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.

Wide-necked bifurcation aneurysms (WNBAs) pose unique challenges for treatment via traditional endovascular approaches, due to the risk of coil herniation and the need to preserve patency in both parent and daughter vessels. The purpose of this study was to summarize published data associated with the occlusion of WNBAs via single and dual stent-assisted coil embolization. A systematic literature review was conducted using PubMed, Google Scholar, Ichushi, Cinii, and Medical Online databases. Studies were eligible for inclusion if they reported outcomes of interest for >10 patients between 1-Jan-2004 and 31-July-2018 in English or Japanese, and were not reviews, commentary, or case reports. At least 80% of the study population must have received endovascular treatment for unruptured or non-emergent WNBAs. Thirty-five publications (1,571 patients) were identified. Ten were non-randomized comparative studies while 25 were single-arm. Twenty utilized dual stent-assisted approaches (e.g., Y-stenting) and 15 utilized a single stent. Commonly reported outcomes included: complete/adequate occlusion, mortality, peri-procedural complications, technical success, recanalization, retreatment, and the modified Rankin Scale. No economic data or patient-reported outcome measures were described. With the exception of one study, assessment of clinical success was performed by the investigator rather than an independent core laboratory. Substantial variation was observed in occlusion rates for both single and dual stent-assisted treatment. For the single stent subgroup, complete occlusion ranged from 12.1-94.1% (immediate; n=9), 66.7-86.5% (6-12M; n=2), and 70.3-89.3% (12-24M; n=7). For the dual stent subgroup, complete occlusion ranged from 25.4-90.0% (immediate; n=10), 60.0-95.7% (6-12M; n=7), and 62.5-85.9% (12-24M; n=5). Retreatment and mortality were similarly reported with substantial variations. The evidence base for conventional endovascular treatments for WNBAs consists of low- to medium- quality studies with a limited scope of reported outcomes. As new therapies become available, conventional treatment approaches need to be better understood as an objective performance benchmark.

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.

Incremental improvements are inherent in medical devices; many of these can offer significant financial benefits which, ultimately, improve the cost-effectiveness of already established technologies. Biventricular pacing, commonly combined with a defibrillator ("Cardiac Resynchronization Therapy – Defibrillator" or CRT-D), has been widely used in patients with Heart Failure (HF) to increase survival, improve QoL, and reduce HF hospitalizations. Nevertheless, traditional CRT-D devices require periodic manual reprogramming (a.k.a. "optimization") guided by echocardiography. Newer devices equipped with innovative algorithms (AdaptivCRT™, Medtronic, MN, USA) monitor heart electrical activity and automatically reprogram the device once-per-minute. In addition to eliminating the manual process, AdaptivCRT™ appeared to positively impact patient allocation to functional classes (as defined by the New York Heart Association – NYHA) against traditional echo-based device optimization. We investigated the financial implications of AdaptivCRT™ in Japan. We conducted a Cost-Minimization Analysis (CMA), comparing AdaptivCRT™ with traditional optimization, using Markov processes. Patients progress from early-stage NYHA classes to more advanced disease, or death. The initial allocation of patients to the classes and the transition probabilities were based on the aCRT RCT. Each NYHA class is associated with higher levels of costs. We used the Japanese fee schedule, local HF treatment guidelines and prescription drug labelling to assess resource utilization within each class. Assuming 3,200 patients (the approximate number of Japanese CRT-D patients per annum), our model predicts overall cohort costs (excluding initial implant costs) of ¥16,545M (USD$165M) with AdaptivCRT™ and ¥17,809M (USD$178M) without. This equates to savings of approximately USD$13M overall, or USD$4,000 per patient. AdaptivCRT™ use appears associated with significant cost-offsets driven by superior outcomes. This demonstrates that incremental device therapy improvements can provide clinical and economic value. Further research should examine AdaptivCRT™ impact on health care utility and improvement in the overall cost-effectiveness of CRT-Ds.