As of December 2020, COVID19 has infected over 13 million Americans and killed over 275,000. Each infection surge leads to increased emergency department (ED) utilization and subsequent critical care admission for patients with acute respiratory distress syndrome (ARDS). Not all COVID19 patients necessitate a ventilator and therefore can remain at home to minimize infection spread and manage hospital capacity concerns. Remote Bluetooth-enabled pulse-oximeter monitoring of moderate-to-severely ill COVID19 patients can be used to closely monitor symptoms and trigger necessary visits to the hospital. Our objective was to analyze remote pulse-oximeter monitoring cost-effectiveness to reduce facility burden and health expenditures. We analyzed home-monitoring with pulse-oximetry cost-utility using a Markov model over a 3-week time horizon in daily cycles from a US health sector perspective. Cost and outcome measures were derived from real-world evidence from University Hospitals. Pulse-oximetry monitoring was implemented for patients presenting at the ED with ARDS-like symptoms but not necessitating immediate care; patients were then remotely monitored by experts for up to 4-days until recovery or a second ED visit. Additional parameters were extracted from literature. Costs (2020 U.S. dollars) and quality-adjusted life years (QALYs) were used to determine the incremental cost-effectiveness ratio (ICER) at a $100,000/QALY cost-effectiveness threshold. Model uncertainty was assessed using one-way and probabilistic sensitivity analysis. Results demonstrated that pulse-oximetry monitoring dominated current standard care for COVID19 patients based on reduced costs and increased QALYs. Individuals with access to remote pulse-oximetry monitoring averaged $49,176 and 0.03 QALYs, whereas standard care increased costs to $113,792 and 0.02 QALYs. Resulting ICER was not sensitive to uncertainty ranges. Remote pulse-oximetry monitoring of symptomatic COVID19 patients increases the specificity of those requiring immediate follow-up. We recommend adoption of this technology across health systems to cost-effectively manage COVID19 volume surges, maintain patients' comfort, reduce infection spread, and simultaneously monitor multiple patients.

Pressure injuries (PrI) in nursing homes (NH) cause significant morbidity and escalating costs. International guidelines suggest repositioning every 2 to 4 hours to prevent PrI. Our objective was to analyze the cost-effectiveness of 3 PrI prevention repositioning frequencies at 2-, 3- and 4-hour intervals to reflect the value of nursing time spent caring for U.S. NH residents. We analyzed resident repositioning frequency cost-utilities using a Markov model to capture US health sector perspectives over a 1-year horizon in hourly cycles. Parameters were abstracted from published literature and the TEAM-UP clinical trial. Although the TEAMP-UP trial observed zero pressure injuries, our model assumed variability in pressure injury rates based on hourly repositioning regimens to reflect potential real-world outcomes. Costs were measured in U.S. dollars, and effectiveness in quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICER) were derived for each comparator at a $100,000/QALY willingness-to-pay threshold. One-way and probabilistic sensitivity analyses (PSA) tested model uncertainty. Base case estimates demonstrated 4-hours is a cost-effective alternative to 2- and 3-hour repositioning frequencies. Relative to 2-hour repositioning at a cost of $129,947 and 1.97 QALYs per-patient, 3-hour resulted in $116,887 and 1.78 QALYs, and 4-hour resulted in $110,945 and 1.70 QALYs. The ICERs indicated that 3- and 4-hour intervals were cost-effective relative to 2-hours at ICERs of $69,124/QALY and $69,752/QALY respectively. Nursing time cost due to repositioning and hourly prevention were the most sensitive parameters. At lower willingness-to-pay thresholds of $70,000 or less, PSAs demonstrated 4-hour intervals were more cost-effective in most simulations. Above $70,000, 2-hour repositioning protocols were more cost-effective. Cost-effectiveness evaluation of 3- and 4-hour repositioning frequencies demonstrates potential for reduced labor costs and shifting of human and financial resources to support other aspects of PrI prevention and long-term nursing tasks, without significant decrements in NH resident outcomes.

