Baseline Assumptions Research Articles

Cost-effectiveness Analysis of Sedation and Analgesia Regimens During Fracture Manipulation in the Pediatric Emergency Department

To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block. We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness. Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, 84.06 US dollars), followed by axillary block (88.18 US dollars), K/M (105.32 US dollars), and F/M (159.79 US dollars), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were 8.1 US dollars and 24.9 US dollars per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively. Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.

State Childrenʼs Health Insurance Program Financing and the Need for Significant Federal Funding Increases as Part of Reauthorization

In order to better inform the debate as federal policymakers prepare to reauthorize the State Children's Health Insurance Program (SCHIP) in 2007, this brief analyzes the key components of the financing structure of SCHIP including capped federal block-grant funding, the methodology for determining state's allotments of federal funding, the period of availability of allotments, and the redistribution of unspent funds. In addition, estimates presented in this brief indicate that under Congressional Budget Office baseline assumptions, SCHIP is reauthorized but annual SCHIP funding will be permanently frozen at 5.04 billion US dollars without any increases for population growth or healthcare inflation. As a result, states will suffer an aggregate federal SCHIP funding shortfall of 10.4 billion US dollars to 12.1 billion US dollars over the 5-year period from 2008 through 2012, thus placing SCHIP coverage of many low-income children at significant risk. As part of SCHIP reauthorization, federal policymakers should include substantial increases to SCHIP funding above baseline levels to avert these shortfalls.

Cost‐effectiveness of growth factors during hepatitis C anti‐viral therapy

Although the current standard of care for controlling anaemia and neutropenia during anti-viral therapy for hepatitis C is to use dose reduction of ribavirin and pegylated interferon, respectively, erythropoietin and granulocyte colony-stimulating factor are now being advocated as alternatives to dose reduction. To determine the cost-effectiveness of erythropoietin and granulocyte colony-stimulating factor as an alternative to anti-viral dose reduction during antihepatitis C therapy. Decision analysis was used to assess cost-effectiveness by estimating the cost of using a growth factor per quality-adjusted life-year gained. Under baseline assumptions, the cost per quality-adjusted life-year of using growth factors ranged from 16,247 US dollars for genotype 1 with neutropenia to 145,468 US dollars for genotype 2/3 patients with anaemia. These findings are sensitive to the relationship between dose reduction and sustained virological response. Based upon our findings and the varying strength of the evidence for a relationship between dose reduction and sustained virological response: granulocyte colony-stimulating factor may be cost-effective for genotype 1 patients; erythropoietin is probably not cost-effective for genotype 2/3 patients; no conclusion can be reached regarding the cost-effectiveness of erythropoietin for genotype 1 patients or granulocyte colony-stimulating factor for genotype 2/3 patients. Randomized trials are needed to firmly establish the relationship between dose reduction and sustained virological response.

17α-hydroxyprogesterone Caproate for the Prevention of Preterm Delivery

To evaluate whether the use of 17alpha-hydroxyprogesterone caproate for the prevention of recurrent preterm deliveries is cost-effective. Using decision-analysis modeling, we compared the cost-effectiveness of using 17alpha-hydroxyprogesterone caproate in four subgroups: 1) Prior preterm deliveries less than 32 weeks; 2) prior preterm deliveries 32-37 weeks; 3) prior term delivery; and 4) no prior delivery. Each subgroup was compared with a "no treatment" group. Costs included those for 17alpha-hydroxyprogesterone caproate, hospital admissions, and complications from preterm deliveries. The main outcome measures include cost per quality-adjusted life-year gained and the number of preterm deliveries prevented. Secondary outcomes include neonatal complications prevented. One-way and multiway sensitivity analyses were performed. The use of 17alpha-hydroxyprogesterone caproate for the prevention of preterm deliveries result in cost-savings in women with prior preterm deliveries less than 32 weeks and 32-37 weeks. The sensitivity analyses revealed the model to be robust over a wide range of values for evaluated variables. Within our baseline assumptions, 17alpha-hydroxyprogesterone caproate was associated with cost-savings when used for the prevention of preterm deliveries in women with prior preterm deliveries.

