Two-way Sensitivity Analysis Research Articles

Micafungin im Vergleich zu Caspofungin bei der Behandlung von invasiven Candida-Infektionen: Eine Kosteneffektivitätsanalyse für Deutschland

Although echinocandins such as micafungin and caspofungin have been shown to be effective and tolerated in the treatment of candidal infections there has been no appraisal of the cost-effectiveness of both echinocandins in Germany. This study compares the cost-effectiveness of micafungin and caspofungin in the treatment of invasive candida infections in Germany. To this end, a health economic decision model, based on a phase-III double-blind randomised controlled trial and German hospitalisation and primary medication costs, was used. The effectiveness outcome is defined as patients who are successfully treated and alive at the end of the study period and cost-effectiveness is measured as total costs per patient related to effectiveness. To test for robustness, a two-way sensitivity analysis and a probabilistic sensitivity analysis (PSA) were performed and a cost-effectiveness acceptability curve (CEAC) was calculated. The two-way sensitivity analysis renders micafungin more cost-effective than caspofungin in the global population sample in 19 out of 20 scenarios (20 out of 20 scenarios in the European subsample). Average costs in the PSA were €38,793 for micafungin and €40,072 for caspofungin, while effectiveness was 59.61% and 57.52%, respectively. The average cost-effectiveness is €65,271 for micafungin and €69,835 for caspofungin. For the European subsample, the calculated average costs in the PSA are €40,025 for micafungin and €40,082 for caspofungin, while the effectiveness is 63.29% and 53.69%. Micafungin shows an average cost-effectiveness of €64,412, compared to €76,791 for caspofungin. The CEAC shows that the probability for micafungin being more cost-effective than caspofungin ranges between 51.6% (no willingness to pay for additional costs per successfully treated patient) and 67.7% (infinitely high willingness to pay) in the total sample and between 48.8% and 79.5% in the European subsample. According to this study both lower costs and higher effectiveness show micafungin to be more cost-effective than caspofungin for the treatment of systemic candida infections in Germany.

Factor VIII Intron 22 Inversion Screening of Newborn Males for Hemophilia A: A Cost-Effectiveness Study

AbstractAbstract 734 Background:Severe hemophilia A is an X-linked congenital bleeding disorder occurring in 1:5,000 male births. Among neonates with severe hemophilia A, failure to recognize hemophilia and associated bleeding may result in severe blood loss anemia from circumcision, central nervous system (CNS) bleeding during the birth process or with head trauma and associated neurologic sequelae, and unrecognized joint bleeding that, when recurrent, increases the risk of joint damage which may lead to chronic disability. In at least one-third of cases, the disease arises as a spontaneous mutation: yet, even among the two-thirds with a family history, most carriers do not undergo carrier testing or prenatal diagnosis, leaving only a minority in whom cord blood screening is performed. About half of newborns with severe hemophilia A have a factor VIII (F.VIII) intron 22 inversion mutation, readily detected by PCR screening. We, therefore, sought to determine the effects of newborn screening by F.VIII intron 22 inversion PCR on early diagnosis in children with severe hemophilia A, specifically, on prevention of early life bleeding and associated cost, morbidity, and quality of life. Methods:We constructed a decision tree model to evaluate the cost effectiveness of newborn F.VIII intron 22 screening for severe hemophilia A. We assumed all newborn males were tested as part of screening, and that treatment modifies the likelihood of bleeding but not bleeding associated morbidity. Rates of major and minor CNS, joint, and procedural/surgical bleeding, including circumcision, morbidity and mortality, cost, and quality of life utilities were obtained from the literature. We assumed the cost of intron 22 PCR testing to be $3.00 per newborn male, that test results were available within 2 days of screening, and that clotting factor was infused prior to procedures and at the first sign of joint bleeding or head trauma. The probability of severe bleeding requiring hospitalization or red blood cell transfusion was estimated to be 5% or less in children with severe hemophilia A. The cost of F.VIII concentrate was based on the average wholesale price, and transfusion and hospitalization costs were based on local data. Outcomes included medical costs for each bleeding event, effectiveness measured as quality-adjusted-life-years (QALY), and the incremental cost-effectiveness ratio (ICER) over the first two years of life. Sensitivity analysis was used to test the robustness of analysis results. Results:Compared to no screening, screening for hemophilia had an ICER of $96,918/QALY, a value considered economically reasonable. Results were sensitive to variation of screening cost and overall detection of hemophilia A by PCR screening (base case 50%). Effects of varying both these parameters in a two-way sensitivity analysis are shown in the Figure. Using a $100,000 per QALY cost-effectiveness criterion over the depicted ranges for both parameters, screening was favored if screening cost ≤$3 or if ≥56% of all newborns with hemophilia A were detected by screening. Conclusion:It is cost effective to perform factor VIII intron 22 PCR screening to identify severe hemophilia A in newborn males in order to prevent bleeding morbidity, if the cost of the test does not exceed $3.00. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Mesh kits for anterior vaginal prolapse are not cost effective

