Assessment of the Cost of the Mediterranean Diet in a Low-Income Region: Adherence and Relationship with Available Incomes

Background The Mediterranean Diet (MD) is recognized as heart-healthy, but the economic cost associated with this type of diet has scarcely been studied. The objective of the present study is to explore the cost and adherence of a low-income region population to the MD and its relationship with income. Methods A population-based study was carried out on 2,833 subjects between 25 and 79 years of age, 54% women, selected at random from the municipalities of Vegas Altas, La Siberia and La Serena in the province of Badajoz, Extremadura (Spain). Average monthly cost of each product included in the MD was computed and related to adherence to the MD using the Panagiotakos Index and average disposable income. Results The monthly median cost was 203.6€ (IQR: 154.04-265.37). Food-related expenditure was higher for men (p<0.001), age cohort between 45 and 54 years (p<0.013) and those living in urban areas (p<0.001). A positive correlation between food-related expenditure and the MD adherence was found. Monthly median cost represents 15% of average disposable income, ranging between 11% for the group with low MD adherence and 17% for the group with high MD adherence. Conclusions The monthly cost of the MD was positively correlated with the degree of adherence to this dietary pattern. Given that the estimated monthly cost is similar to that of other Spanish regions with a higher income level, the economic effort required to be able to afford the Mediterranean diet is higher. This may represent a barrier to access, which should be analyzed in detail by public decision-makers.

Universal Dental Adhesives: Cost-Effectiveness and Duration of Use

The purpose of this study was to conduct a cost-effectiveness analysis (CEA) of different brands of universal dental adhesives used for composite restorations. Four adhesive brands were included: Single-Bond Universal (SB), Tetric N-Bond Universal VivaPen (TN), OptiBond All-In-One (OB), and G-Premio Bond (GP). Adhesives were applied 5 times daily in a standardized class II cavity onto a plastic tooth. A precision-analysis scale was used to measure all of the following parameters before and after use: adhesive bottle, applicator, dosing plate, and plastic tooth. CEA was done by measuring the amount of material utilized/day, waste/day, efficacy, efficiency, average cost-effectiveness ratio (ACER), and incremental cost-effectiveness ratio (ICER). Data were analyzed using Kruskal–Wallis and Dunn’s tests with Bonferroni correction at 0.05 significance level. CEA tested parameters were significantly different between groups (p < 0.001) except for ICER (p = 0.112). GP was the least effective (median = 0.062), and SB was the least efficient (median = 0.366). The highest and lowest ACER values were associated with TN (median cost ≈ USD 317) and SB (median cost ≈ USD 317), respectively. ICER analysis reported an incremental cost for extra material utilized per milliliter of ≈USD 208 for TN, USD 3.8 for GP, and USD −38 for OB, compared to SB. TN seems to be the most efficient and cost-effective dental adhesive.

Outcomes of Complete Surgical Repair Versus Palliative Intervention in Neonates with Tetralogy of Fallot

Background: Surgical management of symptomatic neonates with Tetralogy of Fallot (TOF) is controversial. Either primary surgical repair (EPSR) in neonates with TOF or a staged palliation with initial palliative intervention (PI). Aim: Compare outcomes of neonates with TOF who had EPSR and those who had PI. Materials and Methods: The study utilized the US National Inpatient Sample dataset for the years 2000 to 2018. Patients with EPSR and those with PI (aortic to pulmonary shunt or cardiac catheter palliative intervention) identified. Results: A total of 29,292 neonates with TOF were identified; of them 1726 neonates had EPSR, 4363 had PI. Hospital mortality was similar in both groups (PI 7.4% vs EPSR 8.0%, p = 0.41). Patient in the PI group had more comorbidities; chromosomal anomalies (PI 13.2% vs. ESPR 7.8%, p < 0.001), prematurity (PI 15.1% vs. EPSR 10.4%, p < 0.001), and low birth weight < 2500 grams (PI 15.4% vs. EPSR 10.3%, p < 0.001). Median length of stay and median cost of hospitalization were significantly higher in the EPSR (25 days vs. 19 days, and $312,405 vs. $191,863, respectively, p < 0.001). Conclusion: EPSR had similar mortality to PI but comes with a higher resource utilization and complications. If we include the cumulative morbidity and resource utilization associated with a two staged repair, EPSR could be proven as a better strategy in symptomatic neonates with TOF. A prospective superiority study on symptomatic neonates with TOF randomized to either ESPR or PI is needed to further answer this question.

