Cost-effectiveness Of Photodynamic Therapy Research Articles

283. The efficacy and cost-effectiveness of photodynamic therapy in prevention of surgical site infection

BACKGROUND CONTEXT Incidence rates of surgical site infection (SSI) following instrumented spine surgery vary from 1-9%. We have previously reported significant variability in SSI prevention practice amongst CSS members. Patient skin and nasal cavity colonization with MSSA remains a major risk factor. PURPOSE The purpose of this study was to investigate the efficacy and cost effectiveness of chlorhexidine skin decolonization (CSD) and nasal photo-disinfection therapy (nPDT) on surgical site infection. STUDY DESIGN/SETTING This prospective cohort study was performed at a single quaternary spine referral center. OUTCOME MEASURES SSI rates, microbiological data, treatment data and costs were prospectively recorded. Amongst the spine surgery cases, age, BMI, comorbidities, spine surgery invasiveness index (SSII), blood loss and adverse events (AE) were recorded using the SAVES2 system. METHODS Since 2009, as a local QI initiative at a quaternary referral center, all patients undergoing high risk surgery (including instrumented spine surgery, vascular, cardiothoracic and ortho trauma) received CSD and nPDT preoperatively. Data were prospectively collected in terms of outcome measures. RESULTS From 2009 to 2017 the SSI rate for spine cases decreased from 7.2% to 1.6%, the greatest magnitude of reduction of all surgery types (p 35 (RR 2.25), midline lumbar surgery vs cervical or thoracic (RR 2.2), cervical vs thoracic (RR 1.9), revision surgery (RR 2.9) and in those undergoing more complex instrumentation (SSII> 21) (RR 3.35). The use of CSD / nPDT was not associated with any additional AE's. CONCLUSIONS CSD / nPDT is both efficacious and cost-effective in preventing surgical site infection, particularly in complex instrumented cases in the highest risk patients. Given the minimal resource cost, we recommend the routine use of this technology for SSI prevention. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Effectiveness, safety, and cost-effectiveness of photodynamic therapy in Barrett's esophagus: a systematic review

Barrett's esophagus, the management of which remains controversial, is the precursor condition to esophageal adenocarcinoma. A number of endoscopic treatments have been designed as an alternative to surgical resection for patients with high-grade dysplasia. One of these, photodynamic therapy, involves the light activation of a photosensitizer that causes local tissue destruction via oxidation reactions. The present work reviews the effectiveness, safety, and cost-effectiveness of this treatment. A systematic review of the literature recorded in the Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database, and the National Health Service Economic Evaluation Database was undertaken. Articles reporting randomized clinical trials of photodynamic therapy for the treatment of Barrett's esophagus, and economic assessments of the procedure, were selected. The quality of the articles was checked. Twelve articles were included in this review: eight randomized, controlled clinical trials and four economic assessments. The clinical trials suffered from methodological limitations, but the economic assessments were considered to be good quality. Photodynamic therapy is effective for the ablation of dysplasia in Barrett's esophagus, although the frequency of adverse events is quite high. The procedure is presented as a cost-effective alternative to intense endoscopic monitoring and esophagectomy. However, the evidence regarding its effectiveness in reducing the number of patients who go on to develop cancer is only incipient. Rigorous, controlled studies with longer follow-up times, in which photodynamic therapy is compared with surgical resection and other endoscopic techniques, are needed.

A systematic review of photodynamic therapy in the treatment of pre-cancerous skin conditions, Barrett’s oesophagus and cancers of the biliary tract, brain, head and neck, lung, oesophagus and skin

