Strategy In Terms Of Cost-effectiveness Research Articles

Cost-effectiveness of postoperative imaging surveillance strategies for nonfunctional pituitary adenomas after resection with curative intent.

The aim of this study was to determine an optimal follow-up imaging surveillance strategy in terms of cost-effectiveness after resection of nonfunctioning pituitary adenomas with curative intent. An individual-level state-transition microsimulation model was used to simulate costs and outcomes associated with three postoperative imaging strategies over a lifetime time horizon: 1) annual MRI surveillance, 2) tapered MRI surveillance (annual surveillance for 5 years followed by surveillance every 2 years), and 3) personalized surveillance (annual surveillance for 5 years followed by surveillance every 2 years when MRI shows remnant disease/postoperative changes, and surveillance at 7, 10, and 15 years for disease-free MRI). Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually. Model outcomes included lifetime costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Under base case assumptions, annual surveillance yielded higher costs and lower health effects (QALYs) compared with the tapered and personalized surveillance strategies (dominated). Personalized surveillance demonstrated an additional 0.1 QALY at additional cost ($1298) compared with tapered surveillance (7.7 QALYs at a cost of $12,862). The ICER was $11,793/QALY. The optimal decision was most sensitive to the probability of postoperative changes on MRI after surgery and MRI cost. Accounting for parameter uncertainty, personalized surveillance had a higher probability of being a cost-effective surveillance option compared with the alternative strategies at 79%. Using standard cost-effectiveness thresholds in the US ($100,000/QALY), personalized surveillance that accounted for remnant disease or postoperative changes on MRI was cost-effective compared with alternative surveillance strategies.

Introducing the non-invasive prenatal testing for detection of Down syndrome in China: a cost-effectiveness analysis

ObjectiveThis study aimed to compare the health economic value of a non-invasive prenatal testing (NIPT) strategy against a second-trimester triple screening (STS) strategy for the detection of Down syndrome based...

Cost-effectiveness of first-line treatment options for patients with advanced-stage Hodgkin lymphoma: a modelling study

Several strategies are available for the initial treatment of advanced-stage Hodgkin lymphoma, but the optimal strategy in terms of cost-effectiveness is unclear. The aim of this study was to compare the quality-adjusted effectiveness and costs of five modern treatment options for transplantation-eligible patients with newly diagnosed advanced-stage Hodgkin lymphoma. A Markov decision-analytic model was developed using a 20-year time horizon. Five of the most common treatment approaches were selected based on clinical experience and expert opinion: (1) six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD), including data from the HD2000 trial, Viviani and colleagues, and EORTC trial; (2) six cycles of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP; from the HD15 trial or PET-adapted as in the HD18 trial, two initial cycles of BEACOPP followed by four additional cycles for patients with a positive PET and either two or four additional cycles of BEACOPP for patients with a negative PET); (3) PET-adapted escalation (as in the RATHL trial, two cycles of standard ABVD chemotherapy followed by an additional four cycles of ABVD or AVD in PET-negative patients and four cycles of BEACOPP in PET-positive patients); (4) six cycles of brentuximab vedotin, doxorubicin, vinblastine, dacarbazine (A-AVD) or ABVD as in the Echelon-1 trial; and (5) PET-adapted de-escalation (as in the AHL2011 trial, two cycles of BEACOPP followed by PET2 scan; PET-positive patients received two additional BEACOPP cycles and PET-negative patients received two cycles of ABVD; at PET4, PET-negative patients completed two further cycles of either ABVD or BEACOPP depending on what they received after PET2, and PET-positive patients received salvage therapy). Note that all uses of BEACOPP in these strategies were BEACOPPescalated. The randomised groups of interest from these studies comprised 4255 patients enrolled between April, 2000, and January, 2016. Baseline probability estimates and utilities were derived from the included trials in addition to a systematic review of published studies. A Canadian public health payer's perspective was considered (CAN$1=US$0·74) and adjusted for inflation for 2018. All costs and benefits were discounted by 1·5% per year because life-years now are more valuable than future potential life-years. Probabilistic analyses (10 000 simulations) showed that, for a willingness-to-pay threshold of CAN$50 000, a PET-adapted de-escalation strategy based on AHL2011 was more cost-effective 87% of the time. This strategy had the highest number of life-years (14·6 years [95% CI 13·7-15·1]) and quality-adjusted life years (13·2 years [95% CI 10·2-14·4]), and the lowest direct costs ($53 129 [95% CI 31 914-94 446]) compared with the other treatment regimens. Sensitivity analyses showed that the model was robust to key variables, including probability of treatment-related mortality, relapse, frequency of secondary malignancy, death from secondary malignancy, and probability of infertility after BEACOPP. Our results suggest that, when considering cost, effectiveness, and short and long-term toxicities, the preferred treatment strategy for patients with newly diagnosed advanced-stage Hodgkin lymphoma is the PET-adapted de-escalation regimen starting with BEACOPP and de-escalating to ABVD as appropriate. Although our findings do not provide an absolute best treatment approach for clinicians to follow for all patients, they can contribute to shared decision making between patients and treating physicians. None.

Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder

Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy. IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds. Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.

Vonoprazan versus Lansoprazole for the Initial Treatment of Reflux Esophagitis: A Cost-effectiveness Analysis in Japan.

Objective Gastroesophageal reflux disease (GERD) is a highly prevalent disorder that negatively affects patients' quality of life and reduces their work productivity. The medical expenses associated with the treatment of GERD are the highest among all digestive diseases. Current guidelines recommend the administration of a standard dose of proton pump inhibitor (PPI) for eight weeks as an initial GERD treatment. However, there is growing concern regarding the safety of PPI treatment. Recently, a novel potassium-competitive acid blocker (P-CAB), vonoprazan (VPZ), was approved for the treatment of reflux esophagitis in Japan and may provide clinical benefits in GERD treatment. This study was conducted to evaluate the cost-effectiveness of a P-CAB, VPZ vs. a PPI, lansoprazole (LPZ), for the acute medical treatment of reflux esophagitis. Methods A clinical decision analysis was performed using a Markov chain approach to compare VPZ to LPZ in the acute treatment of reflux esophagitis in Japan. Results The P-CAB strategy was superior to the PPI strategy in terms of cost-effectiveness (direct cost per patient to achieve clinical success) and the number of days for which medication was required. Sensitivity analyses revealed that this superiority was robust within the plausible range of probabilities. This remained true even when the healing rates in cases of mild esophagitis were applied. Conclusion The P-CAB strategy was consistently superior to the conventional PPI strategy using the original LPZ in terms of cost-effectiveness and the number of days for which medication was required. Thus, VPZ appears to be the drug of choice for the acute medical treatment of reflux esophagitis.

A model-based economic evaluation of four newborn screening strategies for cystic fibrosis in Flanders, Belgium

ABSTRACTObjectives: The most cost-effective newborn screening strategy for cystic fibrosis (CF) for Flanders, Belgium, is unknown. The aim of this study was to assess the cost-effectiveness of four existing newborn screening strategies for CF: IRT-DNA (immunoreactive trypsinogen, cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation analysis), IRT-PAP (pancreatitis-associated protein), IRT-PAP-DNA, and IRT-PAP-DNA-EGA (extended CFTR gene analysis).Methods: Using data from published literature, the cost-effectiveness of the screening strategies was calculated for a hypothetical cohort of 65,606 newborns in Flanders, Belgium. A healthcare payer perspective was used, and the direct medical costs associated with screening were taken into account. The robustness of the model outcomes was assessed in sensitivity analyses.Results: The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected (€9314 per CF case detected). The IRT-DNA strategy was more costly (€13,966 per CF case detected), but with an expected sensitivity of 93.4% also the most effective strategy, and was expected to detect 2.2 more cases of CF than the IRT-PAP strategy. The incremental cost-effectiveness ratio of IRT-DNA vs. IRT-PAP was €54,180/extra CF case detected. The IRT-PAP-DNA strategy and the IRT-PAP-DNA-EGA strategy were both strongly dominated by the IRT-PAP strategy.Conclusion: The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected. However, the strategy did not fulfil the European Cystic Fibrosis Society guidelines for sensitivity and positive predictive value. Therefore, the more costly and more effective IRT-DNA strategy may be the most appropriate newborn screening strategy for Flanders.

PMD104 - COST-EFFECTIVENESS AND COST-UTILITY ANALYSIS OF TREATING DIABETIC FOOT ULCERS WITH URGOSTART COMPARED TO A NEUTRAL DRESSING.