To analyze the cost-effectiveness of traditional anterior colporrhaphy (AC), hand-cut mesh, and mesh kit anterior vaginal prolapse (AVP) repair. A decision analysis model was built using mean operating room (OR) times, mesh extrusion rates, and recurrence rates obtained from a meta-analysis along with Medicare reimbursement for surgeon fees and office visits, and hospital costs of supplies, OR time, and room and board. Non-kit mesh repair was $3,380, AC $3,461, and mesh kit $4,678. One-way sensitivity analyses demonstrated recurrence rate of AC would need to be 28% to be equally cost effective. Mesh kit repair did not reach cost equivalence even at 0 min OR time. Two-way sensitivity analysis comparing mesh extrusion and AC recurrence demonstrated AC is more cost effective if recurrence is <20% or extrusion >25%. Mesh kits for AVP repair are not cost effective, regardless of the OR time saved.

E0590 The one-year pharmacoeconomic evaluation of hypertension′s treatment by low dose amlodipine plus telmisartan or amlodipine plus amiroride regimen

ObjectiveTo evaluate the cost-effectiveness of low-dose amlodipine plus telmisartan (group A) or amlodipine plus amiroride (group B) therapy in hypertensive patients using a decision-tree model with a time horizon of...

Renal mass biopsy to guide treatment decisions for small incidental renal tumors: a cost-effectiveness analysis.

To evaluate the effectiveness, cost, and cost-effectiveness of using renal mass biopsy to guide treatment decisions for small incidentally detected renal tumors. A decision-analytic Markov model was developed to estimate life expectancy and lifetime costs for patients with small (< or = 4-cm) renal tumors. Two strategies were compared: renal mass biopsy to triage patients to surgery or imaging surveillance and empiric nephron-sparing surgery. The model incorporated biopsy performance, the probability of track seeding with malignant cells, the prevalence and growth of benign and malignant tumors, treatment effectiveness and costs, and patient outcomes. An incremental cost-effectiveness analysis was performed to identify strategy preference under a willingness-to-pay threshold of $75,000 per quality-adjusted life-year (QALY). Effects of changes in key parameters on strategy preference were evaluated in sensitivity analysis. Under base-case assumptions, the biopsy strategy yielded a minimally greater quality-adjusted life expectancy (4 days) than did empiric surgery at a lower lifetime cost ($3466), dominating surgery from a cost-effectiveness perspective. Over the majority of parameter ranges tested in one-way sensitivity analysis, the biopsy strategy dominated surgery or was cost-effective relative to surgery based on a $75,000-per-QALY willingness-to-pay threshold. In two-way sensitivity analysis, surgery yielded greater life expectancy when the prevalence of malignancy and propensity for biopsy-negative cancers to metastasize were both higher than expected or when the sensitivity and specificity of biopsy were both lower than expected. The use of biopsy to guide treatment decisions for small incidentally detected renal tumors is cost-effective and can prevent unnecessary surgery in many cases.

