Expensive Strategy Research Articles

Hematopoietic Stem Cell Transplantation in the Era of Engineered Cell Therapy.

Cellular therapy using T cells modified to express chimeric antigen receptors (CAR-T cells) has had striking success in patients that have failed previous treatment for CD19+ B cell non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia (CLL), or acute lymphoblastic leukemia (ALL). Curative therapy for this group of diseases has previously been limited to allogeneic hematopoietic cell transplantation HCT (alloHCT). The recent results of CAR-T cell therapy raise the question of how best to integrate CAR-T cell therapy and alloHCT in the care of these patients. Within the past 2years, results from larger trials and increased follow-up of patients treated with CD19 CAR-T cell therapy suggest that some may achieve durable remission without transplant. The balance of efficacy and toxicity for CAR-T cell therapy and alloHCT vary by disease type, disease status at the time of treatment, patient characteristics, and the specific therapy employed. There are early signals that subsequent transplantation of patients who have achieved remission with CAR-T may be a potentially viable (though expensive) strategy.

Strategies and cost–benefit of selecting for a polled sheep nucleus by using DNA testing

The present study assessed the effectiveness and cost–benefit of several genotyping strategies for breeding poll Merino sheep in a closed nucleus with different initial allele frequencies and assuming a single-gene responsible for the horn or poll phenotype. We assumed that selection was based on phenotypes or genotypes for a single gene conferring polledness via a complete-dominance model. Under such a model, a complete fixation of the ‘polled allele’ (P) requires genotyping of the ewe-selection candidates. Testing a higher proportion of female candidates resulted in a faster fixation of the P-allele. Fixation ranged from 1 year of selection with a high starting P-allele frequency of 0.9, to 7 years for low starting P-allele frequencies of 0.3. When premiums of AU$50 or AU$100 were paid for rams with a PP genotype, breeding for PP genotypes was not profitable when the starting P-allele frequency was below 0.7. If the starting allele frequency was above 0.7, net profitability was positive over 10 years when premiums of AU$200 were paid for known PP-genotype rams. While fixing the P-allele, genetic gain for production traits was slowed down in the first 5 years of selection by up to 23% and 3% for initial P allele-frequencies of 0.3 and 0.9 respectively. Lost genetic gain due to fixing the P-allele, which can never be recovered in a closed nucleus, incurred 200–800% higher costs than the DNA testing costs. Rates of genetic gain recovered to pre-P-allele selection level rates of genetic gain once the P-allele was fixed. Testing a maximum of 25% ewe-selection candidates was the least expensive strategy across all starting allele frequencies and premiums. To avoid large losses of genetic gain in a closed nucleus with low P-allele starting frequencies, opening the nucleus should be considered to increase starting P-allele frequencies and also to potentially increase rates of genetic gain to offset the economic loss caused by P-selection.

Effect of breastfeeding education and support intervention (BFESI)\xa0versus routine care on timely initiation and exclusive breastfeeding in Southwest Ethiopia: study protocol for a cluster randomized controlled trial

BackgroundInfant mortality rates are still high in Ethiopia. Breastfeeding is regarded as the simplest and least expensive strategy for reduction of infant mortality rates. Community-based educational and support interventions provided prenatally and postnatally are effective in increasing breastfeeding rates. However, such interventions are not widely implemented in Ethiopia. This study aims to assess the effect of breastfeeding education and support on timely initiation and duration of exclusive breastfeeding.MethodsA cluster-randomized controlled trial at the community level will be conducted to compare the effect of breastfeeding education and support versus routine care. The intervention will be provided by Women Development Army leaders who are already in the country’s health system using a 40-h WHO breastfeeding counseling course, “Infant and Young Child Feeding Counseling: an integrated course” and the “Training of Trainers Manual for Counseling on Maternal, Infant and Young Child Nutrition” in the local language. Culturally appropriate operational packages of information will be developed for them. Using preset criteria at least 432 pregnant women in their third trimester will be recruited from 36 zones. Visits in the intervention arm include two prenatal visits and 8 postnatal visits. Supervisory visits will be conducted monthly to each intervention zone. Data will be entered into Epi-data version 3.1 and analyzed using STATA version 13.0. All analysis will be done by intention to treat analysis. We will fit mixed-effects linear regression models for the continuous outcomes and mixed-effects linear probability models for the binary outcomes with study zone as random intercept to estimate study arm difference (intervention vs. routine education) adjusted for baseline value of the outcome and additional relevant covariates. The protocol was developed in collaboration with the Jimma Zone and Mana district Health office. Ethical clearance was obtained from the Institutional Review Board of University of Oslo and Jimma University. This study is partly funded by NORAD’s NORHED programme.DiscussionWe expect that the trial will generate findings that can inform breastfeeding policies and practices in Ethiopia.Trial registrationClinicalTrials.govNCT 03030651 January 25, 2017 version 3 dated 16 July 2018.

