Reasonable Cost-effectiveness Ratio Research Articles

Methodological aspects of dose calculations in transdermal carbon dioxide therapy: estimation of absorbed dose and confirmation of systemic distribution

Carbon dioxide (CO2) gas is well characterized for medical applications. It is a chemically stable, biocompatible agent that has a long history of traditional use (in natural “mofettes”) particularly in Hungary, as a natural infallible remedy. Medical CO2 gas has been widely used in various area of medicine, mostly in surgical laparoscopy and endoscopic procedures in gastroenterology as an insufflation gas, since it is considered as an inert gas without side effects and the residuals easily absorbed in vascular tissues. On the other hand, the scope of intended use in case of transdermal or intradermal application is substantially different. Based on its primary mechanism of action carbon dioxide along with some other metabolites can cause prompt vasodilation of precapillary sphincters of blood vessels, and consequently a reduction of peripheral resistance and an increase the flow of microcirculation in tissues. Additionally, an increase in perivascular partial oxygen pressure in tissues (tcPO2) has been detected, because of a shift on the oxyhemoglobin dissociation curve, which resulted in an overall enhancement of oxygenation for cells. Scientific literature revealed some other aspects of physiology during transdermal CO2 gas administration, mainly in the field of microcirculation and tissue oxygenation. In this report we confirm the rate of absorption and the systemic elimination and highlight the principles of calculation for distribution and dosing utilizing the methodology of stable isotope ratio analysis. All these data may provide at least one further step supporting the use of carbon dioxide as an effective, non-invasive, convenient therapy. For the future this low-cost treatment option can be considered either (i) as a therapy with a reasonable cost-effectiveness ratio; or (ii) as an adjuvant therapy in rehabilitation with significant increase in quality of life for patients, alternatively (iii) as a prevention transdermal CO2 may provide a safe method for public access with a potential health benefit and reducing the symptoms of arterial and venous disease development.

Rationale and design of the PREDICE project: cost-effectiveness of type 2 diabetes prevention among high-risk Spanish individuals following lifestyle intervention in real-life primary care setting

BackgroundType 2 diabetes is an important preventable disease and a growing public health problem. Based on information provided by clinical trials, we know that Type 2 diabetes can be prevented or delayed by lifestyle intervention. In view of translating the findings of diabetes prevention research into real-life it is necessary to carry out community-based evaluations so as to learn about the feasibility and effectiveness of locally designed and implemented programmes. The aim of this project was to assess the effectiveness of an active real-life primary care strategy in high-risk individuals for developing diabetes, and then evaluate its efficiency.Methods/DesignCost-Effectiveness analysis of the DE-PLAN (Diabetes in Europe - Prevention using Lifestyle, physical Activity and Nutritional intervention) project when applied to a Mediterranean population in Catalonia (DE-PLAN-CAT). Multicenter, longitudinal cohort assessment (4 years) conducted in 18 primary health-care centres (Catalan Health Institute). Individuals without diabetes aged 45-75 years were screened using the Finnish Diabetes Risk Score - FINDRISC - questionnaire and a 2-h oral glucose tolerance test. All high risk tested individuals were invited to participate in either a usual care intervention (information on diet and cardiovascular health without individualized programme), or the intensive DE-PLAN educational program (individualized or group) periodically reinforced. Oral glucose tolerance test was repeated yearly to determine diabetes incidence. Besides measuring the accumulated incidence of diabetes, information was collected on economic impact of the interventions in both cohorts (using direct and indirect cost questionnaires) and information on utility measures (Quality Adjusted Life Years). A cost-utility and a cost-effectiveness analysis will be performed and data will be modelled to predict long-term cost-effectiveness.DiscussionThe project was intended to evidence that a substantial reduction in Type 2 diabetes incidence can be obtained at a reasonable cost-effectiveness ratio in real-life primary health care setting by an intensive lifestyle intervention. As far as we know, the DE-PLAN-CAT/PREDICE project represents the first assessment of long-term effectiveness and cost-effectiveness of a public healthcare strategy to prevent diabetes within a European primary care setting.