The socioeconomics of diabetes from a developing country: A population based cost of illness study

Objective To assess the annual health care expenditure for a patient with diabetes and extrapolate the same to country specific prevalence estimates for 2010. Methods This population based, cost of illness study collected retrospective data for last 12 months on direct costs (medical and non-medical) through records, indirect cost through human capital approach and intangible cost by contingent valuation method from diabetes patients. Results Out of 4677 subjects screened, 1050 had diabetes and 718 participated in the survey. The median annual direct and indirect cost associated with diabetes care was estimated at 25,391 INR ($525.5) and 4970 INR ($102.8), respectively. Extrapolating the direct and indirect estimates to Indian population, the annual costs for diabetes would be 1541.4 billion INR ($31.9 billion) in 2010. Two-way sensitivity analysis assuming 10% variation in both prevalence of diabetes and in treatment costs resulted in an estimated cost range of 1230 billion INR ($25.5 billion) to 1837.3 billion INR ($38.0 billion). Conclusion Keeping the future diabetes explosion in mind, this heavy economic burden highlights the urgent need for the decision makers to allocate resources for planning and implementing strategies in prevention and management of diabetes and its complications.

Modeling screening, prevention, and delaying of Alzheimer's disease: an early-stage decision analytic model

BackgroundAlzheimer's Disease (AD) affects a growing proportion of the population each year. Novel therapies on the horizon may slow the progress of AD symptoms and avoid cases altogether. Initiating treatment for the underlying pathology of AD would ideally be based on biomarker screening tools identifying pre-symptomatic individuals. Early-stage modeling provides estimates of potential outcomes and informs policy development.MethodsA time-to-event (TTE) simulation provided estimates of screening asymptomatic patients in the general population age ≥55 and treatment impact on the number of patients reaching AD. Patients were followed from AD screen until all-cause death. Baseline sensitivity and specificity were 0.87 and 0.78, with treatment on positive screen. Treatment slowed progression by 50%. Events were scheduled using literature-based age-dependent incidences of AD and death.ResultsThe base case results indicated increased AD free years (AD-FYs) through delays in onset and a reduction of 20 AD cases per 1000 screened individuals. Patients completely avoiding AD accounted for 61% of the incremental AD-FYs gained. Total years of treatment per 1000 screened patients was 2,611. The number-needed-to-screen was 51 and the number-needed-to-treat was 12 to avoid one case of AD. One-way sensitivity analysis indicated that duration of screening sensitivity and rescreen interval impact AD-FYs the most. A two-way sensitivity analysis found that for a test with an extended duration of sensitivity (15 years) the number of AD cases avoided was 6,000-7,000 cases for a test with higher sensitivity and specificity (0.90,0.90).ConclusionsThis study yielded valuable parameter range estimates at an early stage in the study of screening for AD. Analysis identified duration of screening sensitivity as a key variable that may be unavailable from clinical trials.

1391 MESH KITS FOR ANTERIOR VAGINAL PROLAPSE (AVP) ARE NOT COST EFFECTIVE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Pelvic Prolapse1 Apr 20101391 MESH KITS FOR ANTERIOR VAGINAL PROLAPSE (AVP) ARE NOT COST EFFECTIVE Sunshine Murray, Rashel Haverkorn, Yair Lotan, and Gary Lemack Sunshine MurraySunshine Murray More articles by this author , Rashel HaverkornRashel Haverkorn More articles by this author , Yair LotanYair Lotan More articles by this author , and Gary LemackGary Lemack More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1041AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES With rising health care costs, cost-effective medicine has been pushed to the forefront. We attempt to analyze the cost of three common forms of AVP repair. METHODS A meta-analysis was performed to obtain average operating room (OR) times, mesh extrusion and recurrence rates for traditional anterior colporrhaphy (AC), hand cut mesh and mesh kit AVP repair. Medicare reimbursement for surgeon fees and office visits, and hospital cost of prolene mesh, mesh kits, OR time, recovery room stay, intravenous fluids and room and board were obtained. OR time for mesh excision was obtained by averaging the times of cases performed at our hospital over the last two years. RESULTS Weighted operative times for mesh kit, mesh non-kit and AC were 58, 64 and 79 minutes respectively. Weighted extrusion rates and recurrence rates for mesh kit and mesh non-kit were 11%/10% and 13%/14%. We estimated recurrence rate at 30% for AC. The professional fee for mesh repair is $895 compared to $630 for AC. The cost of a mesh kit averages $1648 and the cost of a 12x14cm piece of mesh is $400. OR time at our hospital is $13 per minute, with additional overnight costs of $825. Cost of extrusion was calculated assuming 1 additional clinic visit, using the professional fee for mesh excision ($476) and the average OR time for mesh excision (47m). The cost of recurrence was calculated assuming non-kit mesh repair performed at 1.5x initial OR time with an overnight stay. The cost of non-kit mesh repair was $3380, AC was $3461 and mesh kit $4678. When performing one-way sensitivity analyses, the recurrence rate of the traditional repair would need to be 28% to be equally cost-effective. The mesh kit repair did not reach equal cost with either repair even at an OR time of 0 minutes. A two-way sensitivity analysis was performed comparing mesh extrusion and AC recurrence (see figure). At a recurrence rate of up to 20%, AC is more cost effective. When the recurrence rate for AC is 30%, the mesh non-kit repair is more cost effective if the extrusion rate is less than 25%. If recurrence rate is calculated at 50% then hand cut mesh is more cost effective even with a 50% extrusion rate. CONCLUSIONS Mesh kits for repair of AVP are not cost effective, regardless of the time saving in the OR or reduction in recurrence. Non-kit mesh is cost effective for AVP if extrusion rates remain below 25%. Dallas, TX© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e537-e538 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sunshine Murray More articles by this author Rashel Haverkorn More articles by this author Yair Lotan More articles by this author Gary Lemack More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis

The Pulmonary Embolism Rule-out Criteria (PERC) identifies low-risk patients who are treated in the emergency department for suspected pulmonary embolism and for whom testing may be deferred. The purpose of this study is to develop a decision model to determine whether certain elements not included in the PERC methodology could better estimate the testing threshold for pulmonary embolism (ie, the pretest probability below which a patient should not be tested for pulmonary embolism). In addition, we determine which risks and benefits of pulmonary embolism evaluation and treatment have the greatest effect on the testing threshold. We built decision models of low-risk patients with suspected pulmonary embolism, as determined by the PERC. We obtained model inputs from the literature or by using clinical judgment when data were unavailable. One-way sensitivity analysis derived the testing threshold, and 2-way sensitivity analysis was used to determine the main drivers of the testing threshold. We found an average testing threshold of 1.4% across all age and sex cohorts. Two-way sensitivity analysis demonstrated that risk of major bleeding from anticoagulation, mortality from contrast-induced renal failure, risk of cancer from computed tomography scan, and mortality from both treated and untreated pulmonary embolism had the greatest effects on the testing threshold. We found a testing threshold for the PERC similar to that calculated by the Pauker and Kassirer method, using somewhat different assumptions. The 5 major drivers for the testing threshold are variables for which there is a paucity of literature to assess accurately for low-risk patients.

Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States.

BackgroundThe aim of this study was to estimate both the direct and indirect annual costs of treating bacterial conjunctivitis (BC) in the United States. This was a cost of illness study performed from a U.S. healthcare payer perspective.MethodsA comprehensive review of the medical literature was supplemented by data on the annual incidence of BC which was obtained from an analysis of the National Ambulatory Medical Care Survey (NAMCS) database for the year 2005. Cost estimates for medical visits and laboratory or diagnostic tests were derived from published Medicare CPT fee codes. The cost of prescription drugs was obtained from standard reference sources. Indirect costs were calculated as those due to lost productivity. Due to the acute nature of BC, no cost discounting was performed. All costs are expressed in 2007 U.S. dollars.ResultsThe number of BC cases in the U.S. for 2005 was estimated at approximately 4 million yielding an estimated annual incidence rate of 135 per 10,000. Base-case analysis estimated the total direct and indirect cost of treating patients with BC in the United States at $ 589 million. One- way sensitivity analysis, assuming either a 20% variation in the annual incidence of BC or treatment costs, generated a cost range of $ 469 million to $ 705 million. Two-way sensitivity analysis, assuming a 20% variation in both the annual incidence of BC and treatment costs occurring simultaneously, resulted in an estimated cost range of $ 377 million to $ 857 million.ConclusionThe economic burden posed by BC is significant. The findings may prove useful to decision makers regarding the allocation of healthcare resources necessary to address the economic burden of BC in the United States.