Trends in Utilization of Stored Cryopreserved Autologous Peripheral Hematopoietic Cells (APBHC) Intended for a Second (or beyond) Autologous Hematopoietic Cell Transplantation (AHCT) in Patients with Multiple Myeloma (MM): A Single Center Experience

Background: AHCT is a standard of care treatment for eligible patients (pts) with MM. Most consensus guidelines recommend that at the time of first AHCT, enough APBHC should be collected to perform two AHCT. However, recent studies have shown that with each decade after 1990, the use of cryopreserved APBHC for a salvage AHCT has declined and is now in the range of 4.6-15% in the decade between 2010-2018. The collection and storage of APBHC for two AHCT incurs additional costs and a prior single center cost analysis revealed that having had collected for just one AHCT in a cohort of 726 MM pts would have saved 3.8 million USD between 1993 and 2011. 1 Most centers that perform AHCT for MM pts continue to collect and store PBAHC for 2 AHCT. Herein we evaluate utilization trends and costs associated with cryopreserved APBHC in patients with MM. Methods: We retrospectively evaluated the clinicopathologic data from 440 patients with MM who underwent APBHC mobilization and collection at Mayo Clinic Florida between 2010 and 2019. The number of apheresis/collection sessions and APBHC product collection yields were determined for patients who were mobilized by any method. We estimated the costs involved in PBSC collection (apheresis) and cryopreservation storage based on our institution-specific charges as of May 2021. The cost of 1 session of APBHC collection/apheresis was $4,680 and the cost of 1 year of APBHC cryopreservation was $4,790 per patient. Statistical analysis was performed using JMP Pro 15 (SAS). Chi-square and Fischer exact tests were used to carry out univariate analysis for categorical variables and Wilcoxon rank sum/Kruskal Wallis for continuous variables. Results: Patient demographics are shown in Table 1. 440 pts underwent at least one collection session and 347 underwent at least 1 AHCT. The median number of mobilization sessions was 1 (95% CI 1.0-1.03), the median number of collection/apheresis sessions was 2.0 (95% CI 2.39-2.59), 84.3% (n=371) required ≥1 collection session. The median number of CD34 stem cells collected was 7.6 x10 6 (95% CI 7.76-8.19 x10 6), and the median number of infused CD34 cells was 4 x10 6(95% CI 4.13-4.37x10 6). The median cost of total collection sessions (defined as # of apheresis/collection sessions x $4,680) was $9,360 per pt (95% CI $11,181-$12,100). The median cost of cryopreservation (defined as # of years of storage x $4,790) was $19,160 per pt (95% CI $9,682-$22,252). The median number of years of storage was 4 (95% CI 4.11-4.65). 77(17.5%) pts have had APBHC in storage for &lt;2 years, 218 (49.5%) have had APBHC in storage for 2-5 years, and 145 (33%) had have APBHC in storage for &gt;5 years. The median time from MM diagnosis to AHCT was 9.0 months (range 13.8-18.5). 82% of patients collected enough APBHC (≥6x10 6, at least 3x10 6 per AHCT)for 2 AHCT. 8% of patients had all APBHC infused during their first AHCT, 83.5% had half of their APBHC infused during their first AHCT, and 8.1% had a different amount of APBHC infused during their first AHCT thus 91.6% of patients who collected APBHC had cells in storage. The median OS for the entire cohort after AHCT was 94.7 months (95% CI 88.6-100). Out of 347 patients who had stem cells in cryopreservation, 5 (1.4%) underwent a salvage AHCT and 3 (0.9%) underwent a tandem AHCT. 61% percent of patients had ≥1 excess collection sessions for APBHC that ultimately went unused. The median cost of excess collection sessions was $4,680 per pt (range, $4,680-$32,760) and the median total cost for excess collection sessions plus costs for storage was $23,840 per pt (range, $4,680-$85,450). The sum of costs of excess collection sessions was $2,077,920 and the sum of costs of cryopreservation was $5,812,665. Conclusion: The results of this single center analysis show that only 1.4% of patients underwent a salvage AHCT between 2010 and 2019 while 91.6% had APBHC left in storage which confirms the increase in storage of cryopreserved APBHC and declining trend in the use of stored APBHC for salvage AHCT in pts with MM. This is likely due to the advent of next generation novel therapies such as monoclonal antibodies, proteasome inhibitors and immunomodulatory agents. Excess collections, and cryopreservation of unused APBHC incur a cost of nearly $8 million. Institutional policies regarding universal APBHC collection and long-term storage should be reevaluated. 1Phipps C, et al. Bone Marrow Transplantation 2015:50;663-667. Figure 1 Figure 1. Disclosures Murthy: CRISPR Therapeutics: Research Funding. Ailawadhi: Sanofi: Consultancy; Medimmune: Research Funding; Genentech: Consultancy; Ascentage: Research Funding; Pharmacyclics: Consultancy, Research Funding; Xencor: Research Funding; Janssen: Consultancy, Research Funding; Amgen: Consultancy, Research Funding; AbbVie: Consultancy; Beigene: Consultancy; GSK: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Takeda: Consultancy; Cellectar: Research Funding; Karyopharm: Consultancy.