Cost-Effectiveness of Supervised Exercise Therapy in Heart Failure Patients

ObjectiveExercise therapy in heart failure (HF) patients is considered safe and has demonstrated modest reduction in hospitalization rates and death in recent trials. Previous cost-effectiveness analysis described favorable results considering long-term supervised exercise intervention and significant effectiveness of exercise therapy; however, these evidences are now no longer supported. To evaluate the cost-effectiveness of supervised exercise therapy in HF patients under the perspective of the Brazilian Public Healthcare System. MethodsWe developed a Markov model to evaluate the incremental cost-effectiveness ratio of supervised exercise therapy compared to standard treatment in patients with New York Heart Association HF class II and III. Effectiveness was evaluated in quality-adjusted life years in a 10-year time horizon. We searched PUBMED for published clinical trials to estimate effectiveness, mortality, hospitalization, and utilities data. Treatment costs were obtained from published cohort updated to 2008 values. Exercise therapy intervention costs were obtained from a rehabilitation center. Model robustness was assessed through Monte Carlo simulation and sensitivity analysis. Cost were expressed as international dollars, applying the purchasing-power-parity conversion rate. ResultsExercise therapy showed small reduction in hospitalization and mortality at a low cost, an incremental cost-effectiveness ratio of Int$26,462/quality-adjusted life year. Results were more sensitive to exercise therapy costs, standard treatment total costs, exercise therapy effectiveness, and medications costs. Considering a willingness-to-pay of Int$27,500, 55% of the trials fell below this value in the Monte Carlo simulation. ConclusionsIn a Brazilian scenario, exercise therapy shows reasonable cost-effectiveness ratio, despite current evidence of limited benefit of this intervention.

Economic impact of a rotavirus vaccine in Brazil.

The study was done to evaluate the cost-effectiveness of a national rotavirus vaccination programme in Brazilian children from the healthcare system perspective. A hypothetical annual birth-cohort was followed for a five-year period. Published and national administrative data were incorporated into a model to quantify the consequences of vaccination versus no vaccination. Main outcome measures included the reduction in disease burden, lives saved, and disability-adjusted life-years (DALYs) averted. A rotavirus vaccination programme in Brazil would prevent an estimated 1,804 deaths associated with gastroenteritis due to rotavirus, 91,127 hospitalizations, and 550,198 outpatient visits. Vaccination is likely to reduce 76% of the overall healthcare burden of rotavirus-associated gastroenteritis in Brazil. At a vaccine price of US$ 7-8 per dose, the cost-effectiveness ratio would be US$ 643 per DALY averted. Rotavirus vaccination can reduce the burden of gastroenteritis due to rotavirus at a reasonable cost-effectiveness ratio.

Cost-Effectiveness of Alternative Outpatient Pelvic Inflammatory Disease Treatment Strategies

Effectiveness differences between outpatient pelvic inflammatory disease (PID) treatment regimens are uncertain, but significant differences in cost exist. To examine the influence of antibiotic costs on PID therapy cost-effectiveness. The authors used a Markov decision model to estimate the cost-effectiveness of recommended antibiotic regimens for PID and performed a value of information analysis to guide future research. Antibiotic costs vary between USD 43 and USD188. Pairwise comparisons, assuming a hypothetical 1% relative risk reduction in PID complications with the more expensive regimen, showed economically reasonable cost-effectiveness ratios. Value of information and sample size considerations support further investigation to detect 10% PID complication rate differences between regimens with >or=USD 50 cost differences. Within the cost range of recommended regimens, use of more expensive antibiotics would be economically reasonable if relatively small decreases in PID complication rates exist. Further investigation of effectiveness differences between regimens is needed.