New Challenges in Diagnosis of Haemoglobinopathies: Migration of Populations

The current influx of economic migrants and asylum seekers from countries with a high prevalence of haemoglobinopathies creates new challenges for health care systems and diagnostic laboratories. The migration of carriers introduces new and novel haemoglobinopathy mutations to the diagnostic repertoire of a laboratory, often creating new pressures to improve and update the carrier screening technology and diagnostic scope. For antenatal screening programmes, the marriage of partners from different ethnic groups can lead to the risk of compound heterozygote children being born novel mutation combinations, creating problems in the provision of accurate advice regarding the expected phenotype of the thalassaemia or haemoglobinopathy disorder. In the UK, the impact of immigration required the National Haemoglobinopathy Reference laboratory to change the strategy and techniques used for the molecular diagnosis of thalassaemia and the haemoglobinopathies. In 2005, due to the increasingly large range of β-thalassaemia mutations that needed to be diagnosed, the laboratory switched from a three-step screening procedure using ARMS-PCR to a simpler but more expensive one-step strategy of DNA sequencing of the beta and alpha globin genes for all referrals. After ten years of employing this strategy, a further 57 novel thalassaemia and haemoglobionpopthy alleles were discovered (11 new β-chain variants, 15 α-chain variants, 19 β-thalassaemia mutations and 12 α+-thalassaemia mutations), increasing further the extremely heterogeneous spectrum of globin gene mutations in the UK population.

Honeycomb Surface with Shape Memory Behavior Fabricated via Breath Figure Process

AbstractA bio‐inspired honeycomb pattern that exhibits shape memory behavior is successfully fabricated via the breath figure process. By the surface modification along with a chemical crosslinking process to enhance the recoverability, this honeycomb‐like structure with shape memory behavior is realized. The surface wettability is dependent on the surface topography controlled by the deformation of temporary shape (elliptical circle) and recovery of the permanent shape (round circle) at the microscopic scales without the need of micromolding or expensive lithography strategy. This approach opens a facile route to an efficient, inexpensive, and versatile method to prepare films with switchable wettability.

Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis

ObjectiveTo compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm.DesignAn incremental cost-effectiveness analysis...

Cost-effectiveness and public health impact of alternative influenza vaccination strategies in high-risk adults.

High-dose trivalent inactivated influenza vaccine (HD-IIV3) or recombinant trivalent influenza vaccine (RIV) may increase influenza vaccine effectiveness (VE) in adults with conditions that place them at high risk for influenza complications. This analysis models the public health impact and cost-effectiveness (CE) of these vaccines for 50-64year-olds. Markov model CE analysis compared 5 strategies in 50-64year-olds: no vaccination; only standard-dose IIV3 offered (SD-IIV3 only), only quadrivalent influenza vaccine offered (SD-IIV4 only); high-risk patients receiving HD-IIV3, others receiving SD-IIV3 (HD-IIV3 & SD-IIV3); and high-risk patients receiving HD-IIV3, others receiving SD-IIV4 (HD-IIV3 & SD-IIV4). In a secondary analysis, RIV replaced HD-IIV3. Parameters were obtained from U.S. databases, the medical literature and extrapolations from VE estimates. Effectiveness was measured as 3%/year discounted quality adjusted life year (QALY) losses avoided. The least expensive strategy was SD-IIV3 only, with total costs of $99.84/person. The SD-IIV4 only strategy cost an additional $0.91/person, or $37,700/QALY gained. The HD-IIV3 & SD-IIV4 strategy cost $1.06 more than SD-IIV4 only, or $71,500/QALY gained. No vaccination and HD-IIV3 & SD-IIV3 strategies were dominated. Results were sensitive to influenza incidence, vaccine cost, standard-dose VE in the entire population and high-dose VE in high-risk patients. The CE of RIV for high-risk patients was dependent on as yet unknown parameter values. Based on available data, using high-dose influenza vaccine or RIV in middle-aged, high-risk patients may be an economically favorable vaccination strategy with public health benefits. Clinical trials of these vaccines in this population may be warranted.

