Non-Cystic Fibrosis Bronchiectasis (NCFB) is a chronic, progressive respiratory disorder characterized by irreversibly dilated airways and recurrent pulmonary infections. Concomitant infection with Pseudomonas aeruginosa is associated with greater lung function impairment, more frequent exacerbations, greater hospitalization risk, and mortality. NCFB exacerbations are defined as an increase in daily symptoms including cough, sputum, malaise, fatigue, and difficulty breathing. The cost of NCFB illness with Pseudomonas aeruginosa and frequent acute exacerbations have not been quantified.

Bronchiolitis Obliterans Syndrome (BOS) is a rare, life-threatening disease where the immune system attacks the airways of the lungs. BOS is estimated to affect approximately 25,000 individuals worldwide and can occur after hematopoietic stem cell transplantation (HSCT) or lung transplantation, with up to half of all lung transplant recipients developing BOS within 5 years of transplantation. BOS is rapidly progressive and irreversible, leading to lung failure after diagnosis, and making it the leading cause of death. The aim of this analysis was to estimate the lifetime economic burden of illness for BOS patients from the perspective of a US Payer.

PurposeChronic lung allograft dysfunction (CLAD), obstructive phenotype, bronchiolitis obliterans syndrome (BOS) is an obstructive, progressive, irreversible airway disease of the lungs following lung transplantation (LTX). BOS is the leading cause of death in LTX and is linked to a low 5-year survival rate of ∼55% post-transplant. Currently, there are no approved treatment options available, and therapies used have limited effectiveness. BOS may cause major humanistic burden to patients and caregivers that encompass all aspects of patient and caregiver lives. We evaluated the patient experience after BOS diagnosis with a focus on humanistic burden.MethodsThe study was designed to trace BOS patient flow through the US healthcare system by describing the post-lung transplant monitoring strategy with a focus on how health care practitioners understand and communicate a BOS diagnosis to patients. The study also assessed a holistic view of health through the emotional and financial impact of BOS on patient caregivers and their families. Transplant centers (n=22) and non-transplant center physicians (n=3) participated in a 45-minute online survey based on an interview guide and 2-3 patient record forms (PRFs) for patients with BOS at each participating site per physician totaling 61 PRFs.ResultsDemographic characteristics and humanistic burden of BOS after LTX are described in Table 1.ConclusionBOS penetrates every facet of patients' lives encompassing clinical manifestations and quality of life. Patients diagnosed with BOS require intensive support from family members or a spouse. The majority of BOS patients reported the most extreme impacts on their financial well-being and holistic disease burden, while also maintaining full or part-time employment rates of 41%. The diagnosis of BOS presents a tremendous humanistic burden on patients and their families who live with this devastating disease. Chronic lung allograft dysfunction (CLAD), obstructive phenotype, bronchiolitis obliterans syndrome (BOS) is an obstructive, progressive, irreversible airway disease of the lungs following lung transplantation (LTX). BOS is the leading cause of death in LTX and is linked to a low 5-year survival rate of ∼55% post-transplant. Currently, there are no approved treatment options available, and therapies used have limited effectiveness. BOS may cause major humanistic burden to patients and caregivers that encompass all aspects of patient and caregiver lives. We evaluated the patient experience after BOS diagnosis with a focus on humanistic burden. The study was designed to trace BOS patient flow through the US healthcare system by describing the post-lung transplant monitoring strategy with a focus on how health care practitioners understand and communicate a BOS diagnosis to patients. The study also assessed a holistic view of health through the emotional and financial impact of BOS on patient caregivers and their families. Transplant centers (n=22) and non-transplant center physicians (n=3) participated in a 45-minute online survey based on an interview guide and 2-3 patient record forms (PRFs) for patients with BOS at each participating site per physician totaling 61 PRFs. Demographic characteristics and humanistic burden of BOS after LTX are described in Table 1. BOS penetrates every facet of patients' lives encompassing clinical manifestations and quality of life. Patients diagnosed with BOS require intensive support from family members or a spouse. The majority of BOS patients reported the most extreme impacts on their financial well-being and holistic disease burden, while also maintaining full or part-time employment rates of 41%. The diagnosis of BOS presents a tremendous humanistic burden on patients and their families who live with this devastating disease.