Current National Institute of Health and Care Excellence (NICE) guidance does not indicate a preferred dressing for patients with Diabetic Foot Ulcer (DFU). UrgoStart has recently been shown as superior to a neutral dressing in the double blind randomised controlled Explorer trial. This study examined the cost-effectiveness of UrgoStart compared with a neutral dressing for DFU patients. A Markov-model was designed with seven health states: open, closed, and complicated (pre and post amputation), and deceased. Complicated wounds can cause an amputation event, moving a patient to the post-amputation block. The model took the perspective of the National Health Service (NHS) in the United Kingdom, with a cohort of 1000 patients and base-case time horizon of 1 year. The Explorer trial informed transition probabilities and health-state utility scores; there were no statistically significant differences between the characteristics of the treatment arms at baseline. Both deterministic and probabilistic sensitivity analyses were performed. UrgoStart was the dominant treatment strategy in terms of cost-effectiveness, with a cost saving of £666.51 and a 0.022 gain in quality-adjusted-life years, per patient. Using UrgoStart leads to more wounds healed at 52 weeks than a neutral dressing, 653 and 473 respectively at a cost of £4879.84 per healed wound for UrgoStart compared with £8136.19 for a neutral dressing. The use of UrgoStart also avoided 19 amputations over a year. Sensitivity analysis showed UrgoStart as cost saving, even when a comparator was set at £0. Across 1000 runs of the model, UrgoStart was dominant every time. This analysis showed UrgoStart to be a cost-effective treatment option, with benefits to the patient and the NHS. Primary cost drivers such as community nurse visits and hospital admissions; can be reduced significantly with faster healing. UrgoStart should be considered as a treatment for all patients with a DFU.

PMD103 - COST-EFFECTIVENESS AND COST-UTILITY ANALYSIS OF TREATING LEG ULCERS WITH URGOSTART COMPARED TO A NEUTRAL DRESSING.

Leg Ulcers (LUs) cause a burden on the patient and National Health Service (NHS); often taking a long time to heal and requiring significant resources to achieve wound closure. UrgoStart has been demonstrated to improve healing outcomes for patients with LUs. This study examined the cost-effectiveness of UrgoStart compared with a neutral dressing for LU patients. A Markov-model with four health states: open, infected, closed and deceased. Infected wounds had to become open wounds in order to close, and closed wounds had a risk of recurrence. The model took the perspective of the NHS in the United Kingdom, with a cohort of 1000 patients and base-case time horizon of 1 year. The Challenge randomised double blind controlled trial informed the patient characteristics and transitions. The study endpoint was relative wound area reduction at 8 weeks; which was used to calculate the transition probability of healing in the model. Both deterministic and probabilistic sensitivity analyses were performed. UrgoStart was the dominant treatment strategy in terms of cost-effectiveness, with a cost saving of £274.25 and a 0.03 gain in quality-adjusted-life years, per patient. Community nurse visits were the primary cost driver; accounting for 54% and 56% of total costs in the treatment and comparator arm respectively. At 52 weeks 949 wounds had healed using UrgoStart vs 854 wounds using a neutral dressing, at a cost of £1666.80 and £2174.89 per healed wound respectively. Sensitivity analysis showed a cost saving for UrgoStart, even when a comparator was set at £0 cost; over 1000 runs of the model, UrgoStart was dominant in approximately 90% of cases. This analysis showed UrgoStart to be a cost-effective treatment option for treating LU; with benefits for the patient and the NHS. UrgoStart should be considered as a treatment for patients with a LU.

Cost-effectiveness of pneumococcal vaccination strategies for the elderly in Korea.

BackgroundAlthough the 13-valent pneumococcal conjugate vaccine (PCV13) showed good efficacy against pneumococcal disease in the the CAPiTA trial, the 23-valent pneumococcal polysaccharide vaccination (PPSV23) program has been ongoing for older adults aged ≥ 65 years in Korea since May of 2013. This study aimed to evaluate the cost-effectiveness of the current vaccination strategy (a single-dose PPSV23 vaccination) compared to a single-dose PCV13 vaccination and sequential PCV13-PPSV23 vaccinations in the elderly population aged ≥ 65 years.MethodsUsing a Markov model, the incremental cost-effectiveness ratios (ICERs) of three vaccination strategies were assessed in a societal context. The transition probabilities, utility weights to estimate quality adjusted life year (QALY), and disease treatment costs were either calculated or cited from published data and the Health Insurance Review and Assessment Service. Simulations were performed in hypothetical cohorts of Korean adults aged ≥ 19 years. The vaccine effectiveness of PPSV23 was cited from a Cochrane Review report, while PCV13 effectiveness data were gathered from the CAPiTA trial.ResultsCurrent PPSV23 vaccination strategies were cost-effective (ICER, $25,786 per QALY). However, the administration of PCV13 as a substitute for PPSV23 was shown to be more cost-effective than PPSV23 vaccination (ICER, $797 per QALY). Sequential PCV13-PPSV23 vaccination was also more cost-effective than PPSV23 for elderly people aged ≥ 65 years. In sensitivity analysis assuming significant PPSV23 effectiveness (50%) against non-bacteremic pneumococcal pneumonia, the PCV13 vaccination strategy was superior to the PPSV23 vaccination strategy in terms of cost-effectiveness.ConclusionThe results suggest that PCV13 vaccination is more cost-effective in elderly subjects aged ≥ 65 years compared to the current PPSV23 vaccination strategy. When complete data is obtained in 2018 on the maximal herd effects of childhood PCV13 immunization, the incidence of pneumococcal pneumonia and the cost-effectiveness of vaccination strategies need to be reassessed.

