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QALY
Terms modified by QALY Selected AbstractsPatient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysisDIABETIC MEDICINE, Issue 2 2006R. F. Dijkstra Abstract Aims Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. Patients and methods In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. Results Glycated haemoglobin (HbA1c) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. Conclusion Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings. [source] The cost-effectiveness of continuous subcutaneous insulin infusion compared with multiple daily injections for the management of diabetesDIABETIC MEDICINE, Issue 7 2003P. Scuffham Abstract Aims To estimate the cost effectiveness of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) for patients using insulin pumps. Methods We constructed a Markov model to estimate the costs and outcomes for patients with insulin-dependent diabetes (IDDM) treated with CSII using an insulin pump compared with MDI. Key parameters were obtained from the published scientific literature. The primary outcome was quality-adjusted life years (QALYs). Monte Carlo simulations were undertaken for 10 000 hypothetical patients over 8 years of monthly cycles (the expected life of a pump). Results Over an 8-year period an average patient could expect to gain 0.48 [standard deviation (sd) 0.20] QALYs using CSII compared with MDI. The additional cost over 8 years for this gain was £5462 (sd£897). The incremental cost per QALY was £11 461 (sd£3656). CSII was most cost-effective in patients who had more than two severe hypoglycaemic events per year and who required admission to hospital at least once every year. Cases where CSII might be not economically viable are cases where diabetes is well controlled with few severe hypoglycaemic events. Results were most sensitive to the number of hypoglycaemic events per patient and the utility weights used to estimate QALYs. Conclusion CSII is a worthwhile investment when targeted to those who might benefit most. Diabet. Med. 20, 586,593 (2003) [source] Cost-effectiveness of extended buprenorphine,naloxone treatment for opioid-dependent youth: data from a randomized trialADDICTION, Issue 9 2010Daniel Polsky ABSTRACT Aims The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine,naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth. Design Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling. Participants 152 patients aged 15,21 years. Measurements Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12. Findings The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25 049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100 000 per QALY. Conclusions Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth. [source] If you try to stop smoking, should we pay for it?ADDICTION, Issue 6 2010The cost, utility of reimbursing smoking cessation support in the Netherlands ABSTRACT Background Smoking cessation can be encouraged by reimbursing the costs of smoking cessation support (SCS). The short-term efficiency of reimbursement has been evaluated previously. However, a thorough estimate of the long-term cost,utility is lacking. Objectives To evaluate long-term effects of reimbursement of SCS. Methods Results from a randomized controlled trial were extrapolated to long-term outcomes in terms of health care costs and (quality adjusted) life years (QALY) gained, using the Chronic Disease Model. Our first scenario was no reimbursement. In a second scenario, the short-term cessation rates from the trial were extrapolated directly. Sensitivity analyses were based on the trial's confidence intervals. In the third scenario the additional use of SCS as found in the trial was combined with cessation rates from international meta-analyses. Results Intervention costs per QALY gained compared to the reference scenario were approximately ,1200 extrapolating the trial effects directly, and ,4200 when combining the trial's use of SCS with the cessation rates from the literature. Taking all health care effects into account, even costs in life years gained, resulted in an estimated incremental cost,utility of ,4500 and ,7400, respectively. In both scenarios costs per QALY remained below ,16 000 in sensitivity analyses using a life-time horizon. Conclusions Extrapolating the higher use of SCS due to reimbursement led to more successful quitters and a gain in life years and QALYs. Accounting for overheads, administration costs and the costs of SCS, these health gains could be obtained at relatively low cost, even when including costs in life years gained. Hence, reimbursement of SCS seems to be cost-effective from a health care perspective. [source] Cost-effectiveness of pharmacy and group behavioural support smoking cessation services in GlasgowADDICTION, Issue 2 2009Kathleen A. Boyd ABSTRACT Aims Smokers attending group-based support for smoking cessation in Glasgow are significantly more likely to be successful than those attending pharmacy-based support. This study examined the cost-effectiveness of these two modes of support. Design Combination of observational study data and information from National Health Service (NHS) Greater Glasgow and Clyde smoking cessation services. Setting Glasgow, Scotland. Participants A total of 1979 smokers who accessed either of the cessation services between March and May 2007. Intervention Two smoking treatment services offering one-to-one support in pharmacies, and providing group counselling in the community. Measurements Routine monitoring data on resource use and smoking status (carbon monoxide-validated, self-reported, non-quitters and relapsers) at 4-week follow-up. Findings The incremental cost per 4-week quitter for pharmacy support was found to be approximately £772, and £1612 for group support, in comparison to self-quit cessation attempts. These findings compare favourably with previously published outcomes from cost-effectiveness smoking cessation studies. Assuming a relapse rate of 75% from 4 weeks to 1 year and a further 35% beyond 1 year, and combining this with an average of 1.98 quality adjusted life years (QALY) gained per permanent cessation, provides an estimated incremental cost per QALY of £4400 for the pharmacy service and £5400 for group support