P-629: Assisted reproductive treatments versus unprotected intercourse to achieve pregnancy for HIV serodiscordant couples: A cost-effectiveness analysis

P-629: Assisted reproductive treatments versus unprotected intercourse to achieve pregnancy for HIV serodiscordant couples: A cost-effectiveness analysis

Cost-effectiveness analysis of telemedical devices for pre-clinical traffic accident emergency rescue in Germany

The purpose of this study is to assess the cost-effectiveness (net costs per life year gained) of telemedical devices for pre-clinical traffic accident emergency rescue in Germany. Two equipment versions of a telemedical device are compared from a societal perspective with the baseline in Germany, i.e. the non-application of telemedicine in emergency rescues. The analysis is based on retrospective statistical data covering a period of 10 years with discounted costs not adjusted for inflation. Due to the uncertainty of data, certain assumptions and estimates were necessary. The outcome is measured in terms of "life years gained" by reducing therapy-free intervals and improvements in first-aid provided by laypersons. The introduction of the basic equipment version, "Automatic Accident Alert", is associated with net costs per life year gained of euro 247,977 (at baseline assumptions). The full equipment version of the telemedical device would lead to estimated net costs of euro 239,524 per life year gained. Multi-way sensitivity-analysis with best and worst case scenarios suggests that decreasing system costs would disproportionately reduce total costs, and that rapid market penetration would largely increase the system's benefit, while simultaneously reducing costs. The net costs per life year gained in the application of the two versions of the telemedical device for pre-clinical emergency rescue of traffic accidents are estimated as quite high. However, the implementation of the device as part of a larger European co-ordinated initiative is more realistic.

Modelling the Utility of Body Temperature Readings From Primary Care Consults for SARS Surveillance in an Army Medical Centre

There is interest in surveillance systems for outbreak detection at stages where clinical presentation would still be undifferentiated. Such systems focus on detecting clusters of syndromes in excess of baseline levels, which may indicate an outbreak. We model the detection limits of a potential system based on primary care consults for the detection of an outbreak of severe acute respiratory syndrome (SARS). Data from an averaged-sized medical centre were extracted from the Patient Care Enhancement System (PACES) [the electronic medical records system serving the Singapore Armed Forces (SAF)]. Thresholds were set to 3 or more cases presenting with particular syndromes and a temperature reading of >or=38oC (T >or=38). Monte Carlo simulation was used to insert simulated SARS outbreaks of various sizes onto the background incidence of febrile cases, accounting for distribution of SARS incubation period, delay from onset to first consult, and likelihood of presenting with T >or=38 to the SAF medical centre. Valid temperature data was available for 2,012 out of 2,305 eligible syndromic consults (87.2%). T >or=38 was observed in 166 consults (8.3%). Simulated outbreaks would peak 7 days after exposure, but, on average, signals at their peak would consist of 10.9% of entire outbreak size. Under baseline assumptions, the system has a higher than 90% chance of detecting an outbreak only with 20 or more cases. Surveillance based on clusters of cases with T >or=38 helps reduce background noise in primary care data, but the major limitation of such systems is that they are still only able to confidently detect large outbreaks.

Surgical Bypass Versus Endoscopic Stenting for Malignant Duodenal Obstruction Due to Advanced Pancreatic Cancer: A Decision Analysis

Introduction: The optimal procedure for palliating duodenal obstruction from advanced pancreatic cancer remains controversial. Treatment options include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ) and endoscopic stenting (ES). OGJ and LGJ have higher initial costs and higher rates of early morbidity and mortality, but may require fewer late interventions for recurrent obstruction than ES. It is not clear how these factors influence the overall cost-efficacy of the palliative procedures. Aim: To compare the clinical outcomes and costs among ES, OGJ and LGJ in patients who present with duodenal obstruction from advanced pancreatic cancer using a decision model. Methods: We designed our model for patients seen initially with duodenal obstruction from advanced pancreatic cancer. We analyzed failure rates, testing characteristics, complication rates and costs of the three treatment modalities: ES, OGJ and LGJ. Baseline assumptions and outcomes were based on published reports and direct costs were based on 2005 Medicare reimbursement rates. Success was defined as no major procedure-related complication and no obstructive symptoms over a 3 month period after therapy. One-way and multi-way sensitivity analyses were performed to determine the threshold complication rates that would alter treatment strategies. We also compared total costs and performed cost-effectiveness analyses for the various strategies. Results: Under base case assumptions, ES resulted in the highest rate of success, the lowest mortality rate and the lowest cost of the three treatment options (Table 1). Mortality in the OGJ group was 2.7 times that of the ES cohort and 1.8 times that of the LGJ cohort. One- and three-way sensitivity analyses identified ES as the dominant strategy in all cases except when complications for ES exceeded 26.4% and 35.2%, respectively. OGJ and LGJ were inferior strategies based on lower success rates, greater mortality and higher costs. Conclusions: Endoscopic placement of endoluminal, self-expanding metallic stents is the preferred treatment for palliation of duodenal obstruction due to advanced pancreatic cancer. Compared to surgical procedures, ES has a greater success rate, fewer complications and lower cost. Table 1 Clinical Outcomes Strategy Success (%) Mortality (%) Costs (\$) ES 79 1.47 7215 OGJ 70 4.01 10190 LGJ 74 2.59 9766 Open table in a new tab