Residual Fragments After Percutaneous Nephrolithotomy: Cost Comparison of Immediate Second Look Flexible Nephroscopy Versus Expectant Management

We performed a cost comparison of immediate second look flexible nephroscopy vs expectant management for post-percutaneous nephrostolithotomy residual fragments. We used a decision analysis model to compare the cost of managing residual fragments by second look flexible nephroscopy vs observation. Outcomes of residual fragments after percutaneous nephrostolithotomy were determined from institutional experience and published shock wave lithotripsy series. Cost data were obtained from billing records. One-way sensitivity analysis was done to evaluate incurred costs of second look flexible nephroscopy while varying the likelihood of a stone event, the probability of surgery and the cost of surgical intervention. Two-way sensitivity analysis was done to assess the model across a range of scenarios. Based on data in the literature and our institutional experience 40% of patients with residual fragments 4 mm or less had a stone event, of whom 57% required surgical intervention. Based on these estimates the average cost of expectant management for a residual fragment 4 mm or less vs greater than 4 was $1,743 vs $4,674. The average incremental cost of second look flexible nephroscopy at our institution was $2,475. Two-way sensitivity analysis showed that varying assumptions dramatically altered conclusions about the cost benefit of second look flexible nephroscopy. Our model suggests that second look flexible nephroscopy is not cost advantageous in all patients with post-percutaneous nephrostolithotomy residual fragments. Cost benefit analysis is significantly impacted by the likelihood of a stone related event, the need for surgical intervention and surgical costs. Compared to an observational strategy second look flexible nephroscopy incurs lower costs for greater than 4 mm but not for 4 mm or less residual fragments.

Cost-Effectiveness Analysis of Oseltamivir for Influenza Treatment Considering the Virus Emerging Resistant to the Drug in Japan

The purpose of this study is to evaluate the cost-effectiveness of oseltamivir for influenza in Japan considering the complications and the emergence of oseltamivir-resistant virus. Study design is a cost-effectiveness analysis in decision analytic modeling based on previously published evidence. Outcome measures included costs and quality-adjusted life year (QALY). In the base-case analysis, the incremental cost-effectiveness ratio (ICER) of oseltamivir during influenza and complications was JPY398,571 ($3320) per QALY without productivity loss, which implied oseltamivir is evidently cost-effective. Furthermore, considering the productivity loss, the ICER for oseltamivir turned to be negative, which means simply dominant. When the prevalence was in the low range of 10% to 38%, oseltamivir became less cost-effective than conventional treatment. Regarding potential emergence of the drug-resistant virus, we found the dominance of oseltamivir will vanish if the emerging rate becomes larger than 27%. The two-way sensitivity analysis also suggested that if the resistant virus rate becomes less and the prevalence higher, then oseltamivir becomes more advantageous. The analysis for uncertainty, using cost-effectiveness acceptability curve by Monte Carlo simulation, resulted in the estimate of about 80% chance that oseltamivir could be cost-effective at the willingness-to-pay level of JPY6,000,000 ($50,000), which is commonly accepted as an affordable threshold.

Telemedicine in the management of chronic pain: a cost analysis study

Telemedicine provides patients with easy and remote access to consultant expertise irrespective of geographic location. In a randomized controlled trial, this study has applied a rigorous costing methodology to the use of telemedicine in chronic pain management. We performed a randomized two-period crossover trial comparing in-person (IP) consultation with telemedicine (TM) consultation in the management of chronic pain. Over an 18-month period, 26 patients each completed two diaries capturing their direct and indirect travel costs, daily pain scores, and satisfaction with physician consultation. Costing models were developed to account for direct, indirect, fixed, and variable costs in order to perform break-even analyses. Sensitivity analysis was performed over a broad range of assumptions. Direct patient costs were significantly lower in the TM group than in the IP group, with median cost and interquartile range 133 dollars (28-377) vs 443 dollars (292-1075), respectively (P = 0.001). More patients were highly satisfied with the TM consultation than with the IP consultation (56 and 24%, respectively; P < 0.05). Break-even annual patient volume was estimated at 57 patients. A two-way sensitivity analysis controlling for annual patient volume and round-trip distance indicated that TM remains cost-effective at volumes >50 patients/year or at round-trip distances >200 km. Telemedicine is cost-effective over a broad range of assumptions, including annual patient volumes, travel distance, fuel costs, amortization, and discount rates. This study provides data from a real-world setting to determine relevant thresholds and targets for establishing a TM program for patients who are undergoing chronic pain therapy.