service. Conclusions Group support and pharmacy-based support for smoking cessation are both extremely cost-effective. [source] A cost-effectiveness analysis of caspofungin vs. liposomal amphotericin B for treatment of suspected fungal infections in the UKEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 6 2007Karin Bruynesteyn Abstract Objective:, To evaluate the cost-effectiveness of caspofungin vs. liposomal amphotericin B in the treatment of suspected fungal infections in the UK. Methods:, The cost-effectiveness of caspofungin vs. liposomal amphotericin B was evaluated using a decision-tree model. The decision tree was populated using both data and clinical definitions from published clinical studies. Model outcomes included success in terms of resolution of fever, baseline infection, absence of breakthrough infection, survival and quality adjusted life years (QALYs) saved. Discontinuation due to nephrotoxicity or other adverse events were included in the model. Efficacy and safety data were based on additional analyses of a randomised, double blind, multinational trial of caspofungin compared with liposomal amphotericin B. Information on life expectancy, quality of life, medical resource consumption and costs were obtained from peer-reviewed published data. Results:, The caspofungin mean total treatment cost was £9762 (95% uncertainty interval 6955,12 577), which was £2033 (,2489; 6779) less than liposomal amphotericin B. Treatment with caspofungin resulted in 0.40 (,0.12; 0.94) additional QALYs saved in comparison with liposomal amphotericin B. Probabilistic sensitivity analysis found a 95% probability of the incremental cost per QALY saved being within the generally accepted threshold for cost-effectiveness (£30 000). Additional analyses with varying dose of caspofungin and liposomal amphotericin B confirmed these findings. Conclusion:, Given the underlying assumptions, caspofungin is cost-effective compared with liposomal amphotericin B in the treatment of suspected fungal infections in the UK. [source] Quality-adjusted life years: how useful in medico economic studiesFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 6 2005Carmen A. Brauer Abstract Cost-effectiveness analysis has evolved as a practical response to the need to allocate limited resources for health care. It can be used to compare interventions whose effects on health are different if the measure of effectiveness captures all the important health dimensions of the effects of the interventions. Using the quality-adjusted life year (QALY) as the unit of effectiveness attempts to approach this ideal and is currently the approach recommended by many consensus groups. Conventional QALYs represent time spend in a series of "quality-weighted" health states, where the quality weights reflect the desirability of living in the state. Many challenges arise when preferences are incorporated into an economic analysis. The purpose of this paper is to highlight some of the issues surrounding the use of QALYs and to encourage researchers to present their methodology in a clear and transparent way. [source] Cost-utility analysis of Canadian tailored prophylaxis, primary prophylaxis and on-demand therapy in young children with severe haemophilia AHAEMOPHILIA, Issue 4 2008N. RISEBROUGH Summary. Primary prophylaxis is the emerging standard treatment for boys with severe haemophilia. Tailored (escalating-dose) prophylaxis (EscDose), beginning at a low frequency and escalating with repeated bleeding may prevent arthropathy at a lower cost than standard prophylaxis (SP). From a societal perspective, we compared the incremental cost per joint-haemorrhage that is avoided and quality-adjusted-life-year (QALY) gained of SP and EscDose to on-demand (Demand) therapy in severe haemophilia A boys treated to age 6 using a decision analytic model. Costs included factor VIII (FVIII), professional visits and tests, central venous placement/complications, hospitalization, home programmes and parents' lost work-days. Resource utilization was estimated by surveying 17 Canadian clinics. The natural history of bleeding and other probabilities were determined from a longitudinal chart review (n = 24) and published literature. EscDose costs an additional $3192 per joint-haemorrhage that was avoided compared with Demand whereas SP costs an additional $9046 per joint-haemorrhage that was avoided compared with EscDose. Clinic costs and lost wages were reduced by 60,80% for EscDose and SP compared with Demand. EscDose attained more QALYs than SP and Demand on account of less bleeding than Demand and lower need for ports than SP. The incremental cost per QALY for EscDose vs. Demand was $542 938. EscDose was less expensive with similar QALYs compared to SP. Sensitivity analysis was performed on all probability- and cost-estimates, and showed the model was sensitive to the cost of FVIII and the SP and target joint utilities. In conclusion, prophylaxis will substantially improve clinical outcomes and quality of life compared to Demand treatment, but with substantial cost. [source] International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness?HEALTH ECONOMICS, Issue 4 2010Takeru Shiroiwa Abstract Although the threshold of cost effectiveness of medical interventions is thought to be £20,000,£30,000 in the UK, and $50,000,$100,000 in the US, it is well known that these values are unjustified, due to lack of explicit scientific evidence. We measured willingness-to-pay (WTP) for one additional quality-adjusted life-year gained to determine the threshold of the incremental cost-effectiveness ratio. Our study used the Internet to compare WTP for the additional year of survival in a perfect status of health in Japan, the Republic of Korea (ROK), Taiwan, Australia, the UK, and the US. The research utilized a double-bound dichotomous choice, and analysis by the nonparametric Turnbull method. WTP values were JPY 5 million (Japan), KWN 68 million (ROK), NT$ 2.1 million (Taiwan), £23,000 (UK), AU$ 64,000 (Australia), and US$ 62,000 (US). The discount rates of outcome were estimated at 6.8% (Japan), 3.7% (ROK), 1.6% (Taiwan), 2.8% (UK), 1.9% (Australia), and 3.2% (US). Based on the current study, we suggest new classification of cost-effectiveness plane and methodology for decision