Optimal management of adults with pharyngitis--a multi-criteria decision analysis.

BackgroundCurrent practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process.MethodsWe defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use. In our baseline analysis we assumed that all criteria and sub-criteria were equally important except minimizing anaphylactic side effects, which was judged very strongly more important than minimizing minor side effects. Management strategies included: a) No test, No treatment; b) Perform a rapid strep test and treat if positive; c) Perform a throat culture and treat if positive; d) Perform a rapid strep test and treat if positive; if negative obtain a throat culture and treat if positive; and e) treat without further tests. We defined four scenarios based on the likelihood of group A streptococcal infection using the Centor score, a well-validated clinical index. Published data were used to estimate the likelihoods of clinical outcomes and the test operating characteristics of the rapid strep test and throat culture for identifying group A streptococcal infections.ResultsUsing the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies – culture and treat if positive and rapid strep with culture of negative results – are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4. These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis.ConclusionThe optimal clinical management of adults with sore throat depends on both the clinical probability of a group A streptococcal infection and clinical judgments that incorporate individual patient and practice circumstances.

Overview of ASDEX Upgrade results—development of integrated operating scenarios for ITER

Significant progress has been made on ASDEX Upgrade during the last two years in the basic understanding of transport, in the extension of the improved H-mode in parameter space and towards an integrated operating scenario and in the development of control methods for major performance limiting instabilities. The important features were the understanding of particle transport and the control of impurity accumulation based on it, the satisfactory operation with predominantly tungsten-clad walls, the improved H-mode operation over density ranges and for temperature ratios covering (non-simultaneously) the ITER requirements on ν*, n/nGW and Te/Ti, the ELM frequency control by pellet injection and the optimization of NTM suppression by DC-ECCD through variation of the launching angle. From these experiments an integrated scenario has emerged which extrapolates to a 50% improvement in n T τ or a 30% reduction of the required current when compared with the ITER base-line assumptions, with moderately peaked electron and controllable high-Z density profiles.

Should Resistance Testing Be Performed for Treatment-Naive HIV-Infected Patients? A Cost-Effectiveness Analysis

Data from the United States and Europe show a population prevalence of baseline drug resistance of 8%-10% among human immunodeficiency virus (HIV)-infected patients who are antiretroviral naive. Our objective was to determine the clinical impact and cost-effectiveness of genotype resistance testing for treatment-naive patients with chronic HIV infection. We utilized a state-transition model of HIV disease to project life expectancy, costs, and cost-effectiveness in a hypothetical cohort of antiretroviral-naive patients with chronic HIV infection. On the basis of a US survey of treatment-naive patients from the Centers for Disease Control and Prevention, we used a baseline prevalence of drug resistance of 8.3%. A strategy of genotype-resistance testing at initial diagnosis of HIV infection increased per-person quality-adjusted life expectancy by 1.0 months, with an incremental cost-effectiveness ratio of 23,900 dollars per quality-adjusted life-year gained, compared with no genotype testing. The cost-effectiveness ratio for resistance testing remained less than 50,000 dollars per quality-adjusted life-year gained, unless the prevalence of resistance was < or =1%, a level lower than those reported in most regions of the United States and Europe. In sensitivity analyses, the cost-effectiveness remained favorable through wide variations in baseline assumptions, including variations in genotype cost, prevalence of resistance overall and to individual drug classes, and sensitivity of resistance testing. Genotype-resistance testing of chronically HIV-infected, antiretroviral-naive patients is likely to improve clinical outcomes and is cost-effective, compared with other HIV care in the United States. Resistance testing at the time of diagnosis should be the standard of care.