Cost-Effectiveness of Pegfilgrastim versus Six Days of Filgrastim for Preventing Febrile Neutropenia in Breast Cancer Patients

Febrile neutropenia (FN) is a major complication of chemotherapy and is associated with substantial morbidity, mortality and costs. The aim of this study was to evaluate the cost-effectiveness of primary prophylaxis with, pegfilgrastim versus six-day filgrastim in preventing FN in Italian patients with early-stage breast cancer receiving adjuvant chemotherapy associated with a > or = 20% FN risk. The pharmacoeconomic evaluation was based on a decision-analytic model taking into account the possible consequences of FN (e.g., death and reduction/delay of chemotherapy dose). Parameters included in the model were relative risk of FN with pegfilgrastim versus six-day filgrastim; direct costs (drug purchase and FN-related hospitalizations); relative risk of relative dose intensity < 85% with pegfilgrastim versus filgrastim; impact on long-term survival due to relative dose intensity < 85%; and impact of age on FN and relative dose intensity < 85%. Under base-case assumptions, pegfilgrastim was cost-effective compared to six-day filgrastim in Italy. The estimated cost, life expectancy and quality-adjusted life years per person for pegfilgrastim were Euro 3078, 16.47 years, and 15.32; the corresponding figures for six-day filgrastim were Euro 3033, 16.35 years, and 15.22. The corresponding incremental cost-effectiveness ratio with pegfilgrastim was Euro 409 per life-year gained and Euro 429 per quality-adjusted life year gained. One-way sensitivity analyses showed that the results were most sensitive to the relative risk of FN for 6-day filgrastim versus pegfilgrastim. The results were moderately sensitive to the cost of pegfilgrastim and filgrastim, cost of drug administration, cost of FN hospitalization, and number of chemotherapy cycles. Pegfilgrastim remained cost-effective, with an incremental cost-effectiveness ratio well below the accepted limit of Euro 50,000 per life year gained in all one-way sensitivity analyses. A two-way sensitivity analysis on cost of drugs showed a range of pegfilgrastim dominance over six-day filgrastim. At the current official price in Italy, primary prophylaxis with pegfilgrastim improved health outcomes with a very limited cost increase for the National Health Service payer. Even when very low prices of filgrastim and high prices of pegfilgrastim were considered in the model, the resulting incremental cost-effectiveness ratio remained well within the acceptable cost-effectiveness limit of Euro 50,000/quality-adjusted life year.

Cost-Effectiveness of Medical Expulsive Therapy Using Alpha-Blockers for the Treatment of Distal Ureteral Stones

ObjectiveMedical expulsive therapy (MET) has recently emerged as an efficacious and safe option for the initial management of ureteral stones. The objective of this study was to assess the cost-effectiveness of MET compared with conservative therapy for the treatment of ureteral stones using international cost data from the United States and four European countries. Material and methodsA decision analysis model was built with the use of TreeAge Pro 2004 software with linear success rate assumptions. The likelihood of spontaneous passage of ureteral stones according to their size and location was estimated with the use of data derived from a published meta-analysis. The estimated cost of ureteroscopy (URS) in the United States ($4973) was based on the mean cost of 121 consecutive cases performed at a large metropolitan hospital. URS costs for other countries were obtained from a published international survey. The cost of tamsulosin ($2.08 per day), currently the most commonly used medical expulsive agent, was estimated as a mean of the costs obtained from two national pharmacy chains. MET and conservative therapies were compared with the use of one-way and two-way sensitivity analyses. ResultsIn the United States, MET using tamsulosin resulted in a $1132 cost advantage over observation. MET maintained its cost advantage even in countries where the cost of URS is much lower than in the United States. Two-way sensitivity analysis showed that MET remained cost-effective even with very low rates of spontaneous passage, minimal benefit of MET, or low cost of URS. ConclusionMET is a cost-effective strategy for the management of distal ureteral stones—even those with a low rate of spontaneous passage—providing another incentive for initial “facilitated observation” before embarking on surgical intervention.