making. Copyright © 2009 John Wiley & Sons, Ltd. [source] The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approachesHEALTH ECONOMICS, Issue 4 2009Fiona M. Clement (Nee Shrive) Abstract Background: Published guidelines on the conduct of economic evaluations provide little guidance regarding the use and potential bias of the different costing methods. Objectives: Using microcosting and two gross-costing methods, we (1) compared the cost estimates within and across subjects, and (2) determined the impact on the results of an economic evaluation. Methods: Microcosting estimates were obtained from the local health region and gross-costing estimates were obtained from two government bodies (one provincial and one national). Total inpatient costs were described for each method. Using an economic evaluation of sirolimus-eluting stents, we compared the incremental cost,utility ratios that resulted from applying each method. Results: Microcosting, Case-Mix-Grouper (CMG) gross-costing, and Refined-Diagnosis-Related grouper (rDRG) gross-costing resulted in 4-year mean cost estimates of $16,684, $16,232, and $10,474, respectively. Using Monte Carlo simulation, the cost per QALY gained was $41,764 (95% CI: $41,182,$42,346), $42,538 (95% CI: $42,167,$42,907), and $36,566 (95% CI: $36,172,$36,960) for microcosting, rDRG-derived and CMG-derived estimates, respectively (P<0.001). Conclusions: Within subject, the three costing methods produced markedly different cost estimates. The difference in cost,utility values produced by each method is modest but of a magnitude that could influence a decision to fund a new intervention. Copyright © 2008 John Wiley & Sons, Ltd. [source] On future non-medical costs in economic evaluationsHEALTH ECONOMICS, Issue 5 2008Bengt Liljas Abstract Economic evaluation in health care is still an evolving discipline. One of the current controversies in cost-effectiveness analysis regards the inclusion or exclusion of future non-medical costs (i.e. consumption net of production) due to increased survival. This paper examines the implications of a symmetry rule stating that there should be consistency between costs included in the numerator and utility aspects included in the denominator. While the observation that no quality-adjusted life year (QALY) instruments explicitly include consumption and leisure seems to give support to the notion that future non-medical costs should be excluded when QALYs are used as the outcome measure, a better understanding of what respondents actually consider when reporting QALY weights is required. However, the more fundamental question is whether QALYs can be interpreted as utilities. Or more precisely, what are the assumptions needed for a general utility model also including consumption and leisure to be consistent with QALYs? Once those assumptions are identified, they need to be experimentally tested to see whether they are at least approximately valid. Until we have answers to these areas for future research, it seems premature to include future non-medical costs. Copyright © 2007 John Wiley & Sons, Ltd. [source] Valuing avoided morbidity using meta-regression analysis: what can health status measures and QALYs tell us about WTP?HEALTH ECONOMICS, Issue 8 2006George Van Houtven Abstract Many economists argue that willingness-to-pay (WTP) measures are most appropriate for assessing the welfare effects of health changes. Nevertheless, the health evaluation literature is still dominated by studies estimating nonmonetary health status measures (HSMs), which are often used to assess changes in quality-adjusted life years (QALYs). Using meta-regression analysis, this paper combines results from both WTP and HSM studies applied to acute morbidity, and it tests whether a systematic relationship exists between HSM and WTP estimates. We analyze over 230 WTP estimates from 17 different studies and find evidence that QALY-based estimates of illness severity , as measured by the Quality of Well-Being (QWB) Scale , are significant factors in explaining variation in WTP, as are changes in the duration of illness and the average income and age of the study populations. In addition, we test and reject the assumption of a constant WTP per QALY gain. We also demonstrate how the estimated meta-regression equations can serve as benefit transfer functions for policy analysis. By specifying the change in duration and severity of the acute illness and the characteristics of the affected population, we apply the regression functions to predict average WTP per case avoided. Copyright © 2006 John Wiley & Sons, Ltd. [source] Cost-effectiveness of HIV nonoccupational post-exposure prophylaxis in AustraliaHIV MEDICINE, Issue 4 2009D Guinot Objective The aim of the study was to determine the cost-effectiveness of HIV nonoccupational post-exposure prophylaxis (NPEP) in Australia. Methods A retrospective cost analysis of a population-based observational cohort of 1601 participants eligible for NPEP in Australia between 1998 and 2004 was carried out. We modelled NPEP treatment costs and combined them with effectiveness outcomes to calculate the cost per seroconversion avoided. We estimated the cost-utility of the programme, and sensitivity and threshold analysis was performed on key variables. Results The average NPEP cost per patient was A$1616, of which A$848 (52%) was for drugs, A$331 (21%) for consultations, A$225 (14%) for pathology and A$212 (13%) for other costs. The cost per seroconversion avoided in the cohort was A$1 647 476 in our base case analysis, and A$512 410 when transmission rates were set at their maximal values. The cost per quality-adjusted life-year (QALY) was between A$40 673 and A$176 772, depending on the risks of HIV transmission assumed. Conclusions In our base case, NPEP was not a cost-effective intervention compared with the widely accepted Australian threshold of A$50 000 per QALY. It was only cost-effective after receptive unprotected anal intercourse exposure to an HIV-positive source. Although NPEP was a relatively well-targeted intervention in Australia, its cost-effectiveness could be improved by further targeting high-risk exposures. [source] Glucosamine sulphate in the treatment of knee osteoarthritis: cost-effectiveness comparison with paracetamolINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2010S. Scholtissen Summary Introduction:, The aim of this study was to explore the cost-effectiveness of glucosamine sulphate (GS) compared with paracetamol and placebo (PBO) in the treatment of knee osteoarthritis. For this purpose, a 6-month time horizon and a health care perspective was used. Material and methods:, The cost and effectiveness data were derived from Western Ontario and McMaster Universities Osteoarthritis Index data of the Glucosamine Unum In Die (once-a-day) Efficacy trial study by Herrero-Beaumont et al. Clinical effectiveness was converted into utility scores to allow for the computation of cost per quality-adjusted life year (QALY) For the three treatment arms Incremental Cost-Effectiveness Ratio were calculated and statistical uncertainty was explored using a bootstrap simulation. Results:, In terms of mean utility score at baseline, 3 and 6 months, no statistically significant difference was observed between the three groups. When considering the mean utility score changes from baseline to 3 and 6 months, no difference was observed in the first case but there was a statistically significant difference from baseline to 6 months with a p-value of 0.047. When comparing GS with paracetamol, the mean baseline incremental cost-effectiveness ratio (ICER) was dominant and the mean ICER after bootstrapping was ,1376 ,/QALY indicating dominance (with 79% probability). When comparing GS with PBO, the mean baseline and after bootstrapping ICER were 3617.47 and 4285 ,/QALY, respectively. Conclusion:, The results of the present cost-effectiveness analysis suggested that GS is a highly cost-effective therapy alternative compared with paracetamol and PBO to treat patients diagnosed with primary knee OA. [source] Review Article: Economic evaluation of prostate cancer screening with prostate-specific antigenINTERNATIONAL JOURNAL OF UROLOGY, Issue 4 2008Tomoaki Imamura Abstract: Economic issues cannot be ignored in conducting prostate cancer screening using prostate-specific antigen (PSA). Through an electronic search, we reviewed five descriptive cost studies and nine cost-effectiveness/cost-utility analyses concerning PSA screening. Most of the existing evidence was based on mathematical model analysis and the results are enormously disparate. The cost per quality-adjusted life years (QALY) gained was estimated to be $US 63.37 to $68.32, and $8400 to $23 100, respectively, or was dominated by no screening. Economic studies evaluating PSA screening are still far from sufficient. Urologists, epidemiologists and health economists must jointly conduct further studies on not only mortality but also quality of life assessment and economic evaluation, using randomized clinical trials, for a strict evaluation of the actual efficacy of PSA screening. At present, patients should be thoroughly informed of the limitations of PSA screening and, in consultation with urological specialists, make the personal decision of whether to receive it. [source] Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010Kevin D. Frick PhD OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature. SETTING: Model represents population level interventions. PARTICIPANTS: No human subjects were involved in the study. MEASUREMENS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. Salary figures for health professionals were based on Bureau of Labor Statistics data. Using an integrated healthcare system perspective, healthcare costs were estimated based on practice and studies on falls in older adults. Base case incremental cost utility ratios were calculated, and probabilistic sensitivity analyses were conducted. RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls. [source] Cost-Effectiveness of Preventive Occupational Therapy for Independent-Living Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2002Joel Hay PhD OBJECTIVES: To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT. DESIGN: A randomized trial. SETTING: Two government-subsidized apartment complexes. PARTICIPANTS: One hundred sixty-three culturally diverse volunteers aged 60 and older. INTERVENTION: An OT group, a social activity group (active control), and a nontreatment group (passive control). MEASUREMENTS: Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group. RESULTS: Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747,$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively. CONCLUSION: In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures. [source] Are Aggressive Treatment Strategies Less Cost-Effective for Older Patients?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2001Aggressive Care for Patients with Acute Respiratory Failure, The Case of Ventilator Support OBJECTIVES: A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure. DESIGN: Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING: Acute hospital. PARTICIPANTS: 1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld. MEASUREMENTS: We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score ,10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (<65, 65,74, and ,75 years); for each age group, we performed separate analyses for patients with a ,50% probability of surviving at least 2 months (high-risk group) and those with a> 50% probability of surviving at least 2 months (low-risk group). RESULTS: Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (>50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age <65, $44,000 for those age 65,74, and $46,000 for those age ,75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age <65, $100,000 for those age 65,74, and $96,000 for those age ,75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization. CONCLUSIONS: For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages. [source] Why ,Health' is not a Central Category for Public Health PolicyJOURNAL OF APPLIED PHILOSOPHY, Issue 2 2009STEPHEN JOHN abstract We normally think that public health policy is an important political activity. In turn, we normally understand the value of public health policy in terms of the promotion of health or some health-related good (such as opportunity for health), on the basis of the assumption that health is an important constituent or determinant of wellbeing. In this paper, I argue