A Cost-Effectiveness Analysis of Prenatal Screening Strategies for Down Syndrome

To evaluate which Down syndrome screening strategy is the most cost-effective. Using decision-analysis modeling, we compared the cost-effectiveness of 9 screening strategies for Down syndrome: 1) no screening, 2) first-trimester nuchal translucency (NT) only, 3) first-trimester combined NT and serum screen, 4) first-trimester serum only, 5) quadruple screen, 6) integrated screening, 7) sequential screening, 8) integrated serum only, or 9) maternal age. Costs included cost of tests and resources used for raising a child with Down syndrome. One-way and multiway sensitivity analyses were performed for all model variables. The main outcome measures were cost per Down syndrome case detected, rate of delivering a liveborn neonate with Down syndrome, and rate of diagnostic procedure-related pregnancy loss for each strategy. Sequential screening detected more Down syndrome cases compared with the other strategies, but it had a higher procedure-related loss rate. Integrated serum screening was the most cost-effective strategy. Sensitivity analyses revealed the model to be robust over a wide range of values for the variables. The addition of the cost of genetic sonogram to the second-trimester strategies resulted in first-trimester combined screening becoming the most cost-effective strategy. Within our baseline assumptions, integrated serum screening was the most cost-effective screening strategy for Down syndrome. If the cost of nuchal translucency is less than dollars 57 or when genetic sonogram is included in the second-trimester strategies, first-trimester combined screening became the most cost-effective strategy. III.

Treatment of suspected fetal macrosomia: A cost-effectiveness analysis

Treatment of fetal macrosomia presents challenges to practitioners because a potential outcome of shoulder dystocia with permanent brachial plexus injury is costly both to families and to society. Practitioner options include labor induction, elective cesarean delivery, or expectant treatment. We performed a cost-effective analysis to evaluate the treatment strategies that were preferred to prevent the most permanent brachial plexus injuries with the least amount of dollars spent. Using decision analysis techniques, we compared 3 strategies for an infant with an estimated fetal weight of 4500 g: labor induction, elective cesarean delivery, and expectant treatment. The following baseline assumptions were made: Probability of shoulder dystocia in vaginal delivery, .145; labor induction, .03; cesarean delivery, .001; probability of plexus injury, .18; probability of permanent injury, .067; probability of cesarean delivery with induction, .35; with expectant treatment, .33; cost of vaginal delivery, dollar 3376; cost of elective cesarean delivery, dollar 5200; cost of cesarean delivery with labor, dollar 6500; lifetime cost of brachial plexus injury, dollar 1,000,000. Sensitivity analyses were performed. Under baseline assumptions for an infant who weighs 4500 g, expectant treatment is the preferred strategy at a cost of dollar 4014.33 per injury-free child, compared with elective cesarean delivery at a cost of dollar 5212.06 and an induction cost of dollar 5165.08. Sensitivity analyses revealed that, if the incidence of shoulder dystocia and permanent injury remained <10%, expectant treatment is the preferred method. Fetal macrosomia with possible permanent plexus injuries is a concern. Our analysis would suggest that expectant treatment is the most cost-effective approach to this problem.

The potential impact of the next influenza pandemic on a national primary care medical workforce

BackgroundAnother influenza pandemic is all but inevitable. We estimated its potential impact on the primary care medical workforce in New Zealand, so that planning could mitigate the disruption from the pandemic and similar challenges.MethodsThe model in the "FluAid" software (Centers for Disease Control and Prevention, CDC, Atlanta) was applied to the New Zealand primary care medical workforce (i.e., general practitioners).ResultsAt its peak (week 4) the pandemic would lead to 1.2% to 2.7% loss of medical work time, using conservative baseline assumptions. Most workdays (88%) would be lost due to illness, followed by hospitalisation (8%), and then premature death (4%).Inputs for a "more severe" scenario included greater health effects and time spent caring for sick relatives. For this scenario, 9% of medical workdays would be lost in the peak week, and 3% over a more compressed six-week period of the first pandemic wave. As with the base case, most (64%) of lost workdays would be due to illness, followed by caring for others (31%), hospitalisation (4%), and then premature death (1%).ConclusionPreparedness planning for future influenza pandemics must consider the impact on this medical workforce and incorporate strategies to minimise this impact, including infection control measures, well-designed protocols, and improved health sector surge capacity.