Cost-effectiveness analysis of lifestyle intervention in obese infertile women.

What is the cost-effectiveness of lifestyle intervention preceding infertility treatment in obese infertile women? Lifestyle intervention preceding infertility treatment as compared to prompt infertility treatment in obese infertile women is not a cost-effective strategy in terms of healthy live birth rate within 24 months after randomization, but is more likely to be cost-effective using a longer follow-up period and live birth rate as endpoint. In infertile couples, obesity decreases conception chances. We previously showed that lifestyle intervention prior to infertility treatment in obese infertile women did not increase the healthy singleton vaginal live birth rate at term, but increased natural conceptions, especially in anovulatory women. Cost-effectiveness analyses could provide relevant additional information to guide decisions regarding offering a lifestyle intervention to obese infertile women. The cost-effectiveness of lifestyle intervention preceding infertility treatment compared to prompt infertility treatment was evaluated based on data of a previous RCT, the LIFEstyle study. The primary outcome for effectiveness was the vaginal birth of a healthy singleton at term within 24 months after randomization (the healthy live birth rate). The economic evaluation was performed from a hospital perspective and included direct medical costs of the lifestyle intervention, infertility treatments, medication and pregnancy in the intervention and control group. In addition, we performed exploratory cost-effectiveness analyses of scenarios with additional effectiveness outcomes (overall live birth within 24 months and overall live birth conceived within 24 months) and of subgroups, i.e. of ovulatory and anovulatory women, women <36 years and ≥36 years of age and of completers of the lifestyle intervention. Bootstrap analyses were performed to assess the uncertainty surrounding cost-effectiveness. Infertile women with a BMI of ≥29 kg/m2 (no upper limit) were allocated to a 6-month lifestyle intervention programme preceding infertility treatment (intervention group, n = 290) or to prompt infertility treatment (control group, n = 287). After excluding women who withdrew informed consent or who were lost to follow-up we included 280 women in the intervention group and 284 women in the control group in the analysis. Total mean costs per woman in the intervention group within 24 months after randomization were €4324 (SD €4276) versus €5603 (SD €4632) in the control group (cost difference of -€1278, P < 0.05). Healthy live birth rates were 27 and 35% in the intervention group and the control group, respectively (effect difference of -8.1%, P < 0.05), resulting in an incremental cost-effectiveness ratio of €15 845 per additional percentage increase of the healthy live birth rate. Mean costs per healthy live birth event were €15 932 in the intervention group and €15 912 in the control group. Exploratory scenario analyses showed that after changing the effectiveness outcome to all live births conceived within 24 months, irrespective of delivery within or after 24 months, cost-effectiveness of the lifestyle intervention improved. Using this effectiveness outcome, the probability that lifestyle intervention preceding infertility treatment was cost-effective in anovulatory women was 40%, in completers of the lifestyle intervention 39%, and in women ≥36 years 29%. In contrast to the study protocol, we were not able to perform the analysis from a societal perspective. Besides the primary outcome of the LIFEstyle study, we performed exploratory analyses using outcomes observed at longer follow-up times and we evaluated subgroups of women; the trial was not powered on these additional outcomes or subgroup analyses. Cost-effectiveness of a lifestyle intervention is more likely for longer follow-up times, and with live births conceived within 24 months as the effectiveness outcome. This effect was most profound in anovulatory women, in completers of the lifestyle intervention and in women ≥36 years old. This result indicates that the follow-up period of lifestyle interventions in obese infertile women is important. The scenario analyses performed in this study suggest that offering and reimbursing lifestyle intervention programmes in certain patient categories may be cost-effective and it provides directions for future research in this field. The study was supported by a grant from ZonMw, the Dutch Organization for Health Research and Development (50-50110-96-518). The department of obstetrics and gynaecology of the UMCG received an unrestricted educational grant from Ferring pharmaceuticals BV, The Netherlands. B.W.J.M. is a consultant for ObsEva, Geneva. The LIFEstyle RCT was registered at the Dutch trial registry (NTR 1530). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC = 1530.