that the assumption that the value of public health policy should be understood in terms of health leads us to overlook important benefits generated by such policy. To capture these benefits we need to understand the ends of public health policy in terms of the promotion of ,physical safety'. I then go on to argue that the idea that ,health' is an important category for evaluating or estimating individuals' wellbeing in the normative context of social policy is confused. I then clarify the relationship between my arguments and QALY-based accounts of health assessment. In the final section of the paper, I defend this surprising conclusion against various attacks. [source] Models of Quality-Adjusted Life Years when Health Varies Over Time: Survey and AnalysisJOURNAL OF ECONOMIC SURVEYS, Issue 2 2006Kristian Schultz Hansen Abstract., Quality-adjusted life year (QALY) models are widely used for economic evaluation in the health care sector. In the first part of the paper, we establish an overview of QALY models where health varies over time and provide a theoretical analysis of model identification and parameter estimation from time trade-off (TTO) and standard gamble (SG) scores. We investigate deterministic and probabilistic models and consider five different families of discounting functions in all. The second part of the paper discusses four issues recurrently debated in the literature. This discussion includes questioning the SG method as the gold standard for estimation of the health state index, re-examining the role of the constant-proportional trade-off condition, revisiting the problem of double discounting of QALYs, and suggesting that it is not a matter of choosing between TTO and SG procedures as the combination of these two can be used to disentangle risk aversion from discounting. We find that caution must be taken when drawing conclusions from models with chronic health states to situations where health varies over time. One notable difference is that in the former case, risk aversion may be indistinguishable from discounting. [source] Comparison of the metabolic and economic consequences of long-term treatment of schizophrenia using ziprasidone, olanzapine, quetiapine and risperidone in Canada: a cost-effectiveness analysisJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 4 2010Roger S. McIntyre MD FRCPC Abstract Rationale, aims and objectives, Second-generation antipsychotic agents have varying propensities to cause weight gain, elevated lipid levels and associated long-term complications. This study evaluates the cost-effectiveness of four second-generation antipsychotic agents used in Canada for the treatment of schizophrenia (ziprasidone, olanzapine, quetiapine, risperidone) with a focus on their long-term metabolic consequences. Method, Using data from the Clinical Antipsychotic Trials of Intervention Effectiveness Study, a semi-Markov model was developed to predict the incidence and associated costs of type 2 diabetes, cardiovascular complications (e.g. angina, myocardial infarction, stroke, cardiovascular disease death), and acute psychiatric hospitalizations in patients with chronic schizophrenia treated over 5 years. Incremental costs per quality-adjusted life year (QALY) gained were calculated from the perspective of the Canadian provincial ministries of health. Scenario and probabilistic sensitivity analyses were performed. Results, The total average cost of treatment with ziprasidone was $25 301 versus $28 563 with olanzapine, $26 233 with quetiapine and $21 831 with risperidone. Ziprasidone had the lowest predicted number of type 2 diabetes cases and cardiovascular disease events, and the highest QALY gains. Patients receiving quetiapine had the highest predicted number of hospitalizations. Ziprasidone was less costly and resulted in more QALYs compared with olanzapine and quetiapine. Compared with risperidone, ziprasidone was more costly and had higher QALYs, with an incremental cost per QALY gained of $218 060. Conclusion, Compared with olanzapine and quetiapine, ziprasidone produced savings to the health care system. Although ziprasidone generated incremental expenditures versus risperidone, it resulted in more QALYs. Based on this analysis, ziprasidone treatment possesses cost and therapeutic advantages compared with olanzapine and quetiapine. [source] Feasibility and cost-effectiveness of using magnification chromoendoscopy and pepsinogen serum levels for the follow-up of patients with atrophic chronic gastritis and intestinal metaplasiaJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 10 2007Mário Dinis-Ribeiro Abstract Background:, The follow-up of patients with atrophic chronic gastritis or intestinal metaplasia may lead to early diagnosis of gastric cancer. However, to-date no cost-effective model has been proposed. Improved endoscopic examination using magnification chromoendoscopy together with non-invasive functional assessment with pepsinogen serum levels are accurate in the diagnosis of intestinal metaplasia (extension) and minute dysplastic lesions. The aim of this study was to assess the feasibility and cost-effectiveness of a follow-up model for patients with atrophic chronic gastritis and intestinal metaplasia based on gastric mucosal status using magnification chromoendoscopy and pepsinogen. Methods:, A cohort of patients with lesions as severe as atrophic chronic gastritis were followed-up according to a standardized protocol using magnification chromoendoscopy with methylene blue and measurement of serum pepsinogen I and II levels. A single node decision tree and Markov chain modeling were used to define cost-effectiveness of this follow-up model versus its absence. Transition rates were considered time-independent and calculated using primary data following cohort data analysis. Costs, quality of life and survival were estimated based on published data and extensive sensitivity analysis was performed. Results:, A total of 100 patients were successfully followed-up over 3 years. Seven cases of dysplasia were diagnosed during follow-up, all among patients with incomplete intestinal metaplasia at baseline, six of whom had extensive (pepsinogen I to II ratio <3) incomplete intestinal metaplasia. For those individuals with atrophic chronic gastritis or complete