Query optimization for dynamic imputation

Missing values are common in data analysis and present a usability challenge. Users are forced to pick between removing tuples with missing values or creating a cleaned version of their data by applying a relatively expensive imputation strategy. Our system, ImputeDB, incorporates imputation into a cost-based query optimizer, performing necessary imputations on-the-fly for each query. This allows users to immediately explore their data, while the system picks the optimal placement of imputation operations. We evaluate this approach on three real-world survey-based datasets. Our experiments show that our query plans execute between 10 and 140 times faster than first imputing the base tables. Furthermore, we show that the query results from on-the-fly imputation differ from the traditional base-table imputation approach by 0--8%. Finally, we show that while dropping tuples with missing values that fail query constraints discards 6--78% of the data, on-the-fly imputation loses only 0--21%.

Intelligent robotic gripper with adaptive grasping force

The on-off control robot gripper is widely employed in pick-and-place operations in Cartesian space for handling hard objects between two positions. Without contact force monitoring, it can not be applied in fragile or soft objects handling. Although, an appropriate grasping force or gripper opening for each target could be searched by trial-and-error process, it needs expensive force/torque sensor or an accurate gripper position controller. It has too expensive and complex control strategy disadvantages for most of industrial applications. In addition, it can not overcome the target slip problem due to mass uncertainty and dynamic factor. Here, an intelligent gripper is designed with embedded distributed control structure for overcoming the uncertainty of object’s mass and soft/hard features. A communication signal is specified to integrate both robot arm and gripper control kernels for executing the robotic position control and gripper force control functions in sequence. An efficient model-free intelligent fuzzy sliding mode control strategy is employed to design the position and force controllers of gripper, respectively. Experimental results of pick-and-place soft and hard objects with grasping force auto-tuning and anti-slip control strategy are shown by pictures to verify the dynamic performance of this distributed control system. The position and force tracking errors are less than 1 mm and 0.1 N, respectively.

Cost-effectiveness of cervical cancer screening and preventative cryotherapy at an HIV treatment clinic in Kenya

ObjectiveThis study evaluated the potential cost-effectiveness of cervical cancer screening in HIV treatment clinics in Nairobi, Kenya.MethodsA Markov model was used to project health outcomes and costs of cervical cancer screening and cryotherapy at an HIV clinic in Kenya using cryotherapy without screening, visual inspection with acetic acid (VIA), Papanicolaou smear (Pap), and testing for human papillomavirus (HPV). Direct and indirect medical and non-medical costs were examined from societal and clinic perspectives.ResultsCosts of cryotherapy, VIA, Pap, and HPV for women with CD4 200–500 cells/mL were $99, $196, $219, and $223 from a societal perspective and $19, $94, $124, and $113 from a clinic perspective, with 17.3, 17.1, 17.1, and 17.1 years of life expectancy, respectively. Women at higher CD4 counts (>500 cells/mL) given cryotherapy VIA, Pap, and HPV resulted in better life expectancies (19.9+ years) and lower cost (societal: $49, $99, $115, and $102; clinic: $13, $51, $71, and $56). VIA was less expensive than HPV unless HPV screening could be reduced to a single visit.ConclusionsPreventative cryotherapy was the least expensive strategy and resulted in highest projected life expectancy, while VIA was most cost-effective unless HPV could be reduced to a single visit.

Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis

Fallopian tubes are commonly removed during laparoscopic and open hysterectomy to prevent ovarian and tubal cancer but are not routinely removed during vaginal hysterectomy because of perceptions of increased morbidity, difficulty, or inadequate surgical training. We sought to quantify complications and costs associated with a strategy of planned salpingectomy during vaginal hysterectomy. We created a decision analysis model using TreeAgePro. Effectiveness outcomes included ovarian cancer incidence and mortality as well as major surgical complications. Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. We also modeled subsequent benign adnexal surgery beyond the postoperative window. Those whose procedures were converted from a vaginal route were assumed to undergo bilateral salpingectomy, regardless of treatment group, following American College of Obstetricians and Gynecologists guidelines. Costs were gathered from published literature and Medicare reimbursement data, with internal cost data from 892 hysterectomies at a single institution used to estimate costs when necessary. Complication rates were determined from published literature and from 13,397 vaginal hysterectomies recorded in the National Surgical Quality Improvement Program database from 2008 through2013. Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women having surgery and prevents death from ovarian cancer in 1 of every 450 women having surgery. Overall, salpingectomy was a less expensive strategy than not performing salpingectomy ($7350.62 vs $8113.45). Sensitivity analysis demonstrated the driving force behind increased costs was the increased risk of subsequent benign adnexal surgery among women retaining their tubes. Planned opportunistic salpingectomy had more major complications than hysterectomy alone (7.95% vs 7.68%). Major complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. Therefore, routine salpingectomy results in 0.61 additional complications per case of cancer prevented and 1.21 additional complications per death prevented. A surgeon therefore must withstand an additional ∼3 complications to prevent 5 cancer diagnoses and ∼6 additional complications to prevent 5 cancer deaths. Salpingectomy should routinely be performed with vaginal hysterectomy because it was the dominant and therefore cost-effective strategy. Complications are minimally increased, but the trade-off with cancer prevention is highly favorable.

What is the impact on the healthcare system if access to bariatric surgery is delayed?

BackgroundBariatric surgery has been available as part of the Brazilian Public Health System for patients with body mass index>40 kg/m2 (or>35 kg/m2 with co-morbidities) since 1999. However, access to surgery is challenging, with eligible patients waiting up to 7 years before surgery. ObjectiveOur objective was to compare costs and effectiveness of different waiting times before surgery versus prompt surgery. SettingsPublic practice. MethodsA Markov microsimulation model compared 5 different strategies: no surgery, prompt surgery, and delaying surgery for 1, 2, 4, and 7 years. Markov tracker variables and states reflected changes in body mass index, type 2 diabetes status (including remission and relapse), and cardiovascular events. Time horizon was 20 years; discount rate, 5%; and the perspective of the Brazilian Public Health System. Effectiveness was calculated as quality adjusted life years. ResultsPrompt surgery was the least costly and most effective strategy compared with any delay. Costs increased and effectiveness diminished progressively with the length of delays. Waiting 7 years for surgery was the most expensive and least effective strategy. Prompt surgery maintained dominance in 99.9%, 90.7%, 96.1%, and 94.2% of simulations in probabilistic sensitivity analyses versus 1-, 2-, 4-, and 7-year delays, respectively. Immediate surgery was very cost effective compared with no surgery in the case base. In the scenario with all patients having type 2 diabetes, immediate surgery was dominant to any strategy, including the no surgery group. ConclusionsDelaying bariatric operations is more expensive and less effective compared with prompt surgery and very cost effective compared with no surgery. Public health systems should pursue strategies to accelerate access to surgery to decrease obesity related complications and mortality of patients, but also to improve cost effectiveness.

