Mount Sinai Hospital

Indocyanine green fluorescence angiography is being increasingly used in colorectal surgery to reduce anastomotic leak risk, but few studies have analyzed its cost efficacy. In this study, cost modeling was used to compare costs in the United States using versus not using indocyanine green fluorescence angiography. Exhaustive searches of PubMed/MEDLINE, EMBASE, and Scopus were used to identify all meta-analyses and randomized controlled trials assessing the effectiveness of indocyanine green fluorescence angiography in reducing anastomotic leaks. Additionally, we conducted our own meta-analysis restricted to randomized controlled trials with ≥100 patients in both indocyanine green fluorescence angiography and control groups. Three years (2021-2023) of Medicare Provider Analysis and Review billing data were then employed to identify direct health care costs. Minimum, intermediate, and maximum cost analysis models were created using indocyanine green fluorescence angiography-associated anastomotic leak reduction rates identified by synthesizing the results of meta-analyses and randomized controlled trials, procedural and complication-related costs identified via Medicare Provider Analysis and Review, and $225 as the per-unit cost of indocyanine green administration. Synthesis of the results of our own and 19 published meta-analyses revealed a 51.9% reduction in anastomotic leak rate with indocyanine green fluorescence angiography, whereas 5 meta-analyses restricted to randomized controlled trials, including our own, revealed level 1 evidence of at least a 36.5% reduction. Minimum and maximum cost analysis models were generated using conservative anastomotic leak reduction rates of 35% and 50%, from which mean per-patient cost reductions ranged from $962 to $1,138, and overall health care system savings ranged from $71 million to $84 million. For anastomotic assessments in colorectal surgery, indocyanine green fluorescence angiography reduces direct per-patient health care costs in the United States by $962 to $1,138. Additional savings may be derived from reduced rehospitalization and reoperation rates.

Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality globally. Low-density lipoprotein cholesterol is a causal risk factor for atherosclerotic cardiovascular disease, with multiple classes of cholesterol-lowering therapies effective at reducing atherosclerotic cardiovascular disease risk. Despite robust efficacy data from randomized trials, real-world implementation of guideline-recommended lipid-lowering therapies is suboptimal. Barriers to the implementation of guideline lipid-lowering therapy recommendations exist at the healthcare systems level, the medical therapy level, and the patient level. A combination of strategies, including the incorporation of quality improvement and cost-effectiveness analysis among payers, pharmacist-based educational initiatives, digital health tools directed towards patients, the simplification of drug regimens via polypill, and emerging novel therapies, including PCSK9 gene silencing and editing technologies, may bridge these implementation gaps. This review highlights challenges and solutions to alleviating barriers to optimal implementation of guideline-recommended lipid-lowering therapies.