intestinal metaplasia, a yearly measurement of pepsinogen levels or an endoscopic examination on a 3-yearly basis would cost ,455 per quality-adjusted life year (QALY) gain. Endoscopic examination and pepsinogen serum level measurement on a yearly basis would cost ,1868 per QALY for patients with extensive intestinal metaplasia. Conclusions:, The follow-up of patients with atrophic chronic gastritis or intestinal metaplasia is both feasible and cost-effective if improved accurate endoscopic examination of gastric mucosa together with non-invasive assessment of gastric mucosal status are used to identify individuals at high-risk for development of gastric cancer. [source] Cost-utility analysis of proton pump inhibitors and other gastro-protective agents for prevention of gastrointestinal complications in elderly patients taking nonselective nonsteroidal anti-inflammatory agentsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 12 2010C. CAMERON Aliment Pharmacol Ther,31, 1354,1364 Summary Background The use of proton pump inhibitors (PPIs) among elderly patients using nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) has increased; the price of PPIs is higher than that of majority of alternative treatment strategies. Aim To evaluate the cost-effectiveness of nsNSAIDS + PPIs relative to alternative gastroprotective regimens in the prevention of GI complications among elderly patients (aged ,65 years). Methods An incremental cost-utility analysis, comparing PPIs with alternative gastroprotective regimens was conducted using a decision analytical model. Clinical outcomes, costs and utilities were derived from recently published studies. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the results to variation in model inputs and assumptions. Results The incremental cost-utility ratio (ICUR) of PPIs, relative to nsNSAID alone, was $206 315 per QALY gained or were more costly and less effective. Other co-prescribed treatment options had higher costs per QALY gained. In patients with a history of a complicated or uncomplicated ulcer, PPIs had ICURs of $24 277 and $40 876, respectively. Conclusions Use of PPIs in all elderly patients taking nsNSAIDs is unlikely to represent an efficient use of finite healthcare resources. Co-prescribing PPIs, however, to elderly patients taking nsNSAIDs who have a history of complicated or uncomplicated ulcers appears to be economically attractive. [source] Methylnaltrexone bromide for the treatment of opioid-induced constipation in patients with advanced illness , a cost-effectiveness analysisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 8 2010S. R. EARNSHAW Aliment Pharmacol Ther,31, 911,921 Summary Background, Opioid-induced constipation is a common adverse event in patients with advanced illness and has a significant negative impact on patients' quality of life and costs. Aim, To examine the cost-effectiveness of treating opioid-induced constipation with methylnaltrexone bromide (MNTX) plus standard care compared with standard care alone in patients with advanced illness who receive long-term opioid therapy from a third-party payer perspective in the Netherlands. Methods, A decision-analytical model was created in which advanced-illness patients with constipation were treated with MNTX plus standard care or standard care alone. Clinical efficacy in terms of percentage of patients with rescue-free laxation and time to rescue-free laxation were obtained from a randomized, controlled clinical study. Resource use, costs, utilities and mortality were obtained from published literature and supplemented with data from clinical experts. Results, Treatment with MNTX plus standard care results in more days without constipation symptoms. Cost of MNTX was mostly offset by reduction in other constipation-related costs. Thus, treating with MNTX plus standard care is cost-effective, with an incremental cost per QALY of ,40 865. Results were robust to changes in all parameters. Conclusions, Although using MNTX may increase total costs, MNTX plus standard care is cost-effective in treating advanced-illness patients with opioid-induced constipation. [source] The cost-effectiveness of macrogol 3350 compared to lactulose in the treatment of adults suffering from chronic constipation in the UKALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2010R. R. TAYLOR Background, It is unknown whether macrogol 3350 (Movicol) affords the UK's National Health Service (NHS) a cost-effective addition to the current range of laxatives. Aim, To estimate the cost-effectiveness of macrogol 3350 compared with lactulose in the treatment of chronic constipation, from the perspective of the UK's NHS. Methods, A decision model depicting the management of chronic constipation was constructed using clinical outcomes and resource use values derived from patients suffering from chronic constipation in The Health Independent Network (THIN) database. The model was used to estimate the cost-effectiveness of a GP prescribing macrogol 3350 instead of lactulose to treat adults ,18 years of age suffering from chronic constipation. Results, Sixty-eight percent of patients given macrogol 3350 were successfully treated within 6 months after starting treatment compared to 60% of patients given lactulose.Patients' health status at 6 months was estimated to be 0.458 and 0.454 quality-adjusted life years (QALYs) in the macrogol 3350 and lactulose groups respectively. The total 6-monthly NHS cost of initially treating patients with macrogol 3350 or lactulose was estimated to be £420 (US $688) and £419 (US $686) respectively. Hence, the cost per QALY gained with macrogol 3350 was estimated to be £250 (US $410). Conclusion, Macrogol 3350 affords the NHS a cost-effective addition to the range of laxatives available for this potentially resource-intensive condition. Aliment Pharmacol Ther,31, 302,312 [source] Cost-effectiveness of biological therapy for Crohn's disease: Markov cohort analyses incorporating United Kingdom patient-level cost dataALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 3 2009K. BODGER Summary Background, Anti-TNF-alpha agents for Crohn's disease (CD) have good clinical efficacy but high acquisition cost compared to rival drugs. Aim, To assess the cost-effectiveness of infliximab and adalimumab