Cost-effective Use Of Healthcare Resources Research Articles

Diagnostic accuracy of flow rate testing in urology

To highlight the importance of methodological standards in diagnostic testing in urology, by reviewing the extent of compliance with these standards in reports of published evaluations. Sixteen papers evaluating the diagnostic accuracy of urinary flow-rate testing were independently assessed by two reviewers for compliance with the following methodological standards: specification of study population, analysis of pertinent subgroups, avoidance of evaluation (verification) bias, avoidance of review bias, reporting of precision of estimates of test accuracy, indeterminate test results, and test reproducibility. Compliance with each standard was expressed as a percentage with a 95% confidence interval. Compliance ranged from just 12.5 (1.5-38)% for reporting of test reproducibility to 87.5 (62-98)% for specification of the study population. Only nine of the 16 evaluations complied with four or more of the methodological standards; one paper did not comply with any. This evaluation of urological flow-rate testing show poor compliance with accepted methodological standards. The study design, reporting and evaluation of new diagnostic tests can be improved by adhering to these standards. Policy-makers, purchasers and providers would be less likely to adopt new diagnostic tests inappropriately if they were to appraise published evaluations against the standards. A reduction in the inappropriate use of tests would in turn lead to more cost-effective use of healthcare resources.

Guidelines for the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by progressive decline in lung function. It imposes a considerable burden on patients, healthcare services and society that is likely to increase in the future. It is, therefore, important to ensure that this disease is managed as effectively as possible. In many therapeutic areas, management guidelines have been developed in an attempt to ensure that physicians are aware of optimal disease management and cost-effective use of healthcare resources. Such guidelines are usually prepared by consensus among clinical experts or following a systematic review of the evidence. However, there are a number of barriers to the implementation of treatment guidelines, including the sheer weight of guidelines in all therapeutic areas, a focus on scientific knowledge rather than on clinical practice, lack of trust in the recommendations, practical considerations (e.g. time, resources, budget) and failure to include the perspective of patients.The management guidelines most likely to be implemented are those that are quick and easy to use, relevant to the user's practice and from a credible source. In COPD, over 40 guidelines have been developed, mainly by local respiratory societies as a result of local expert consensus.The guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) are evidence-based and have the backing of international experts. Local implementation plans have been developed to help ensure that GOLD recommendations are implemented in practice. In all COPD guidelines, however, lung function measures feature prominently, with limited reference to outcome measures of interest to patients and healthcare payers (e.g. frequency of exacerbations requiring hospitalization). Low expectations among physicians and patients may also impair implementation. In conclusion, guidelines may improve the management of COPD, but the main challenge is to ensure implementation.

How cost-effective is it to leave perineal skin unsutured?

This paper describes a cost-effectiveness evaluation based on a randomized controlled trial comparing two policies for surgical repair of perineal trauma. Data were collected for 1780 women who were randomly allocated to either a two-stage postpartum perineal repair policy leaving the skin unsutured (n=890) or a three-stage postpartum perineal repair policy that required suturing of the skin (n=890). The two-stage postpartum perineal repair policy was found to reduce the risk of adverse outcomes at 10days and at 3months, without leading to a significant increase in health-care costs. A widespread adoption of a two-stage postpartum perineal repair policy leaving the skin unsutured following perineal trauma is likely to represent a cost-effective use of health-care resources.

Economic evaluation of a primary care-based education programme for patients with osteoarthritis of the knee.

This study is an economic evaluation of a general practice-based nurse-led education programme for patients with osteoarthritis of the knee. The OAK study failed to demonstrate improvements in knowledge, self-efficacy in arthritis management, or health outcomes after 1 year. Not only were the differences not statistically significant, they were not consistent in direction. The cost analysis showed a highly significant increase in costs for the patients randomised to receive the education programme. There was no evidence that the costs of the educational intervention were offset by reduced utilisation of other health services during the period of follow-up. This evidence lends support to contention that general practice-based patient education programmes for knee osteoarthritis are not a cost-effective use of healthcare resources. However further evidence is required before this can be confirmed.