Análisis de coste-efectividad de la vacunación antineumocócica en España

To perform a cost-effectiveness analysis of pediatric pneumococcal vaccination in Spain.A deterministic population-based model in the form of a decision-tree with a 1-year time horizon was used to estimate the impact of vaccination with Synflorix® or Prevenar13® in children aged less than 2 years in Spain from the perspective of the National Health System. Epidemiological data were obtained from the hospital discharge minimum data set (MDS) and the literature. Data on costs were obtained from national health costs databases. The main outcomes measured were the number of cases avoided of invasive pneumococcal disease, acute otitis media (AOM) and myringotomies, and hospital admissions for pneumonia. All costs were expressed in 2010 euros. Effectiveness was measured as the number of quality-adjusted life years (QALYs) gained.The efficacy of Synflorix® in preventing episodes of AOM caused by non-typeable Haemophilus influenzae could lead to additional prevention of 41,513 episodes of AOM, 36,324 antibiotic prescriptions and 382 myringotomy procedures and 143 QALYs gained compared with Prevenar13®. The total vaccination cost with Synflorix® would result in savings of 22 million euros.Pneumococcal vaccination with Synflorix® in comparison with Prevenar13® in children aged less than 2 years old in Spain could achieve a higher number of QALYs and a substantial cost offset. Vaccination with Synflorix® would be a dominant strategy in terms of cost-effectiveness.

Cost-effectiveness of early colonoscopy surveillance after cancer resection

Short-interval surveillance colonoscopy at 1 year has been recently recommended following curative-intent surgery for colorectal cancer. However, the efficacy and cost-effectiveness of this endoscopic strategy is largely unknown. To assess the clinical and economic impact of early surveillance post-surgical colonoscopy at 1 year in relation to the detection of metachronous colorectal cancer. A decision analysis model was constructed in order to compare a strategy of 1-year endoscopic surveillance versus no early endoscopy following surgical resection for colorectal cancer. A 2-year cancer upstaging was modelled in order to simulate cancer progression in patients with metachronous colorectal cancer who were not referred to early endoscopy. Endoscopic prevalence of metachronous colorectal cancer was estimated from a previous pooled data analysis based on systematic review of the literature. Costs of colonoscopy and cancer care were estimated from Medicare reimbursement data. Outcome measures were the number of early colonoscopies needed to detect one case of cancer or to prevent one cancer-related death and the incremental cost-effectiveness ratio. The number of early 1-year colonoscopies needed to detect one colorectal cancer and to prevent one colorectal cancer-related death was 143 and 926, respectively. The incremental cost-effectiveness ratio of the early 1-year colonoscopy as compared to a policy of not performing it was $40,313 per life-year gained. The incremental cost-effectiveness ratio of performing early surveillance colonoscopy was sensitive to the changes in cancer prevalence. However, only a reduction from the baseline value of 0.7% to 0.19% was associated with an incremental cost-effectiveness ratio higher than $150,000. Other assumptions about cancer upstaging, initial distribution of cancer, and costs had a lesser influence on incremental cost-effectiveness ratio differences. Our study shows that the recently recommended short-interval 1-year surveillance colonoscopy following colorectal cancer resection is a clinically efficient and cost-effective strategy in terms of cancer detection and cancer-specific death prevention.