for Crohn's disease from the perspective of the UK NHS, incorporating recent trial and observational data. Methods, Lifetime Markov analyses constructed to simulate quality-adjusted life-years (QALYs) and costs. CD was represented by four health-states representing: Full response, partial response, nonresponse, surgery and death. The course of CD under standard care was based on the Olmsted county cohort. Systematic review identified ACCENT I (infliximab) and CHARM (adalimumab) as sources for efficacy data. We modelled an intention-to-treat strategy for biologics including surgical rates based on observational data, cost estimates from our UK dataset and utilities from an algorithm converting CDAI to EQ-5D utilities. Results, The incremental cost-effectiveness ratios (ICERs) compared to standard care for 1-year of treatment with infliximab or adalimumab were £19 050 and £7190 per QALY gained, respectively. Lifetime therapy was dominated by standard care. Analyses over shorter time horizons, matched to treatment duration, resulted in unfavourable ICERs. Conclusion, The model suggests acceptable ICERs for biological agents when considering a lifetime horizon with periods of up to 4 years continuous therapy. As with all economic evaluations, the results may not be generalizable beyond the perspective of analysis. [source] Health-economic analysis: cost-effectiveness of scheduled maintenance treatment with infliximab for Crohn's disease , modelling outcomes in active luminal and fistulizing disease in adultsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2008J. LINDSAY Summary Background, Infliximab has been shown to be efficacious in moderate-to-severe Crohn's disease (CD). Aim, To evaluate the cost-effectiveness of scheduled maintenance treatment with infliximab in luminal and fistulizing CD patients. Methods, Markov models were constructed to simulate the progression of adult CD patients with and without fistulae during treatment with infliximab (5 mg/kg). Transitions were estimated from published clinical trials of infliximab. Standard care, comprising immunomodulators and/or corticosteroids was used as a comparator. An average weight of 60 kg was used to estimate the dose of infliximab. The costs and outcomes were discounted at 3.5% over 5 years. The primary effectiveness measurement was quality-adjusted life years (QALYs) estimated using EQ-5D. One-way and probabilistic sensitivity analyses were performed by varying the infliximab efficacy estimates, costs and utilities. Results, The incremental cost per QALY gained was £26 128 in luminal CD and £29 752 in fistulizing CD at 5 years. Results were robust and remained in the range of £23 752,£38 848 for luminal CD and £27 047,£44 206 for fistulizing CD. Patient body weight was the most important factor affecting cost-effectiveness. Conclusion, Eight-week scheduled maintenance treatment with infliximab is a cost-effective treatment for adult patients suffering from active luminal or fistulizing CD. [source] Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysisALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 10 2007N. S. WINSTEAD Summary Background, Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous erythromycin to clear the stomach of blood before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH). These studies have shown clinical effectiveness. Aim, To evaluate the cost-effectiveness of this intervention. Methods, We sought to determine the cost-effectiveness of erythromycin before EGD from the payer's perspective. We found three relevant studies of erythromycin and used these data for the analysis. We obtained costs for intravenous erythromycin and charges for peptic ulcer hospitalization, EGD, surgery, and angiographic embolization. Complication rates were also incorporated from the literature. We implemented a model of health-related quality of life to measure the impact of the intervention. We created a decision-analysis tree and performed a probabilistic sensitivity analysis. Results, A strategy of erythromycin prior to EGD resulted in a cost-effective outcome in a majority of trials using willingness-to-pay figures of $0, $50 000 and $100 000 (US) per quality-adjusted life-year (QALY). Conclusion, Because of the implications for cost saving and increase in QALY, we would recommend giving erythromycin prior to EGD for UGIH. [source] Cost-effectiveness of the oral adsorbent AST-120 versus placebo for chronic kidney diseaseNEPHROLOGY, Issue 5 2008TOMOHIKO TAKAHASHI SUMMARY: Aim: This study was designed to evaluate the cost-effectiveness of AST-120, an oral adsorbent that attenuates the progression of chronic kidney disease. Methods: We developed a Markov model with six health states, including four levels of serum creatinine, haemodialysis and death, using data from a randomized clinical trial conducted in Japan. Direct costs relevant to chronic kidney disease were calculated from a Japanese reimbursement perspective. Projected quality-adjusted life years (QALY) and costs were compared between the AST-120 and placebo groups. The target population was nondiabetic patients with serum creatinine levels from 5.0 to 8.0 mg/dL (442,707 µmol/L) at baseline. Probabilistic sensitivity analysis was performed to evaluate the stability of the results. Results: At 3 years, mean total costs per patient were estimated at ¥6.67 million (US$56 982) in the AST-120 group and ¥9.38 million (US$80 196) in the placebo group. Mean total costs were ¥2.72 million (US$23 205) lower among patients receiving AST-120. QALY per patient were 0.295 (approximately 3.5 months) greater for patients receiving AST-120 than for those receiving placebo over 3 years. The finding that treatment with AST-120 dominated placebo (i.e. was less costly and resulted in more QALY) was upheld in sensitivity analyses. Conclusion: The use of AST-120 in patients with advanced chronic kidney disease may help to slow the rate of growth in expenditures for kidney disease. [source] Latest news and product developmentsPRESCRIBER, Issue 6 2008Article first published online: 24 APR 200 Government responds to NICE report The Government has published its response to the Health Select Committee's report into NICE, broadly arguing that the Committee's recommendations are either already being