Preconception Cystic Fibrosis Carrier Screening: Costs and Consequences

The objective of the study was to determine net costs of four potential preconception cystic fibrosis (CF) carrier screening strategies, and to identify the most important cost-related parameters. An estimate was made of the costs of screening carried out during general practitioner (GP) consultations, and screening carried out during group educational sessions. Two test strategies were evaluated: single-entry two-step (SETS) and double- entry two-step (DETS). Several sensitivity analyses were performed. Under the baseline assumptions, SETS screening during GP consultations was the least expensive (net costs US dollar 1,111,354 per year). The sensitivity analysis showed that the costs depend greatly on the estimated lifetime costs of care for a CF patient and the strategy used to inform the target population. Adaptations could be made to the screening program, resulting in economic savings while the primary goal of the screening--to enable participants to make an autonomous informed choice--is guaranteed.

Assessing Cost-Effectiveness of Sealant Placement in Children

The lack of cost-effectiveness information regarding sealant placement strategies is thought to have influenced reimbursement policies and subsequent sealant utilization in dental practice. This study compared three strategies for managing the occlusal surfaces of first permanent molars: seal all (SA), risk-based (RBS), and seal none (SN). A decision tree was developed for various possible outcomes following each of the above strategies. Due to the complexity of the decision tree, a Markov model was used to allow for the construction of a chain of events representing the natural history of sealant retention, caries formation, and their associated health states. The outcome measures were the incremental cost per month gained in a cavity-free state over a ten-year period. Our theoretical model showed that RBS strategy improved clinical outcomes, in the form of cavity-free months, and saved money over SN. The strategy of sealing both high and low risk teeth (SA) further improved outcomes but at an additional cost compared to RBS. However, the cost was small, .08 dollars for each additional cavity-free month gained per tooth. Further, minor changes in the baseline assumptions resulted in the SA strategy being the dominant strategy. This study provides evidence that sealing children's first permanent molars can improve outcomes and save money by delaying or avoiding invasive treatment and the destructive cycle of caries. In a time of limited funds for dental services, these results can assist payers in establishing more rational sealant reimbursement policies.

Cost‐effectiveness of rituximab (MabThera®) in diffuse large B‐cell lymphoma in the Netherlands

To determine the incremental cost-effectiveness ratio (ICER) of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) vs. CHOP plus rituximab (R-CHOP) in diffuse large B-cell lymphoma (DLBCL) patients in the Netherlands. A state transition model was developed to estimate the clinical course, costs and quality of life of patients with stage II, III or IV DLBCL receiving initial treatment with CHOP or R-CHOP to arrive at the ICER. The base year for the cost analysis was 2002 and was performed from the societal perspective. Only direct medical costs were included. The time horizon of the model was 15 yr and both costs and effects were discounted at 4%. Sensitivity analyses were performed to determine the effect of varying base-line assumptions of the model. The incremental gain in quality adjusted life years (QALYs) was 0.88 in both the younger and the older patient groups. The costs were 12 343 higher in the younger group of patients and 15 860 in the older patients. This resulted in an ICER of 13 983 for the younger and 17 933 for the older patients per QALY gained. These results were sensitive to the time horizon of the model, other variations had a marginal impact on the outcome. The addition of rituximab to standard therapy for DLBCL results in a gain of 0.88 QALYs. The ICER of 13 983 for younger and 17 933 for older patients per QALY gained should, seen in the light of disease severity, be considered acceptable by most policy makers in priority setting for budget allocation.