Re: Cost‐effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early‐onset group B streptococcal disease

COBJECTIVE: To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline. DESIGN: Cost-effectiveness analysis based on decision model. SETTING: Obstetric care system in the Netherlands. POPULATION/SAMPLE: Hypothetical cohort of 200,000 neonates. METHODS: A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY). RESULT: The risk-based strategy will prevent 352 cases of early-onset GBS for 5.0 million Euros, indicating a cost-effectiveness ratio of 7600 Euros per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of 59,300 Euros per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio. CONCLUSION: In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable. hemicals / CAS: chlorhexidine, 3697-42-5, 55-56-1

Cost-effectiveness of Different Advanced Life Support Providers for Victims of Out-of-hospital Cardiac Arrests

The survival rate of out-of-hospital cardiac arrest (OHCA) is only about 1.4% in Taiwan. The best configuration to achieve optimal outcomes in OHCA is still uncertain for many communities. The purpose of this study was to investigate the cost-effectiveness of two models of providing advanced life support (ALS) services, emergency medical technicians (EMTs) vs. emergency physicians (EPs), in a two-tiered emergency medical services (EMS) system. This was a prospective, observational, multicenter study comparing ALS provided by EMTs vs. EPs for the management of victims of OHCA. The study population consisted of patients experiencing OHCA of non-traumatic origin in Taipei city, Taiwan, between November 1999 and December 2000, for whom ALS was activated. We performed a cost-effectiveness analysis to determine the economic attractiveness of these two ALS provider programs. The outcome measurements were aggregate costs, survival and incremental cost per life saved. Sensitivity analyses were performed on all variables. The expected total cost per OHCA patient was 2,248.19 US$ and 832.07 US$ for the EMT and EP programs, respectively. The overall survival rate was 4.4%. The survival rate was 9.3% for the EMT program and 2.6% for the EP program. The incremental cost-effectiveness ratio (ICER) of EMTs vs. EPs was 21,136 US$ per life saved. The ICER was sensitive to hospital admission cost changes and the probability of survival to discharge in patients admitted to hospital in the EMT program. The increased survival rate of OHCA patients in the EMT program may be attributable to the services of the hospital and/or the EMT program. The use of EMTs as ALS care providers for OHCA patients in the two-tiered EMS system resulted in a reasonable cost-effectiveness ratio. EMTs could be considered as the second tier of EMS systems in urban areas in Taiwan.

Cost-effectiveness of prophylactic low molecular weight heparin in pregnant women with a prior history of venous thromboembolism

Purpose Women with a history of prior venous thromboembolism have an increased risk for recurrence during pregnancy. Although thromboprophylaxis reduces this risk, recent evidence suggests that, in many cases, prophylaxis can be safely withheld because the estimated recurrence risk is very low. The balance of risks and benefits in women with different recurrence risks has not been examined. Methods We developed a Markov state transition decision analytic model to compare prophylactic low molecular weight heparin to expectant management for pregnant women with a single prior venous thromboembolism. A lifetime time horizon and societal perspective were assumed. Input data were obtained by literature review. Outcomes were expressed as U.S. dollars per quality-adjusted life-year (QALY). Results For “low-risk” women with a prior venous thromboembolism associated with a transient risk factor and no known thrombophilic condition (recurrence risk 0.5%), expectant management was both more effective and less costly than prophylaxis. For “high-risk” women with prior idiopathic venous thromboembolism or known thrombophilic condition (recurrence risk 5.9%), prophylaxis was associated with a reasonable cost-effectiveness ratio ($38,700 per QALY) given a risk of bleeding complications <1.0% (base case 0.5%). Conclusion For low-risk women with prior venous thromboembolism, expectant management during pregnancy leads to better outcomes than administration of prophylactic low molecular weight heparin. For high-risk women, antepartum thromboprophylaxis is a cost-effective use of resources.

Cost‐effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early‐onset group B streptococcal disease

To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline. Cost-effectiveness analysis based on decision model. Obstetric care system in the Netherlands. Hypothetical cohort of 200,000 neonates. A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY). The risk-based strategy will prevent 352 cases of early-onset GBS for 5.0 million Euros, indicating a cost-effectiveness ratio of 7600 Euros per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of 59,300 Euros per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio. In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable.

Cost–benefit analysis of a PMTCT program in Mozambique

The costs and benefits of a HIV/AIDS PMTCT program in a Mozambican city were calculated. The provision and non-provision of infant feeding formula were considered, along with voluntary counselling and testing, and anti-retroviral treatment with Nevirapine. Costs were calculated in monetary units and benefits as deaths averted and disability-adjusted life years. The UNAIDS cost-effectiveness tool for evaluating ARV drug and substitute feeding interventions was used. The costs of the program were compared with the costs of treating HIV-infected children. With no infant feeding formula, there would be a total savings of US$5242 and a negative cost per DALY of US$1.53 without infant feeding formula. With formula, net annual costs would be US$141,268 and cost per DALY US$38.69. Citywide, each year 132 infant deaths would be averted by use of Nevirapine and eight averted by the breastmilk replacement program. All program options have reasonable cost-effectiveness ratios.

Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies.

To assess the clinical and economic consequences of 3 diagnostic strategies-magnetic resonance imaging (MRI), computed tomography followed by MRI for positive results (CT-MRI), and no neuroimaging with close clinical follow-up-in the evaluation of children with headache suspected of having a brain tumor. Three risk groups based on clinical variables were evaluated. A decision-analytic Markov model and cost-effectiveness analysis was performed incorporating the risk group prior probability, MRI and CT sensitivity and specificity, tumor survival, progression rates, and cost per strategy. Outcomes were based on quality-adjusted life year (QALY) gained and incremental cost per QALY gained. For low-risk children with chronic nonmigraine headaches of >6 months' duration as the sole symptom (prior probability of brain tumor 0.01%), no neuroimaging with close clinical follow-up was less costly and more effective than the 2 neuroimaging strategies. For the intermediate-risk children with migraine headache and normal neurologic examination (prior probability of brain tumor 0.4%), CT-MRI was the most effective strategy but cost >$1 million per QALY gained compared with no neuroimaging. For high-risk children with headache of <6 months' duration and other clinical predictors of a brain tumor such as an abnormal neurologic examination (prior probability of brain tumor 4%), the most effective strategy was MRI, with cost-effectiveness ratio of $113 800 per QALY gained compared with no imaging. Our analysis suggests that MRI maximizes QALY gained at a reasonable cost-effectiveness ratio in children with headache at high risk of having a brain tumor. Conversely, the strategy of no imaging with close clinical follow-up is cost saving in low-risk children. Although the CT-MRI strategy maximizes QALY gained in the intermediate-risk patients, its additional cost per QALY gained is high. In children with headache, appropriate selection of patients and diagnostic strategy may maximize quality-adjusted life expectancy and decrease costs of medical workup.

Reporting the Potential Benefits of New Technologies for Cervical Cancer Screening

The AHCPR released its evidence-based report, “Evaluation of Cervical Cytology” in early 1999. This report represents the most comprehensive analysis available to date of Pap smears and new technologies designed to improve cervical cancer screening. Both the ACOG and the AHCPR have released simplified summaries of the results of the evidence report that may lead to misunderstandings of the potential clinical impact of these new technologies. This report reviews the 4 major statements in these summaries and discusses how they are either incorrect based on the full AHCPR report or may be misinterpreted because their ramifications are not fully discussed. New screening technology has the potential to finally bring the sensitivity of a new Pap test to an acceptable level. The increased sensitivity afforded by these new technologies can reduce negative outcomes at reasonable cost-effectiveness ratios and at an equivalent or superior specificity compared to the conventional Pap smear.

Reporting the Potential Benefits of New Technologies for Cervical Cancer Screening

The AHCPR released its evidence-based report, "Evaluation of Cervical Cytology" in early 1999. This report represents the most comprehensive analysis available to date of Pap smears and new technologies designed to improve cervical cancer screening. Both the ACOG and the AHCPR have released simplified summaries of the results of the evidence report that may lead to misunderstandings of the potential clinical impact of these new technologies. This report reviews the 4 major statements in these summaries and discusses how they are either incorrect based on the full AHCPR report or may be misinterpreted because their ramifications are not fully discussed. New screening technology has the potential to finally bring the sensitivity of a new Pap test to an acceptable level. The increased sensitivity afforded by these new technologies can reduce negative outcomes at reasonable cost-effectiveness ratios and at an equivalent or superior specificity compared to the conventional Pap smear.

Cost-effectiveness of diagnostic strategies for patients with chest pain.

Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated. To determine the cost-effectiveness of diagnostic strategies for patients with chest pain. Cost-effectiveness analysis. Published data. Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test. Lifetime. Societal. No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone. Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness. The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36,400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41,900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54,800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57,700 per QALY saved. On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old men with atypical angina. Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.