No abstract

ᅟWe analyze one-year costs and savings of a telemedically supported case management program after kidney transplantation from the perspective of the German Healthcare System. Recipients of living donor kidney transplantation (N = 46) were randomly allocated to either (1) standard aftercare or (2) standard aftercare plus additional telemedically supported case management. A range of cost figures of each patient’s medical service utilization were calculated at month 3, 6 and 12 and analyzed using two-part regression models.In comparison to standard aftercare, patients receiving telemedically supported case management are associated with substantial lower costs related to unscheduled hospitalizations (mean difference: €3,417.46 per patient for the entire one-year period, p = 0.003). Taking all cost figures into account, patients receiving standard aftercare are associated, on average, with one-year medical service utilization costs of €10,449.28, while patients receiving telemedically supported case management are associated with €5,504.21 of costs (mean difference: € 4,945.07 per patient, p < 0.001). With estimated expenditures of €3,001.5 for telemedically supported case management of a single patient, we determined a mean difference of €1,943.57, but this result is not statistically significant (p = 0.128). Sensitivity analyses show that the program becomes cost-neutral at around ten participating patients, and was beneficial starting at 15 patients. Routine implementation of telemedically supported case management in German medium and high-volume transplant centers would result in annual cost savings of €791,033 for the German healthcare system.Patients with telemedically supported case management showed a lower utilization of medical services as well as better medical outcomes. Therefore, such programs should be implemented in medium and high-volume transplant centers.Trial registrationDRKS00007634 (http://www.drks.de/DRKS00007634).

Objectives: There are few data available regarding the clinical course of tick-borne encephalitis virus (TBEV) vaccination breakthrough infections. The published studies suggest that vaccination breakthrough infections may have a more severe course than native TBEV infection in unvaccinated individualsdpotentially due to antibody-dependent enhancement. Here we report a large analysis of vaccination breakthrough infections. Methods: This retrospective analysis was based on a national surveillance dataset spanning the years 2001e2018. Variables reflecting disease severity, such as 'CNS symptoms', 'myelitis', 'fatal outcome' and 'hospitalization' were analysed as well as general epidemiological variables. Cases were categorized as 'unvaccinated' or 'ever vaccinated', the latter category including cases with at least one dose of a TBEV vaccine. Results: A total of 6073 notified TBEV infection cases were included in our analysis. Sufficient data on vaccination status were available for 95.1% of patients (5777/6073); of these, 5298 presented with a native infection. A total of (334/5777) cases developed an infection despite having been vaccinated at least once. Comparing unvaccinated patients with those with at least one vaccination, we find an odds ratio (OR) 2.73, (95% confidence interval (CI) 0.79e9.50) regarding the variable fatal outcome that did not reach statistical significance. Analysing the clinical variables 'CNS symptoms' and 'myelitis', there is no difference between these groups (OR 0.86, 95% CI 0.68e1.08; and OR 1.30, 95% CI 0.74e2.27 respectively). Patients who were vaccinated and had an assumed protection at symptom onset (n ¼ 100) had a higher risk for the development of myelitic symptoms (OR 2.21, 95% CI 1.01e4.86]) than unvaccinated patients. Conclusion: Our findings could neither verify that vaccination breakthrough infections might cause a more severe disease than native infections nor prove a clear antibody-dependent enhancement phenomenon. It remains unclear whether the increased myelitis risk in a subgroup of vaccinated patients is a true effect or confounded.

Patients with POD after TAVR are at increased risk for in-hospital mortality. However, after adjusting for postoperative events and comorbidities, stroke and bleeding, but not POD, are independent mortality predictors.

ObjectivesWe examine the volume–outcome relationship in isolated transcatheter aortic valve implantations (TAVI). Our interest was whether the volume–outcome relationship for TAVI exists on the centre level, whether it occurs equally for different outcomes and how it develops over time.DesignSecondary data analysis of electronic health records. The comprehensive German Federal Bureau of Statistics Diagnosis Related Groups database was queried for data on all isolated TAVI procedures performed in Germany between 2008 and 2014. Logistic and linear regression analyses were carried out. Risk adjustment was applied using a predefined set of patient characteristics to account for differences in the risk factor composition of the patient populations between centres and over time. Centres performing TAVI were stratified into groups performing <50, 50–99 and ≥100 procedures per year.SettingGermany 2008–2014.ParticipantsAll patients undergoing isolated TAVI in the observation period.InterventionsNone.Primary and secondary outcome measuresIn-hospital mortality, bleeding, stroke, probability of ventilation >48 hours, length of hospital stay and reimbursement.ResultsBetween 2008 and 2014, a total of 43 996 TAVI procedures were performed in 113 different centres in Germany with a total of 2532 cases of in-hospital mortality. Risk-adjusted in-hospital mortality decreases over the years and is lower the higher the annual procedure volume at the centre is. The magnitude of the latter effect declines over the observation period. Our results indicate a ceiling effect in the volume–outcome relationship: the volume–outcome relationship is eminent in circumstances of relatively unfavourable outcomes. Alongside improving outcomes, however, the volume–outcome relationship decreases. Also, a volume–outcome relationship seems to be absent in circumstances of constantly low event rates.ConclusionsThe hypothesised volume–outcome relationship for TAVI exists but diminishes and may disappear over time. This should be taken into account when considering mandatory minimum thresholds.