Photodynamic therapy (PDT) is the use of a light-sensitive drug, in combination with light of a visible wavelength, to destroy target cells. PDT is used either as a primary treatment or as an adjunctive treatment. It is fairly well accepted in clinical practice for some types of skin cancer but has yet to be fully explored as a treatment for other forms of cancer. To systematically review the clinical effectiveness and safety of PDT in the treatment of Barrett's oesophagus, pre-cancerous skin conditions and the following cancers: biliary tract, brain, head and neck, lung, oesophageal and skin. The search strategy included searching electronic databases (between August and October 2008), followed by update searches in May 2009, along with relevant bibliographies, existing reviews, conference abstracts and contact with experts in the field. Randomised controlled trials (RCTs) in skin conditions and Barrett's oesophagus, non-randomised trials for all other sites. People with Barrett's oesophagus, pre-cancerous skin conditions or primary cancer in the following sites: biliary tract, brain, head and neck, lung, oesophageal and skin. Any type of PDT for either curative or palliative treatment. Any comparator including differing applications of PDT treatments (relevant comparators varied according to the condition). The outcomes measured were mortality, morbidity, quality of life, adverse events and resource use. A standardised data extraction form was used. The quality of RCTs and non-randomised controlled studies was assessed using standard checklists. Data extracted from the studies were tabulated and discussed in a narrative synthesis, and the influence of study quality on results was discussed. Meta-analysis was used to estimate a summary measure of effect on relevant outcomes, with assessment of both clinical and statistical heterogeneity. Two reviewers independently screened all titles and abstracts, and data extracted and quality assessed the trials, with discrepancies resolved by discussion or referral to a third reviewer. A scoping review was also undertaken. Overall, 88 trials reported in 141 publications were included, with some trials covering more than one condition. For actinic keratosis (AK), the only clear evidence of effectiveness was that PDT appeared to be superior to placebo. For Bowen's disease, better outcomes with PDT were suggested when compared with cryotherapy or fluorouracil. For basal cell carcinoma (BCC), PDT may result in similar lesion response rates to surgery or cryotherapy but with better cosmetic outcomes. For nodular lesions, PDT appeared to be superior to placebo and less effective than surgery but suggestive of better cosmetic outcome. For Barrett's oesophagus, PDT in addition to omeprazole appeared to be more effective than omeprazole alone at long-term ablation of high-grade dysplasia and slowing/preventing progression to cancer. No firm conclusions could be drawn for PDT in oesophageal cancer. Further research into the role of PDT in lung cancer is needed. For cholangiocarcinoma, PDT may improve survival when compared with stenting alone. There was limited evidence on PDT for brain cancer and cancers of the head and neck. A wide variety of photosensitisers were used and, overall, no serious adverse effects were linked to PDT. There were few well-conducted, adequately powered RCTs, and quality of life (QoL) and resource outcomes were under-reported. Problems were identified with reporting of key study features and quality parameters, making the reliability of some studies uncertain. Methodological limitations and gaps in the evidence base made it difficult to draw firm conclusions. Evidence of effectiveness was found for PDT in the treatment of AK and nodular BCC in relation to placebo, and possibly for treating Barrett's oesophagus. However, the effectiveness of PDT in relation to other treatments is not yet apparent. High-quality trials are needed to compare PDT with relevant comparators for all meaningful outcomes, including QoL and adverse effects. Further research is also needed on patient experience of PDT, as well as on the cost-effectiveness of PDT.

An Introduction to Decision Analysis in the Economic Evaluation of the Prevention and Treatment of Vision-Related Diseases

Economic evaluation in the form of reports of cost-effectiveness of the treatment and prevention of disease has only recently found widespread application in the visual sciences. While economic evaluation takes a number of forms: cost-minimization analysis, cost-benefit analysis, and cost-effectiveness analysis—it is the latter that is seen most often in the evaluation of vision-related health programs. Cost-effectiveness analysis is in particular seen most commonly in its very particular form of cost-utility analysis. Decision analysis is the analytic method most commonly used to perform cost-effectiveness analysis. In decision analysis, the expected cost and effectiveness of a health program are estimated in a rigorous fashion. In this report, we take the reader through the process of decision analysis including building the tree; populating the model with parameters for risk, cost and benefit; estimating expected cost and benefit; and deterministic and probabilistic sensitivity analysis. Examples employed include prominent studies of the cost-effectiveness of photodynamic therapy for treatment of neovascular macular degeneration and the treatment ocular hypertension to prevent glaucoma.

Trends in provision of photodynamic therapy and clinician attitudes: a tracker survey of a new health technology.

BackgroundThere has been debate about the cost-effectiveness of photodynamic therapy (PDT), a treatment for neovascular age-related macular degeneration. We have been monitoring trends for the provision of PDT in the UK National Health Service. The fourth annual 'tracker' survey took place as definitive National Institute for Clinical Excellence (NICE) guidance was issued. We assessed trends in PDT provision up to the point of release of the NICE guidance and identified likely sources of pressure on ophthalmologists to provide PDT.MethodsNational postal questionnaire survey of clinicians with potential responsibility for PDT provision. The survey explored reported local provision, beliefs about the effectiveness of PDT and what sources of opinion might influence attitudes towards providing PDT.ResultsThe response rate was 73% (111/150). Almost half of the surveyed ophthalmology units routinely provided PDT, as part of a trend of steady growth in provision. The proportion of respondents who believed that further proof of effectiveness was required has also declined despite the absence of any new substantial evidence. Attitudes towards providing PDT were positive, on average, and were more strongly associated with perceived social pressure from local colleagues than from other sources. Local colleagues were seen as being most approving of PDT.ConclusionThose responsible for implementing the NICE guidance need to address ophthalmologists' beliefs about the evidence of effectiveness for PDT and draw upon supportive local individuals or networks to enhance the credibility of the guidance.

