; Diagnosis Procedure Code (DPC): 070230xx01xxxx) between 07/01/2017 – 9/30/2017 and were excluded in case of in-hospital mortality, length of stay (LOS) > 60 days, and uni-compartmental or bilateral arthroplasties. Stakeholder interviews and DPC files were used to reconstruct the clinical pathway outside the Operating Theater (OT), while direct observations using time-and-motion techniques were used within the OT. The cost of performing TKA surgery was calculated using TDABC methodology, by combining resource use time (min) with its associated capacity rate (¥/min). Major resource categories included: healthcare personnel, medical consumables/implants, and facility overhead estimated from sources such as the OT master records, hospital financial statements, materials purchasing data, and administrative databases. The average LOS for TKA was 19.7d spread across the pre-op (2.1d), surgery (1.0d), acute ward (8.7d), and sub-acute ward (7.9d) periods. Total surgery time was 117 min from incision to closure. Selected personnel capacity rates were as follows: orthopedic surgeons (143.1 ¥/min), nurses (51.5 ¥/min), physical therapists (53.4 ¥/min), clinical engineers (55.7 ¥/min), medical social workers (34.2 ¥/min), and health information specialists (52.4 ¥/min). The total cost to perform TKA was ¥1,119,373 per case. Of this, labor, direct materials (both reimbursed and non-reimbursed), and indirect facility overhead contributed 25.5%, 44.6%, and 27.7%, respectively. The use of TDABC provides granular, realistic insights into care processes at the service line level, and may inform strategic decision-making, reduce operational inefficiencies, and accurately define costs, and thereby value, in clinical care.

Patient safety concerns have led to the emergence of alternative training models (eg. workshops, simulator training) that allow surgeons to develop surgical proficiency outside the operating theatre. In Moore’s educational outcomes measurement framework, the ultimate goal of surgical education is improved patient and community health.1 This literature review aimed to qualitatively assess published evidence on the impact of surgical education on clinical and economic outcomes. A pragmatic literature search of PubMed and Chinese Knowledge Infrastructure was performed (August 2015-November 2015) using search terms developed from “surgical”, “training”, “education”, “clinical” and “economic”. Primary studies, economic studies and reviews reporting clinical or economic outcomes associated with surgical education interventions were included. A total of 47 studies were identified (5 systematic literature reviews, 4 RCTs, 34 cohort studies, 3 review papers, 1 case study). Surgical education reduced technical error rates and operative times when assessed under simulation. Several studies reported favourable clinical outcomes (reduced blood loss, complication rates, mortality). ~50% studies reported outcomes that could indirectly contribute to improved patient safety: procedural/anatomical knowledge acquisition, improved technical skills (instrument/tissue handling, speed, accuracy), improved non-technical skills (decision-making, teamwork, stress management). Economic data primarily comprised direct training costs (simulator costs, cost of faculty time); few studies reported cost-comparative analyses between surgical education models. While evidence for the clinical benefit of surgical education exists, conclusive interpretation was limited due to the pragmatic method of review, heterogeneity of studies and inherent limitations of studies identified (before-after studies, surveys). There is a need to critically evaluate how the impact of surgical education is assessed. Current studies focus on surgical learning outcomes; further research is needed to strengthen the evidence base for the impact of surgical education on not only surgeons, but also patients and hospitals. 1Moore D et al. J Contin Educ Health Prof. 2009;29(1):1-15