The diagnosis of renal involvement in non-insulin-dependent diabetes mellitus

Efforts aimed at early detection and effective treatment and prevention of renal involvement in non-insulin-dependent diabetes mellitus are needed to limit the increasing social burdens of end-stage renal disease and related complications. Microalbuminuria seems to meet all the criteria required for screening of early renal disease (incipient nephropathy) and detection of patients at increased cardiovascular risk. Histologic examination is needed to ensure diagnosis of overt diabetic nephropathy in patients with macroalbuminuric non-insulin-dependent diabetes mellitus without retinopathy. Regular screening for micro- and macroalbuminuria ensures that renal and extrarenal complications may be identified early and that preventive intervention therapy is instituted, including good metabolic control and raised blood pressure correction. Preliminary evidence suggests that this is a very cost-effective use of health-care resources.

Alteplase: a pharmacoeconomic evaluation of its use in the management of myocardial infarction.

Alteplase (recombinant tissue plasminogen activator; rt-PA) is a thrombolytic agent that when given in an accelerated regimen with intravenous heparin has survival advantages compared with streptokinase in the treatment of acute myocardial infarction, as shown by the results of the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial. Although alteplase is more fibrin-specific than streptokinase, alteplase therapy is associated with a small relative increase in the incidence of haemorrhagic stroke, but appears to cause a small relative decrease in the incidence of major bleeding. Because alteplase has a higher acquisition cost than alternative thrombolytic agents, analyses have been undertaken to assess whether administration of alteplase after myocardial infarction is a cost-effective use of healthcare resources. In retrospective analyses undertaken before completion of the GUSTO trial, it was generally assumed, on the basis of better 90-minute patency rates, that alteplase would provide survival advantages compared with streptokinase or conventional nonthrombolytic therapy. Alteplase had acceptable cost-effectiveness ratios compared with conventional therapy and streptokinase therapy from both third-party payer and hospital perspectives. Subgroup analyses demonstrated that alteplase was more cost effective when given early after symptom onset and when given to patients with large infarcts. Prospective evaluations of the cost effectiveness of alteplase in 3-hour and accelerated regimens have similarly demonstrated that alteplase therapy after myocardial infarction improves survival at an 'acceptable' cost. The largest prospective evaluation undertaken to date was performed in conjunction with the GUSTO trial. Primary analysis, on the basis of the clinical findings of the GUSTO trial and prospective collection of cost data from US patients, revealed that the cost-effectiveness ratio for accelerated alteplase therapy compared with streptokinase was $US32,687 (1993 dollars) per year of life saved (YLS). This value is most relevant for US patients and lies within the definition of 'cost effective' if $US50,000/YLS is the benchmark for acceptable use of resources. The cost-effectiveness ratio for alteplase was most sensitive to assumptions regarding long term survival and cost differences after the first year following treatment. In subgroup analyses, alteplase was a cost-effective treatment option for all elderly patients (> 60 years of age) and all patients > 40 years of age with anterior infarction. Alteplase therapy appears to have in-hospital costs/charges similar to those for primary percutaneous transluminal coronary angioplasty (PTCA), mainly because PTCA appears to have a favourable effect on duration of hospitalisation. Given the technical expertise and facilities required for PTCA, it is likely that thrombolytic therapy will remain the management option of choice in most centres. In conclusion, under the conditions of the GUSTO study, accelerated alteplase in combination with intravenous heparin confers survival advantages compared with streptokinase therapy. While decision-makers must choose how best to use their available healthcare resources, pharmacoeconomic evaluations have confirmed that, on the basis of accepted benchmark values, alteplase therapy is a cost-effective therapeutic option for the treatment of acute myocardial infarction, especially in elderly patients with either anterior or inferior infarcts and nearly all patients with anterior myocardial infarction. Thus, on the basis of clinical and economic data, predominantly provided by the GUSTO trial, alteplase is a cost-effective first-line management option for acute myocardial infarction.