The interplay between free sampling and word of mouth in the online software market

Free sampling in digital format has become a common business practice in the online market offering consumers first-hand experience with products, due to its low marginal cost and extensive online distribution. At the same time, online word of mouth (WOM) has also been a prevalent strategy on the Internet for increasing product visibility and providing trustworthy product information. Those two online marketing strategies are generally considered to stand alone by marketers and prior research. Nevertheless, by drawing on integrated information response theory as well as theories for explaining online consumers' review sharing, we argue that free sampling complements WOM in the online market by amplifying its sales effect and facilitating its implementation. We provide supportive empirical evidence through a Bayesian analysis of software free sampling on CNET Download.com (CNETD) and sales and WOM from Amazon.com over a 25-week data set. Our results show that adoptions of CNETD free sampling positively interact with Amazon WOM in influencing Amazon software sales. In addition, more adoptions of CNETD free sampling lead to a larger volume of Amazon WOM, and this impact is more significant for less popular products. These findings contribute to our understanding of free sampling in the online market such that, in addition to its direct sales effect, free sampling can also potentially affect sales through influencing online WOM. Therefore, we suggest that marketers evaluate the free sampling strategy by including its interplay with online WOM and apply low-cost free sampling to facilitate the relatively more expensive online WOM marketing strategy, especially for unpopular products.

Societal costs and effects of implementing population-based mammography screening in Greenland

ABSTRACTWith a low breast cancer incidence and low population density, Greenland is geographically and organisationally challenged in implementing a cost effective breast cancer screening programme where a large proportion of the Greenlandic women will have to travel far to attend. The aim of this paper is to evaluate the cost effectiveness and cost utility of different strategies for implementing population-based breast cancer screening in Greenland. Two strategies were evaluated: Centralised screening in the capital Nuuk and decentralised screening in the five municipal regions of Greenland. A cost effectiveness and cost utility analysis were performed from a societal perspective to estimate the costs per years of life saved and per QALY gained. Two accommodation models for the women’s attendance were examined; accommodation in ordinary hotels or in patient hotels. The least costly accommodation model was the hotel model compared with the patient hotel model, regardless of screening strategy. The decentralised strategy was more cost effective compared with the centralised strategy, resulting in 0.5 million DKK per years of life saved (YLS) and 4.1 million DKK per quality-adjusted life year (QALY) gained within the hotel model. These ratios are significantly higher compared with findings from other countries. The sensitivity analysis showed a substantial gap between the most and least favourable model assumptions. The investigated strategies were all estimated to be extremely costly, mostly due to high transportation and accommodation costs and loss of productivity, and none would be accepted as cost-effective per YLS/QALY gained within a conventional threshold level. The least expensive strategy was regional screening with hotel accommodation.

Prosthetic Joint Infections and Cost Analysis?

Prosthetic joint infection is a devastating complication of arthroplasty surgery that can lead to debilitating morbidity for the patient and significant expense for the healthcare system. With the continual rise of arthroplasty cases worldwide every year, the revision load for infection is becoming a greater financial burden on healthcare budgets. Prevention of infection has to be the key to reducing this burden. For treatment, it is critical for us to collect quality data that can guide future management strategies to minimise healthcare costs and morbidity / mortality for patients. There has been a management shift in many countries to a less expensive 1-stage strategy and in selective cases to the use of debridement, antibiotics and implant retention. These appear very attractive options on many levels, not least cost. However, with a consensus on the definition of joint infection only clarified in 2011, there is still the need for high quality cost analysis data to be collected on how the use of these different methods could impact the healthcare expenditure of countries around the world. With a projected spend on revision for infection at US$1.62 billion in the US alone, this data is vital and urgently needed.

PCV16 - PCSK9 Inhibitors May Improve Cardiovascular Outcomes- Can We Afford Them?

