Harold Hastings’s journal round-up for 24th December 2018

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Mandatory Medicare bundled payment program for lower extremity joint replacement and discharge to institutional postacute care: interim analysis of the first year of a 5-year randomized trial. JAMA [PubMed] Published 4th September 2018

I will focus on two themes: one local to the United States – bundled payments for Medicare, and one global – the economic burden of sepsis. Finkelstein, Ji, Mahoney, and Skinner described the results of a study aimed at assessing the effects of bundled Medicare payments (as opposed to payments for each component of treatment) upon care and costs of lower extremity joint replacement. Finkelstein et al. found only one significant difference between the bundled carte group and a control group: the percentage discharged to institutional care decreased from 33.7% in the control group to 30.8% in the bundled care group, that is, one fewer patient per 33 treated. There was no significant difference in costs or quality of care. In this sense I must differ from the optimism of an associated editorial; to me, a true success would include a significant reduction in cost together with an improvement in outcome. Thus, in terms of bundled Medicare payments, we are not at the end, not even the beginning of the end, but perhaps near the end of the beginning (my apologies to Winston Churchill).

Epidemiology and costs of sepsis in the United States—an analysis based on timing of diagnosis and severity level. Critical Care Medicine [PubMed] Published 1st December 2018

Epidemiology of sepsis in Brazil: incidence, lethality, costs, and other indicators for Brazilian Unified Health System hospitalizations from 2006 to 2015. PLoS One [PubMed] Published 13th April 2018

Sepsis care continues to pose among the most significant health challenges world-wide, both in terms of economics and mortality, with mortality ranging from 10% to almost 80% depending upon severity. In terms of cost, sepsis treatment in the US averages over $18,000 per hospitalization with almost 1 million cases admitted annually, while Brazil spends 1/30 of this amount (~$600 per hospitalization), and 1/10 of this amount for sepsis treatment in the ICU ($1,700 per hospitalization). Mortality in Brazil is higher than that in the US and higher in public hospitals than in private hospitals. The studies offer complementary suggestions for improvement: in the US study, Paoli et al. call for early detection of sepsis as a way to reduce its severity and thus its cost. In the Brazilian study, Neira et al. conclude that limited economic resources may contribute significantly to high mortality, an observation that should concern all of us interested in world-wide health. Clearly both improved detection and more effective, lower cost treatments are essential to address the health and economic burdens of sepsis. The following paper reviews a potential answer to the latter question – that of more effective, lower cost treatments.

Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Critical Care [PubMed] Published 29th October 2018

In terms of the cost of sepsis treatment, it is interesting to note that an intervention successful in a single-site, retrospective review involved a combination of three “cheap and readily available agents with a long safety record in clinical use since 1949.” Mortality decreased from 40% to 8.5%. The 2018 review describes mixed reaction based on informal cost/benefit/risk analysis while nine trials are underway. If these trials prove successful, it might be hoped that the low cost would spur world-wide incorporation of ascorbate-corticosteroid-thiamine therapy for sepsis – addressing world-wide incidence of 15 million cases annually and mortality approaching 60% in less developed countries. An optimist might even hope for reduced mortality at significantly reduced costs, reminiscent of oral rehydration therapy for diarrhoea developed in Bangladesh 50 years ago and responsible for a 90% relative reduction in mortality.

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