Healthcare utilisation after discharge in patients admitted with gout in Western Australia

Objectives Evidence suggests that gout is associated with high health care costs and that many inpatient admissions are preventable. Understanding the drivers of health care costs in patients with gout will allow more targeted intervention. The objective was to examine factors associated with high health service utilisation and costs in patients admitted to hospital with gout. Methods Hospital and emergency department data was obtained for patients who had been admitted to hospital with a diagnosis of gout for the first time between 2002 and 2009. The total number, cost and potentially preventable events for the follow-up period was calculated for up to five years post the initial gout hospitalisation. The association between patient characteristics with health service utilisation and health care costs was examined using generalised linear models. Results The cohort included 4,379 individuals, that had 22,222 ED attendances (median cost: $1,826 per patient, IQR: $433 - $4,414), and 58,920 hospital admissions (median cost: $25,009 per patient, IQR: $6,844 - $60,535). Gout was not a primary driver of ED attendances or hospitalisations. A history of smoking and comorbidities including cardiovascular disease, diabetes and mental health disorders were associated with an increase health service utilisation and costs. Conclusion The presence of comorbidities play an important role the risk of health service utilization in people with gout and represents an opportunity to both improve the health-related outcomes for these patients and reduce re-presentations and associated health care costs for the health care system.

The impact of childhood RSV infection on children's and parents' quality of life: a prospective multicenter study in Spain

Background Several immunisation candidates against RSV are in late-stage clinical trials. To evaluate the benefits of a potential vaccination programme, both economic and health benefits will be needed. Health benefits are usually measured in Health-related Quality of Life (HRQoL) loss using standardised questionnaires. However, there are no RSV-specific questionnaires validated for children under 2 years, in whom most RSV episodes occur. Therefore, HRQoL estimates are taken from literature or inadequate tools. We determined HRQoL loss and direct costs due to an RSV episode in children younger than 2 years and their caregivers during a month of follow up, using a new questionnaire administered online. Methods An observational prospective multicentre surveillance study was conducted in children aged younger than two years. Children were recruited from 8 primary care centres and 1 hospital in the Valencia region and Catalonia (Spain). RSV-positive cases were obtained by immunochromatographic test. HRQoL was assessed using a new ad-hoc 38 item-questionnaire developed. Parents of infected children completed 4 questionnaires at four timepoints (day 0, 7, 14 and 30) after diagnosis. Results 117 children were enrolled in the study and 86 (73.5%) were RSV + . Median (interquartile range; IQR) scores were 0.52 (0.42–0.68), 0.65 (0.49–0.79), 0.82 (0.68–0.97) and 0.94 (0.81–1), for days 0, 7, 14 and 30, respectively. Compared to total recovery (Q30), HRQoL loss was 37.5%, 31.5% and 8.9% on days 0, 7 and 14 since diagnosis of the disease. The total median cost per patient (including treatments) was €598.8 (IQR: 359.63–2425.85). Conclusions RSV had almost 40% impact on HRQoL during the first week since onset of symptoms and the median cost per episode and patient was about €600. These results represent a substantial input for health-economic evaluations of future RSV-related interventions such as vaccination.