Cost-effectiveness of drug-eluting coronary stents in Quebec, Canada

The aim of this investigation was to assess the incremental cost-effectiveness of replacing bare metal coronary stents (BMS) with drug-eluting stents (DES) in the Province of Quebec, Canada. The strategy used was a cost-effectiveness analysis from the perspective of the health-care provider, in the province of Quebec, Canada (population 7.5 million). The main outcome measure was the cost per avoided revascularization intervention. Based on the annual Quebec rate of 14,000 angioplasties with an average of 1.7 stents per procedure and a purchase cost of $2,600 Canadian dollar (CDN) for DES, 100 percent substitution of BMS with DES would require an additional $45.1 million CDN of funding. After the benefits of reduced repeat revascularization interventions are included, the incremental cost would be $35.2 million CDN. The cost per avoided revascularization intervention (18 percent coronary artery bypass graft, 82 percent percutaneous coronary intervention [PCI]) would be $23,067 CDN. If DES were offered selectively to higher risk populations, for example, a 20 percent subgroup with a relative restenosis risk of 2.5 times the current bare metal rate, the incremental cost of the program would be $4.9 million CDN at a cost of $7,800 per avoided revascularization procedure. Break-even costs for the program would occur at DES purchase cost of $1,161 for 100 percent DES use and $1,627 for selective 20 percent DES use for high-risk patients for restenosis (RR = 2.5). Univariate and Monte Carlo sensitivity analyses indicate that the parameters most affecting the analysis are the capacity to select patients at high risk of restenosis, the average number of stents used per PCI, baseline restenosis rates for BMS, the effectiveness ratio of restenosis prevention for DES versus BMS, the cost of DES, and the revascularization rate after initial PCI. Sensitivity analyses suggest little additional health benefits but escalating cost-effectiveness ratios once a DES penetration of 40 percent has been attained. Under current conditions in Quebec, Canada, selective use of DES in high-risk patients is the most acceptable strategy in terms of cost-effectiveness. Results of such an analysis would be expected to be similar in other countries with key model parameters similar to those used in this model. This model provides an example of how to evaluate the cost-effectiveness of selective use of a new technology in high-risk patients.

3375 Where do eus and mrcp fit in the management of the patient with acute biliary pancreatitis: a decision analytic model.

Background: In the absence of biliary sepsis, the role of endoscopic retrograde cholangiopancreatography (ERCP)in acute biliary pancreatitis (ABP) is controversial. ERCP has not reliably decreased morbidity or mortality, and procedure-related complications may occur. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are new modalities for CBD visualization that could lower costs and complications related to ERCP.We performed cost-effectiveness and Bayesian analyses of these modalities to define their potential role in ABP. Methods: A decision analytic model of the natural history of ABP was constructed (DATA 3.5, TreeAge Inc., Williamstown, MA). The transition probabilities between health states and test performance characteristics (sensitivity and specificity)were derived from the medical literature using Medline™. All costs(including the diagnostic procedures evaluated) were obtained from Medicare reimbursement rates and supplemented by the medical literature. The strategies evaluated were: 1)ERCP at 48 hours, 2)MRCP at 48 hours followed by ERCP if positive for CBD stone, 3)EUS at 48 hours followed by ERCP if positive for CBD stone and 4) Observation and endoscopic intervention only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies. The outcome measures utilized were total costs, costs per ABP death prevented, costs per ERCP death prevented and costs per stone detected. Results: The total costs per patient with ABP were: Observation $8,821; EUS $9,828; ERCP $9,970; MRCP $10,253. The incremental cost-effectiveness ratio (ICER) per ABP death prevented was equal for ERCP, EUS and MRCP ($900K). The ICER per ERCP-related death prevented was $70K for Observation, $92K for EUS and $95K for MRCP. At a pre-test probability of CBD stones between 0-40%, EUS was the most cost-effective strategy in terms of dollars per stone detected, whereas ERCP was preferable at probabilities >40%. Conclusions: In terms of preventing deaths due to ABP and ERCP, observation is the most cost-effective strategy. From a practical standpoint, if concern exists about retained stones, EUS is most cost-effective, at a pretest probability of stones between 0-40%. If the probability of retained CBD stones is greater than 40%, ERCP is the dominant strategy. Development and validation of clinical predictors of retained CBD stones will facilate cost-effective care in these patients.

Prevention effectiveness of rollover protective structures--Part III: Economic analysis.

The purpose of this part of the study is to assess the costs and benefits of either installing rollover protective structures (ROPS) on tractors lacking ROPS and for which ROPS are available or replacing the tractors with newer ROPS-equipped ones, relative to doing nothing. The methods used are cost-effectiveness and cost-benefit analyses. The cost-effectiveness analysis shows that compared to the "do nothing" strategy, the "install ROPS" strategy would cost $489,373 per injury averted and the "replace tractor" strategy would cost $14.3 million per injury averted over a 23-year period. The cost-benefit analysis shows that compared to the "do nothing" strategy, the "install ROPS" strategy would save society $1.5 billion while the "replace tractor" strategy would cost society $18.7 billion. While both the "install ROPS" and the "replace tractor" strategies are effective at saving lives and preventing injuries, this study has concluded that the preferred strategy in terms of cost-effectiveness is to "install ROPS" on tractors lacking them and for which ROPS are available.