Abstract Background/Objectives Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) can significantly lower low-density lipoprotein (LDL) cholesterol levels. Early evidence suggests that use of PCSK9i also reduces the incidence of major adverse cardiovascular events (MACE). Our objective was to determine preliminary economic implications of PCSK9i use to avoid MACE, based on the current data from major phase III clinical trials. Methods Outcome data of the 4529 patients treated with PCSK9i in the OSLER and ODYSSEY LONG TERM trials were collected from the published reports. Cost of preventing MACE was evaluated based on the existing outcome data and current US prices of PCSK9i. The pooled results were compared to the cost of curing Hepatitis C Virus (HCV) patients with novel HCV drugs. Results PCSK9i treatment in the OSLER and ODYSSEY LONG TERM trials resulted in prevention of 35 MACE in a total of 4903 patient-years: 8 cardiovascular deaths, 22 myocardial infarctions, 0 strokes and 5 unstable anginas. The cost of PCSK9i drugs consumed during the trial's current follow-up period, could have reached $70,172,141. Therefore, the cost of preventing any MACE would be $2,004,918 and the cost of preventing one death would be $8,777,518. These figures are one hundred fold higher than the cost of curing one HCV patient (~$84,000). Conclusions According to the current published data, using PCSK9i to prevent MACE seems to be a very expensive strategy. If upcoming outcome trials will demonstrate similar results, it seems that at current prices, using these drugs would not be affordable for most healthcare systems.

PCSK9 inhibitors may improve cardiovascular outcomes—Can we afford them?

Background/ObjectivesProprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) can significantly lower low-density lipoprotein (LDL) cholesterol levels. Early evidence suggests that use of PCSK9i also reduces the incidence of major adverse cardiovascular events (MACE). Our objective was to determine preliminary economic implications of PCSK9i use to avoid MACE, based on the current data from major phase III clinical trials. MethodsOutcome data of the 4529 patients treated with PCSK9i in the OSLER and ODYSSEY LONG TERM trials were collected from the published reports. Cost of preventing MACE was evaluated based on the existing outcome data and current US prices of PCSK9i. The pooled results were compared to the cost of curing Hepatitis C Virus (HCV) patients with novel HCV drugs. ResultsPCSK9i treatment in the OSLER and ODYSSEY LONG TERM trials resulted in prevention of 35 MACE in a total of 4903 patient-years: 8 cardiovascular deaths, 22 myocardial infarctions, 0 strokes and 5 unstable anginas. The cost of PCSK9i drugs consumed during the trial's current follow-up period, could have reached $70,172,141. Therefore, the cost of preventing any MACE would be $2,004,918 and the cost of preventing one death would be $8,777,518. These figures are one hundred fold higher than the cost of curing one HCV patient (~$84,000). ConclusionsAccording to the current published data, using PCSK9i to prevent MACE seems to be a very expensive strategy. If upcoming outcome trials will demonstrate similar results, it seems that at current prices, using these drugs would not be affordable for most healthcare systems.

A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis.

BackgroundThere is a lack of information about the sensitivity, specificity and costs new diagnostic tests should have to improve early diagnosis of rheumatoid arthritis (RA). Our objective was to explore the early cost-effectiveness of various new diagnostic test strategies in the workup of patients with inflammatory arthritis (IA) at risk of having RA.MethodsA decision tree followed by a patient-level state transition model, using data from published literature, cohorts and trials, was used to evaluate diagnostic test strategies. Alternative tests were assessed as add-on to or replacement of the ACR/EULAR 2010 RA classification criteria for all patients and for intermediate-risk patients. Tests included B-cell gene expression (sensitivity 0.60, specificity 0.90, costs €150), MRI (sensitivity 0.90, specificity 0.60, costs €756), IL-6 serum level (sensitivity 0.70, specificity 0.53, costs €50) and genetic assay (sensitivity 0.40, specificity 0.85, costs €750). Patients with IA at risk of RA were followed for 5 years using a societal perspective. Guideline treatment was assumed using tight controlled treatment based on DAS28; if patients had a DAS28 >3.2 at 12 months or later patients could be eligible for starting biological drugs. The outcome was expressed in incremental cost-effectiveness ratios (€2014 per quality-adjusted life year (QALY) gained) and headroom.ResultsThe B-cell test was the least expensive strategy when used as an add-on and as replacement in intermediate-risk patients, making it the dominant strategy, as it has better health outcomes and lower costs. As add-on for all patients, the B-cell test was also the most cost-effective test strategy. When using a willingness-to-pay threshold of €20,000 per QALY gained, the IL-6 and MRI strategies were not cost-effective, except as replacement. A genetic assay was not cost-effective in any strategy. Probabilistic sensitivity analysis revealed that the B-cell test was consistently superior in all strategies. When performing univariate sensitivity analysis for intermediate-risk patients, specificity and DAS28 in the B-cell add-on strategy, and DAS28 and sensitivity in the MRI add-on strategy had the largest impact on the cost-effectiveness.ConclusionsThis early cost-effectiveness analysis indicated that new tests to diagnose RA are most likely to be cost-effective when the tests are used as an add-on in intermediate-risk patients, and have high specificity, and the test costs should not be higher than €200–€300.Electronic supplementary materialThe online version of this article (doi:10.1186/s13075-016-1020-3) contains supplementary material, which is available to authorized users.