Cost of an unforced error in tennis: a statistical approach

The objective of this paper is to (1) introduce a scientific way of measuring the cost of an unforced error in tennis during various match situations and (2) to provide a basis for players and coaches to choose the right strategy among extremely cautious and adventurous playing styles based on a statistical approach. To do this, we analyzed a total of 2,490 different match situations. The results of this study show that the cost of an unforced error varies greatly depending on the match situation. Players are better served by playing a high percentage, low-risk game in situations when the cost of an unforced error is higher than the median cost and adapt a high-risk approach when it is lower than the median cost.

Utilization, Complications, and Costs of Inpatient versus Outpatient Total Elbow Arthroplasty

Background Although total hip and knee arthroplasty have largely moved to the outpatient setting, total elbow arthroplasty (TEA) remains a predominantly inpatient procedure. Currently, evidence on the safety and potential cost savings of outpatient TEA is limited. Therefore, we aimed to compare the costs and complications associated with performing TEA in the inpatient versus outpatient setting. Methods We identified patients who received elective TEA using the Truven Health MarketScan database. Outcomes of interest were 90-day complication rate, readmission rate, and procedure costs in the inpatient and outpatient settings. We used propensity score matching and logistic regression analysis to assess how patient comorbidities and surgical setting influenced complications and readmission rates. The median cost per patient was compared using the Mann-Whitney U test. Results We identified 307 outpatient and 414 inpatient TEA procedures over a 9-year period. Elixhauser comorbidity scores were higher for the inpatient cohort. The incidence of surgical complications was significantly higher in the inpatient than the outpatient cohort (27% vs 9%). The odds of 90-day readmissions were similar in the 2 groups (37% vs 25%). In terms of cost, the median inpatient TEA was more expensive than outpatient TEA ($26 817 vs $18 412). However, the median cost for occupational therapy within 90 days of surgery was higher for outpatient TEA patients ($687 vs $571). Conclusions The results of this study demonstrate that surgeons can consider a transition toward outpatient TEA for patients without significant comorbidities, as this will substantially reduce health care costs.

A pre-pandemic COVID-19 assessment of the costs of prevention and control interventions for healthcare associated infections in medical and surgical units in Québec

Background Healthcare-associated infections (HCAIs) present a major public health problem that significantly affects patients, health care providers and the entire healthcare system. Infection prevention and control programs limit HCAIs and are an indispensable component of patient and healthcare worker safety. The clinical best practices (CBPs) of handwashing, screening, hygiene and sanitation of surfaces and equipment, and basic and additional precautions are keystones of infection prevention and control (IPC). Systematic reviews of IPC economic evaluations report the lack of rigorous empirical evidence demonstrating the cost-benefit of IPC program in general, and point to the lack of assessment of the value of investing in CBPs more specifically. Objective This study aims to assess overall costs associated with each of the four CBPs. Methods Across two Quebec hospitals, 48 healthcare workers were observed for two hours each shift, for two consecutive weeks. A modified time-driven activity-based costing framework method was used to capture all human resources (time) and materials required (e.g. masks, cloths, disinfectants) for each clinical best practice. Using a hospital perspective with a time horizon of one year, median costs per CBP per hour, as well as the cost per action, were calculated and reported in 2018 Canadian dollars. Sensitivity analyses were performed. Results A total of 1831 actions were recorded. The median cost of hand hygiene (N = 867) was 19.6 cents per action. For cleaning and disinfection of surfaces (N = 102), the cost was 21.4 cents per action, while cleaning of small equipment (N = 85) was 25.3 cents per action. Additional precautions median cost was $4.13 per action. The donning or removing or personal protective equipment (N = 720) cost was 75.9 cents per action. Finally, the total median costs for the five categories of clinical best practiced assessed were 27.2 cents per action. Conclusion The costs of clinical best practices were low, from 20 cents to $4.13 per action. This study provides evidence based arguments with which to support the allocation of resources to infection prevention and control practices that directly affect the safety of patients, healthcare workers and the public. Further research of costing clinical best care practices is warranted.