dealt with or are not appropriate. The Committee recommended appraisals for all new drugs, shorter, rapid appraisals to coincide with their launch, and improved mechanisms for setting drug prices. The Government says its negotiations on the PPRS preclude a detailed response but suggests a rapid system may not be transparent or legally robust. It is exploring how high-cost drugs can be brought within the payment-by-results tariff. While defending NICE's reliance on QALYs, the Government accepts the need to explore how wider economic factors can be considered. As for the threshold cost per QALY by which NICE defines cost effectiveness, it says this is being validated scientifically and NICE will continue to determine the threshold. More topically, the Committee criticised the quality of clinical trial data available to NICE. The Government sees no need to compel pharmaceutical companies to disclose information and says NICE is already becoming more involved with research programmes. All clinical trials must be registered (confidentially) with the EU and the Government believes mandatory registration in the UK would be ineffective and illegal. Prescription charge up again from April The Government has raised the prescription charge by 25p to £7.10 per item with effect from 1 April. Prescription prepayment certificates will cost £27.85 for three months and £102.50 for 12 months. The increase, below the annual rate of inflation for the 10th successive year, will be levied on the 12 per cent of prescriptions that are liable for the charge: 5 per cent via prepayment certificates and 7 per cent from other prescriptions. The charge will generate £435 million in England in 2008/09; this excludes money from prescriptions written by dispensing doctors, which is retained by the PCT. Following criticism of the charge by the Health Select Committee, the Government says it has reviewed the charge and is now consulting on ,cost-neutral' options. MHRA safety update The MHRA warns of possible dose errors associated with Boots Medisure Domiciliary Dosage System in its latest issue of Drug Safety Update (2008;1:issue 8). One case has been reported in which incomplete sealing allowed tablets to mix between compartments. No other cases are known and the MHRA says no harm was reported but the risk is serious. The system should be carefully sealed and inspected visually and physically. The MHRA reaffirms its plans to reclassify all pseudoephedrine and ephedrine products to prescription-only status in 2009 if the new restrictions on sales do not reduce misuse. Other topics in this month's Update include revised indications for oral ketoconazole (Nizoral), restricting its use to selected conditions unresponsive to topical therapy; reformulation of the injectable antibiotic Tazocin (piperacillin plus tazobactum); the risk of peripheral neuropathy associated with pegylated interferon and telbivudine (Sebivo) in the treatment of hepatitis B; and serious adverse events associated with modafinil (Provigil). First oral anticoagulant since warfarin In January this year the EMEA issued a positive opinion to recommend marketing authorisation of the oral, fixed-dose, direct thrombin inhibitor dabigatran etexilate (Pradaxa) for the primary prevention of venous thromboembolism (VTE) in adult patients that have undergone elective knee or hip replacement surgery. Marketing authorisation for the EU (including the UK) is expected from the European Commission in the next few weeks, making dabigatran the first oral anticoagulant since warfarin was introduced in 1954. Dabigatran etexilate has been shown to be as safe and effective as enoxaparin (Clexane) with a similar adverse event profile in the noninferiority phase III RENOVATE (Lancet 2007;370: 949-56) and RE-MODEL (J Throm Haemost 2007;5:217885) trials, which investigated the efficacy and safety of dabigatran compared to enoxaparin in reducing the risk of VTE after total hip and knee surgery respectively. Dabigatran has the practical advantage over low-molecular-weight heparin of oral postoperative administration and no risk of heparin-induced thrombocytopenia and, unlike warfarin, does not require monitoring or dose titration. Risk scale predicts anticholinergic effects US investigators have developed a scale for predicting the risk of anticholinergic side-effects from older patients' medicines (Arch Intern Med 2008;168: 508-13). The scale assigns a score from 1 (low) to 3 (high) for the risk of anticholinergic effects such as dry mouth, constipation and dizziness associated with commonly prescribed medicines. Checking the scale retrospectively in older patients in residential care, a higher score was associated with a 30 per cent increased risk of side-effects after adjustment for age and number of medicines. When this was repeated prospectively in a primary-care cohort, the increased risk was 90 per cent. HRT cancer risk persists The latest analysis of the Women's Health Initiative (WHI) trial of HRT shows that the small increase in the risk of cancer persists for up to three years after stopping treatment (J Am Med Assoc 2008;299:1036-45). WHI was stopped after 5.6 years' follow-up when it became clear the risks of HRT outweighed its benefits. This follow-up after a further three years (mean 2.4) involved 15 730 women. The annual risk of cardiovascular events was similar for HRT (1.97 per cent) and placebo (1.91 per cent). Cancers were more common among women who had taken HRT (1.56 vs 1.26 per cent), in particular breast cancer (0.42 vs 0.33 per cent). All-cause mortality was higher, but not statistically significantly so, with HRT (1.20 vs 1.06 per cent). Tight glycaemic control may increase falls Maintaining HbA1C at or below 6 per cent with insulin is associated with an increased risk of falls, a US study suggests (Diabetes Care 2008;31:391-6). The Health, Aging and Composition study involved 446 older people with type 2 diabetes (mean age 74) followed up for approximately five years. The incidence of falls ranged from 22 to 30 per cent annually. Comparing subgroups with HbA1C of ,6 per cent and >8 per cent, an increased risk of falls was associated with insulin use (odds ratio 4.4) but not oral hypoglycaemic drugs. Copyright © 2008 Wiley Interface Ltd [source] | ||||||||||||||||||||||||||||