Cost of care for patients with age-related macular degeneration in Switzerland and cost-effectiveness of treatment with verteporfin therapy

The cost-effectiveness of photodynamic therapy with verteporfin in the treatment of patients with predominantly classic subfoveal choroidal neovascularization secondary to age-related macular degeneration was investigated by a Markov Model over a time horizon of three years in Switzerland. This model describes patients moving between three levels of visual acuity (e.g., good vision, impaired vision, highly impaired vision) and death in terms of transition probabilities. Transition probabilities as well as effectiveness values were derived from a randomized, controlled, double-masked clinical trial. Effectiveness for verteporfin therapy and for placebo was calculated in terms of vision years: 1.068 and 0.494, respectively. Cost per level of visual acuity was assessed in ascending order by expert panels from a societal perspective. Cost strongly increased parallel with vision loss on a patient-per-year basis from 4683 CHF at good vision to 8443 CHF at impaired vision, and was highest with 15231 CHF at highly impaired vision. The model-calculated cost per visionyear were 14907 CHF for patients in the verteporfin therapy group, versus 21047 CHF for patients in the placebo group. The incremental cost per vision-year additionally saved through verteporfin therapy was 9624 CHF. The study demonstrated that greater effectiveness of verteporfin therapy versus placebo compensated for the cost of the therapy so that verteporfin therapy was clearly costeffective. Therefore, for the indicated patients with AMD that causes severe vision loss, verteporfin therapy can be recommended as the therapy of choice, on both clinical and economic grounds.

Analysis of the Cost‐effectiveness of PhotodynamicTherapy in Early Stage Lung Cancer

Methods A cost-effectiveness analysis was carried out for photodynamic therapy (PDT) performed in early stage lung cancer cases, which by definition have no lymph node metastasis. The alternative treatment method was lobectomy, which conventionally would have been the first choice of treatment. Costs (C) and effectiveness (E) both of the PDT group and operation group were compared. Effectiveness was determined using quality adjusted life years saved (QALYs) which is the 5-year survival rate adjusted in terms of the quality of life of the patient, and the cost-effectiveness rate was obtained based on the costs of treatment methods during the patient's stay in the hospital. Health care costs, including drugs, were calculated according to the 1992 National Health Insurance list in yen. Costs which were non-reimbursable by the public insurance system, such as for special rooms and sun block cream, were also expressed in yen. Results The total cost of the operated group was ¥1,793,832 and that for the PDT group was ¥1,017,104. The cost-effectiveness rate of the operated group, that is the average cost of treatment per postoperative living month, was ¥37,537, while that of the entire PDT group was ¥30,003. This indicates that the cost-effectiveness rate for the operated group is apparently 1.3 times higher than that of the PDT group. The monthly cost-effectiveness rate for the PDT group of lesions smaller than 2 cm was ¥25,533. Therefore the cost in the operated group is 1.5 times higher. Conclusions This study demonstrated the merits of PDT for early stage lung cancer from the point of view of cost-effectiveness.

Cost-effectiveness of photodynamic therapy for high grade dysplasia in patients with Barrett's esophagus

Management of patients with Barrett's and high grade dysplasia (HGD) is controversial. Photodynamic therapy (PDT) has been proposed as an alternative to surgical resection for HGD in patients with Barrett's esophagus. AIM: To assess the cost-effectiveness of PDT for Barrett's esophagus with HGD compared with surgical resection. METHODS: Clinical data from published literature on the risks and survival following esophagectomy and PDT in patients with Barrett's esophagus with HGD was used in a Markov model that simulates lifetime events. Where data was unavailable, expert opinion was used and assessed with sensitivity analysis. We took the perspective of a payer and included direct costs for PDT and surgery. Our final outcome measure was cost per quality adjusted life year ($/QALY). RESULTS: By varying the efficacy of PDT, our model predicts that for PDT to be more effective than surgery, it needs to achieve an efficacy of > 85%. With this level of efficacy, the $/QALY was $ 26,812 which compares favorably with other health care interventions. Sensitivity analysis confirmed the robustness of our results nn efficacy of PDT. Average cost per patient in the surgical strategy was consistently lower