AB0806 THE JOURNEY OF AXIAL SPONDYLOARTHRITIS IN SPAIN: FROM THE GENERAL PRACTITIONER TO THE RHEUMATOLOGIST

Background:The delay in the diagnosis of axial spondyloarthropathies (AxSp), with the morbidity and economic burden that this entails, is well known1,2. According to the 2017 Atlas of axial spondyloarthritis in Spain3, the mean diagnostic delay was 8,5 years, with an average total cost per patient of 659,8€ including medical consultations and complementary tests until diagnosis. However, nowadays there are still many patients who are incorrectly referred from the general practitioner (GP) despite showing typical features of AxSp.Objectives:To describe the AxSp journey until diagnosis and treatment. To analyze additional costs of either a wrong or a delayed referral of the patients with AxSp to rheumatologists.Methods:Type of study: observational, retrospective, descriptive. We included all the patients who were referred to our Department of Rheumatology from Jan-2019 to Dec-2020 and whose final diagnosis was AxSp. All the data since the first contact to the GP until the final diagnosis and initiation of treatment in Rheumatology were collected, including consultations to our emergency department (EmD) and other specialists. The number of consultations, complementary tests (analytical and imaging), as well as the direct costs of all of them were also collected4. A descriptive and associative analysis of these data was carried out using the SPSS software. We used median and interquartile range (IQR) for descriptive analysis and a significant p value < 0,05.Results:From Jan-2019 to Dec-2020, 15 patients with AxSp and a median age of 43 (Interquartile range (IQR) 34-51) years were diagnosed, 10 women and 5 men. The main reason for referral was inflammatory low back pain (66.7%). The 60% of the patients were referred from the GP, followed by the EmD (20%). Despite typical symptoms, 4 patients (26,7%) were initially referred to Traumatology, and 3 out of them returned to the GP without the right diagnosis.The median delay for referral from the GP to the rheumatologist was 47 (IQR 20-173) days. A wrong referral of the patient was associated with a delayed diagnosis (p 0, 018) and higher direct costs of management (p 0, 018). The average cost (including medical consultation and complementary tests) of the patient referred directly to Rheumatology was 267,71 (IQR 193,7-462,3) €, while the average cost of patients referred to other specialists was 578,83 (IQR 368,32-898,7) €. The extra cost of a wrong referral of a patient with AxSp was 311€ on average per patient in our sample (Table 1).Table 1.Women/men10/5Median age (years; IQR)43; 34-51Median diagnostic delay (days; IQR)45; 20-173Median cost of patient referred initially to Rheumatology (€; IQR)267,71; 193,7-462,3Median cost of patient referred initially to another specialist (€; IQR)578,83; 368,32-898,7Extra cost of wrong referral per patient(€)311Conclusion:AxSp is still a disease with a not negligible diagnostic delay, but it seems to be lower than previously reported. A wrong referral of the patient to other specialists, mainly Traumatology, is associated with this delay and can double the cost of managing these patients. This demonstrates the still unmet need of improving the management and referral of the patients with AxSp from the GP to the rheumatologist, ensuring an early diagnosis and treatment at the lowest cost for the system. Our study has limitations due to its small sample size, but preliminary results indicate that a larger-scale study would be necessary to correctly assess the magnitude of this problem.References:[1]Fernández Carballido C. Diagnosing early spondyloarthritis in Spain: the ESPeranza program. Reumatol Clin. 2010;6(SUPPL. 1):6-10[2]Muñoz-Fernández S et al. A model for the development and implementation of a national plan for the optimal management of early spondyloarthritis: The Esperanza Program. Ann Rheum Dis. 2011;70(5):827-830[3]Garrido Cumbrera M et al. Atlas de Espondilartritis Axial En España 2017. Vol 45.; 2017.[4]Generalitat Valenciana. LEY 20/2017, de 28 de diciembre, de la Generalitat, de tasas. [2017/12159]:96-222.Acknowledgements:We would like to thank Novartis for its support.Disclosure of Interests:None declared