Pressure injuries (PrI) in nursing homes (NH) cause significant morbidity and escalating costs. Technology advances may offer nurses a reduced time commitment to prevention while maintaining patients' safety. Our objective was to analyze the cost-effectiveness of 3 PrI prevention protocols with varied repositioning frequencies to reflect the value of nursing time caring for U.S. NH residents. We analyzed repositioning frequency cost-utilities at 2-, 3- and 4-hour intervals to prevent PrIs. A Markov model captured US societal and health sector perspectives over a 1-year time horizon in hourly cycles. Data parameters were abstracted from published literature and the TEAM-UP clinical trial. Model outcomes were driven by nursing time costs associated with prevention protocols. Costs were measured in U.S. dollars, and effectiveness in quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios (ICER) were derived for each comparator at a $100,000/QALY willingness-to-pay threshold. One-way and probabilistic sensitivity analyses (PSA) tested model uncertainty. Repositioning frequencies at 3- and 4-hours were associated with lower projected nursing time costs than the 2-hour frequency care standard. Relative to 2-hour repositioning at a cost of $135,500 and 7.59 QALYs per-patient, 3-hour resulted in $123,369 and 6.47 QALYs, and 4-hour resulted in $117,769 and 6.33 QALYs. The ICERs indicated that 3- and 4-hour intervals were cost-effective relative to 2-hours at ICERs of $10,862/QALY and $14,021/QALY respectively. Nursing time cost is the most sensitive parameter in this model. PSAs demonstrated 4-hour intervals were cost-effective in 100% of simulations. Repositioning is an accepted PrI prevention strategy with every 2-hour repositioning defined as standard of care. Cost-effectiveness evaluation of 3- and 4-hour repositioning frequencies demonstrates their potential for reduced labor costs and shifting of human and financial resources to support other aspects of PrI prevention.

Severe, neonatal onset mitochondrial disorders (MitD) are difficult to diagnose and cause substantial strain on patients and caregivers. This study explores the value of Early Whole Exome Sequencing (eWES), an expensive, last-line diagnostic, relative to the current standard of care (SOC) for the diagnosis of newborns suspected of having a severe MitD. We conducted a cost-effectiveness analysis from the US societal perspective, using a hybrid decision tree Markov model, over a 25-year time horizon and an annual 3% discount rate. Parameters were populated using published literature values of comparable disease states, expert opinion and the Pediatric Health Information System database, which collects inpatient encounter data from 47 U.S. children’s hospitals. Incremental cost-effectiveness ratios and incremental net monetary benefits (iNMB) were calculated relative to the SOC. One-way sensitivity analyses, probabilistic sensitivity analyses (PSA) and cost-effectiveness acceptability curves were also generated. INMBs of eWES relative to SOC at a willingness to pay (WTP) of $50,000 and $200,000 per quality-adjusted life year for the base case were $24,888 and $25,200, respectively. eWES, SOC diagnostic probabilities and neonatal intensive care unit length of stay were revealed as important parameters driving base case results. PSA revealed that eWES had a 68% likelihood of being cost-effective at a WTP of $50,000, a 74% likelihood of being cost-effective at $200,000 and 66% likelihood of being cost-effective at $0. EWES dominates SOC in diagnosing patients suspected of having a MitD. As the WTP threshold increases, eWES increasingly becomes more likely to be cost-effective relative to SOC, indicating that the mechanism of cost-effectiveness is cost-minimization. Our findings demonstrate this current wave of innovative sequencing is a cost-effective measure for diagnosing severe MitD in select neonates, while also highlighting future research necessary to determine the value of genetic diagnostics for MitD neonates.

# 1 Is laparoscopic sleeve gastrectomy a reasonable stand-alone procedure for super morbidly obese patients? {#article-title-2} Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well established standard of care in the treatment of obesity and its associated comorbidities. Laparoscopic sleeve

The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will he accomplished by bilateral nl stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization anti will participate in a maintenance program of pulmonary rehabilitation after randomization, The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs, In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function, The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.