Recent studies using continuous glucose monitors (CGMs) in T1D produce multiple daily readings used to define a novel construct called time in range (TIR; sanctioned by the International Consensus on TIR Targets, 2/2019), optimally between 70 mg/dl and 180 mg/dl. Multiple readings allow for calculation of a %TIR that has been linked to HbA1c improvements, greater risk for severe hypoglycemia (SH) <54 mg/dl, and diabetic ketoacidosis (DKA) >270 mg/dl. A COA was performed comparing clinical cost offsets for two CGM systems (rt-CGM and is-CGM) in T1D subjects (n=2,000) with impaired awareness of hypoglycemia (IAH; ∼30% of T1D) applied to eight countries over a one-year period. Clinical effects included %TIR (Reddy, 2017) for glucose as a proxy HbA1c measure (algorithm from Beck, 2019), reduced hospitalizations for SH and DKA (Charleer, 2018) based on %time spent in low and high glucose ranges (Reddy, 2017), respectively. Costs attributable to HbA1c reduction, SH and DKA hospitalizations were taken from country-specific published literature and inflated to 2019 values. RT-CGM %TIR compared to is-CGM (Reddy, 2017) resulted in estimated HbA1c reductions of -0.95% and -0.52%, respectively. The %time spent at low glucose (<54 mg/dl) between the groups yielded 132 fewer SH hospitalizations for rt-CGM. The %time spent at high glucose (>270 mg/dl) yielded one fewer DKA hospitalization for rt-CGM. Estimated annual cost offsets per T1D subject with IAH using rt-CGM over is-CGM is as follows: USA, $US 1,114; UK, £454; Spain, €494; France, €650; Italy, €655; Germany, €673; Canada, $CAN 703; Australia, $AUS 722. Recent RCTs comparing rt-CGM with is-CGM have demonstrated important differences in %time spent at low, optimal, and high glucose that are likely to translate into significant clinical and economic benefits for rt-CGM. The %TIR metric may grow in clinical significance as the relationship to HbA1c is more fully described.

SummaryWe describe a novel method of sampling the esophageal lining fluid in children and show that levels of eotaxin-1 and MCP-4 differentiate those children with a histological diagnosis of EoE from those without.This article is protected by copyright. All rights reserved.

Bariatric surgical procedure volumes have increased as more hospitals offer the service. Strictures following bariatric surgery using circular staplers are a common complication. The objective was to assess the cost of gastrointestinal strictures following laparoscopic bariatric surgery that employed circular surgical staplers in the index procedure. Laparoscopic bariatric surgery inpatient discharges (ICD-9-CM:44.31, 44.39) with mention of circular staplers were identified in the Premier Perspective® Database for CY2008 and CY2009. Esophageal balloon dilation procedure codes (CPT:43235, 43245; ICD-9-CM:44.22) for inpatient and outpatient discharges were used to identify single or multiple strictures within 6 months following bariatric surgery. Groups were propensity score matched (1:1) on age, gender, race, region, hospital teaching status and APR-DRG severity. The initial bariatric surgery costs, hospital length of stay (LOS) and operating room (OR) time between the stricture and no-stricture groups were compared between the matched groups. The cost of strictures was assessed for patients in the stricture group. A total of 4,731 laparoscopic bariatric surgery discharges utilizing circular staplers were identified. 201(4.3%) of these had a mention of at least one balloon dilation procedure within 6 months of the index procedure. 170 (84.6%) and 31(15.4%) were performed in outpatient and inpatient settings, respectively. 200 patients were propensity matched between the stricture and no-stricture groups. There were no significant differences in initial bariatric surgery costs, LOS and OR time between groups .For the outpatient setting; mean total costs of 1st (N=169), 2nd (N=29), 3rd (N=7) and the 4th stricture (N=3) were $1251, $1025, $1603 and $1610 respectively. One patient had more than 4 strictures. For the inpatient setting, mean total cost was $7110 for the 1st (N=31) stricture. Post surgical strictures can increase treatment costs for laparoscopic bariatric surgery patients utilizing circular staplers.