Should all pregnant diabetic women undergo a fetal echocardiography? A cost-effectiveness analysis comparing four screening strategies

To determine if a policy of universal fetal echocardiography for all pregnant diabetic women is cost-effective as a screening tool for congenital heart defects. Using a decision-analysis model, we compared the cost-effectiveness of four screening strategies: (1) none--no ultrasound is performed; (2) selective fetal echocardiography after abnormal detailed anatomic survey; (3) fetal echocardiography for only high hemoglobin A1C, and (4) universal fetal echocardiography for all diabetics. The sensitivity and specificity for each strategy were derived by literature search. The analysis was from a societal perspective using a willingness-to-pay threshold (50,000 dollars) and a theoretic cohort of 40,000 pregnant diabetics. Costs included costs of tests and the costs of complications and of raising a child with a cardiac defect. Outcomes were reported as cost per quality-adjusted life years (QALY) gained for each congenital heart defect prevented by each strategy and the number of congenital heart defects detected. One-way, multiway and probabilistic sensitivity analyses were performed. Compared with the other strategies, selective fetal echocardiography after abnormal detailed anatomic survey costs less per QALY gained for cardiac defect screening. Although universal fetal echocardiography was associated with a higher detection rate for cardiac defects, it was more costly. The sensitivity analyses revealed a robust model over a wide range of values. Under the baseline assumptions, selective fetal echocardiography after an abnormal detailed anatomic survey is more cost-effective compared with universal fetal echocardiography as a screening strategy for cardiac defects in pregnant diabetics.

Ultrasound screening of fetuses at increased risk for Down syndrome: how many missed diagnoses?

To determine the number of Down syndrome (DS) fetuses identified, amniocenteses performed, and procedure-related losses incurred when second-trimester ultrasound is used to screen high-risk patients in order to determine who should undergo an amniocentesis. A decision analytic model was designed for women at increased risk for a DS fetus due to either advanced maternal age (AMA) or a positive expanded maternal serum alpha fetoprotein (MSAFP) screening test, also known as a triple screen (+triple) test. The model compared: (1) the current standard of offering all at-risk women amniocentesis to (2) a policy of performing amniocentesis only when sonographic markers of DS are seen on ultrasound. Baseline assumptions included a sensitivity of 60.6% for targeted ultrasound and a screen-positive rate of 16.2%. If targeted ultrasound is used to determine whether high-risk patients should undergo amniocentesis, 56% (3933/7025) of all DS fetuses are missed. The diagnosis of DS is missed most frequently among women at highest risk for DS (AMA and +triple). In this subgroup of patients, there are 3152 DS fetuses in the second trimester, of which 2815 (89%) are identified by triple screen test. When an ultrasound screen is added, only 1709 (54%) of DS fetuses will be identified. Substantially fewer DS fetuses will be detected when targeted ultrasound is used as a screen among already identified high-risk patients.

Paper 37: Cost Effectiveness of Incorporating a Clinical Nurse Practitioner in a Urogynecology Practice in the United States

OBJECTIVE: To determine the cost-effectiveness of a clinical nurse practioner in a urogyecology practice. METHODS: A financial model to identify all incremental revenues and costs associated with incorporating a clinical nurse practitioner into a urogynecology practice was developed. Baseline assumptions included a 40-hour work week, office visit: procedure session ratio of 6:4, time spent per patient twice that of a physician and a 6-month time period to achieve full capacity. A detailed analysis based on this model was performed including calculation of net present value of incremental cash flow over a 5-year period and payback period. Sensitivity analysis was performed for effect of the number of office visits and procedures performed, time taken to reach capacity, nurse practitioner compensation, discount rate, and reimbursement rate. RESULTS: Based on our financial model, incorporation of a clinical nurse practitioner into a busy urogynecology practice is profitable in less than 6 months under conservative assumptions. Net present value is significantly dependent on the level of procedures performed and the number of office visits scheduled for the nurse practitioner. Sensitivity analysis showed that under the assumption of no procedures and moderate office visit schedule, net present value was decreased by 58%. Net present value is moderately affected by nurse practitioner salary and benefits; a 50% increase in total compensation resulted in a 22% decrease in net present value. Net present value is minimally affected by length of time to achieve full clinical capacity, the discount rate, and the Medicare Geographic Adjustment Factor. Extending time to full capacity to 1 year and doubling the discount rate each resulted in a 9% decrease in net present value. Using the most unfavorable Medicare Geographic Adjustment Factor to weight Relative Value Units in calculating reimbursement rates resulted in a 4% decrease in net present value. Under all tested scenarios, net present value remained positive. Payback period calculations were relatively similar under all scenarios, achieving profitability within 1 year (range 5–10 months). CONCLUSIONS: A robust model to determine the cost-effectiveness of a nurse practitioner in a urogynecology practice can be developed. Incorporation of a clinical nurse practitioner into a urogynecology practice is cost effective and financially favorable in most geographic areas of the country.