Screening for Congenital Heart Disease in Infants with Down Syndrome: Is Universal Echocardiography Necessary?

Current guidelines recommend that all neonates with Down syndrome (DS) be screened for congenital heart disease (CHD) with an echocardiogram. We sought to determine the effectiveness of a more accessible and less expensive screening strategy consisting of physical examination, electrocardiogram (ECG), and chest X-ray. The Intermountain Healthcare Enterprise Data Warehouse was used to identify infants with a positive karyotype for DS who were born between January 1, 2000, and June 30, 2012. Infants with the results of an echocardiogram, physical examination, ECG, and chest X-ray documented at age ≤6months were included. Infants with an abnormality on physical examination, ECG, or chest X-ray were considered to have a positive screen. Echocardiography was the gold standard for calculating sensitivity, specificity, positive and negative predictive values for major CHD, defined as any heart defect that would typically require intervention during early childhood. Of 408 eligible infants, 240 (59%) had major CHD, of whom 228 (95%) had a positive screen. Screening missed eight infants with moderate/large patent ductus arteriosus and four infants with a moderate/large atrial septal defect. In 11 of these infants, the defect resolved spontaneously by age ≤4months. One infant had a moderate atrial septal defect persisting at 2-year follow-up. Sensitivity and specificity of the screening for detecting CHD were 95% (CI 92-98%) and 41% (CI 32-47%); positive and negative predictive values were 69% (CI 63-73%) and 85% (CI 75-92%). Screening with physical examination, ECG, and chest X-ray is an effective method of identifying which infants with DS should have an echocardiogram. This method would have resulted in 69 (17%) fewer echocardiograms without missing infants with major CHD.

Game Theory Analysis On The Effects Of Marketing Communication Strategies On Brand Awareness In Telecommunication Industry In Kumasi-Kejetia: A Prospective Data On Mtn And Glo Customers

Globalization and civilization has led to the innovation of information technology products such as computer, mobile phones, I pads, e.t.c. With this innovation of new information technology, it has called in for several telecommunications to the economy of Ghana which includes MTN, Vodafone, Tigo, Airtel, Expresso and Glo which in effects produce a wide range of goods and services and these are not an end in themselves. However, how to get to the targeted customers through their unique brands for profit making is what many businesses of the telecommunication contemplate and find it difficult to answer and achieve. This brings in the issue of how to market and communicate the product to the loyal and new customers. This study aimed at exploring the effects of marketing communication strategies on brand awareness of consumers in the telecommunication industry and their effects on the market share. Three hundred (300) respondents were sampled. The study adopted a qualitative approach in its design and convenience sampling methods, with questionnaires and interview for data collection from the field. With the help of SPSS and game theory analysis, the data were analyzed. The study showed that significant number of respondents had some level of awareness and knowledge of the various telecommunication products. Also, marketing communication strategies helped improve awareness of the brand. It also showed that radio and television advertisement (media) was the preferred marketing communications strategy of both the consumers and the brand managers of telecommunication, although it was an expensive communication strategy. The study recommended that the various telecommunications should leverage on its popularity and preference to consumers. Keyword: Marketing communication, Game theory, Telecommunication, media, brand and Awareness