Cerebral aneurysms are pathological dilatations of the cerebrovasculature that are prone to rupture. Risk of aneurysm rupture is determined by size, location and patient co-morbidies, and five-year cumulative rupture rates have been reported to be as high as 50% in giant aneurysms [1]. The current study was undertaken to assess the differences in overall hospital discharge costs, length of stay (LOS) and all-cause mortality rates between inpatients with ruptured versus. unruptured cerebral aneurysms. All inpatient discharges were selected from the Premier Perspective™ Database that had a primary diagnosis code for a ruptured or unruptured aneurysm, AND a primary procedure code for treatment of the aneurysm between 1/1/2008 and 6/30/2010 (index hospitalization). Costs, LOS and mortality were compared between ruptured and unruptured aneurysm groups. To minimize differences in baseline characteristics between groups, propensity adjustment was performed for age, gender and severity of illness (based on the Patient Refined Diagnosis Related Groups). A total of 2977 ruptured and 3836 unruptured aneurysm discharges met the inclusion criteria for the study. After 1:1 propensity matching, 1163 patients in each group were included in the analysis for outcome comparisons. Mean total cost per discharge was significantly higher in the ruptured group ($51,118, s.d. $33,790) than the unruptured group ($33,585, s.d. $32,255). Mean LOS was also significantly higher in the ruptured group (13.6 days, s.d. 12.7) versus. the unruptured group (6.5 days, s.d. 11.2). The all-cause mortality rate was significantly higher in ruptured (7.7%) versus. unruptured (1.8%) cerebral aneurysms. Preventing rupture in patients with cerebral aneurysms would likely decrease burden to the health care system, and also improve survival rates for patients. 1International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured Intracranial Aneurysms: Natural History, Clinical Outcome, and Risks of Surgical and Endovascular Treatment. ([1] Lancet; 2003; 362:103-10)

Laparoscopic thoracic procedures have often been associated with shorter hospitalizations. However, the economic impact of laparoscopic thoracic procedures compared to open thoracic procedures have not been fully assessed. In this study, we examined the differences in cost and hospital length of stay for open versus laparoscopic thoracic procedures in the United States. The Premier Perspective™ Database (PPD) was used to estimate the incidence and costs of laparoscopic versus open thoracic procedures in the United States. PPD is the largest hospital-based database in the USA providing detailed resource utilization and cost data. Patients with principal procedure codes for open or laparoscopic procedures between January 1, 2007 through December 31, 2009 were selected. Combinations of ICD-9 diagnosis codes and CPT procedure codes were used to identify surgical site infections, hemorrhage and blood transfusions. A total of 22,640 patients with a primary procedure code for thoracic procedures were identified between January 1, 2007 and December 31, 2009. The surgical approach was laparoscopic in 57.3% patients, and open in 42.7% patients. Mean cost per discharge was significantly higher in open thoracic procedures compared to laparoscopic procedures, $24,995 vs. $19,238, respectively(p<0.001). Patients undergoing laparoscopic thoracic procedures had a significantly lower rate of surgical site infections compared to patients who underwent open procedures (4.8% vs. 5.8%, respectively, p<0.001). There was a significantly higher rate of blood transfusions with patients undergoing open surgery compared to patients undergoing laparoscopic procedures (13.2% vs. 6.3%, respectively, p<0.001). Laparoscopic thoracic procedures were associated with shorter hospital lengths of stay, lower rate of surgical site infections, hemorrhage, blood transfusion and mortality rates. The mean costs for laparoscopic procedures were significantly lower than mean costs for open procedures. These observations highlight the potential cost advantages of providing thoracic procedures through laparoscopic techniques as a method to potentially save increasingly scarce healthcare funds for hospitals.

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