Decision analysis model evaluating the cost‐effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia

To evaluate the cost-effectiveness of three antipsychotic medications (olanzapine, risperidone and haloperidol) in the treatment of schizophrenia using the Positive and Negative Symptom Scale. A decision analysis model was created to evaluate the cost-effectiveness of two atypical antipsychotics (risperidone and olanzapine) and haloperidol. Outcome probabilities were determined from published clinical trials. The main dependent variable of interest was to compare the incremental cost-effectiveness ratios (ICER) of the atypical antipsychotic with haloperidol, and also to compare the ICER of olanzapine and risperidone. Sensitivity analyses were conducted for olanzapine and risperidone to determine the effects of altering drug cost, efficacy and re-hospitalization rate on total costs. Risperidone and olanzapine were dominant strategies compared with haloperidol (less costly and more effective). Risperidone was also dominant when compared with olanzapine. A one-way sensitivity analysis for efficacy indicated that the efficacy of risperidone would need to decrease by approximately 3% from the base-case in order for olanzapine and risperidone to have equal total costs. In a two-way sensitivity analysis varying both the cost of olanzapine and risperidone, the difference in drug costs between them would have to increase from $2.12 per day to $4.12 per day in order to have equal total costs. In terms of varying re-hospitalization rates, the re-hospitalization rate for risperidone would have to increase from 3% to 33% greater than the re-hospitalization rate for olanzapine in order to have equal total direct costs. Based on this decision model, atypical antipsychotics were a dominant strategy over haloperidol primarily because of increased efficacy and lower re-hospitalizations. The ICER indicated that risperidone was dominant over olanzapine because of lower drug costs and increased number of responders, which leads to decreased total costs.

Corrections

For an article (1) in the August 2006 issue, the authors recently discovered an error in the methodology of the cost-effectiveness model that was described. The authors have revised parts of the Abstract and the Results section. The authors also corrected the data in Table 3 per the changes induced in the model by the corrected progression rate for Gleason sum 2−7 cancers. This table has implications for other chemoprevention trials such as SELECT and REDUCE and for future chemoprevention trials since it provides a framework for estimating cost-effectiveness in the settings of other potential agents and higher-risk populations. The main conclusions of the article, however, remain unchanged.The text corrections appear in bold in the following.Chemoprevention with finasteride resulted in a gain of 8.7 life years per 1000 men at a cost of $1.107 million per life year saved(LYS). However, if finasteride is assumed to not increase the incidence of highgrade tumors, it renders a gain of 16.6 life years per 1000 men at a cost of $578,400 per LYS; finasteride must cost $160 per year to reach $100,000 per LYS. When applied to a population at higher risk (lifetime prevalence ≥40%) for developing prostate cancer, the cost of finasteride must be reduced from its current cost ($62/month) to &lt;$15/month for the cost-effectiveness to fall below $50,000 per LYS.Our first analysis assumed the grade distribution of the PCPT-reduced overall prostate cancer and increased high-grade prostate cancer in the finasteride versus the placebo arm. Under this assumption, finasteride chemoprevention resulted in a gain of 8.7 life years per 1000 men. At an increased lifetime cost of $9,631 per person, this render sad is counted incremental costeffectiveness ratio of $1,107,000 per life year saved (LYS) for finasteride versus no treatment.Based on evidence that the higher distribution of Gleason score ≥7 in the finasteride versus the placebo arm of the PCPT may have been more apparent than real, our second analysis assumed that finasteride reduces overall prostate cancer and does not increase the incidence of high-grade disease. Under this assumption, finasteride chemoprevention resulted in a gain of 16.6 life years per 1000 men. At an increased lifetime cost of $9,600 per person, this renders a discounted incremental costeffectiveness ratio of $578,400 per LYS for finasteride versus no treatment.A two-way sensitivity analysis relaxing the assumptions regarding the disease prevalence and the relative risk reduction in the incidence of prostate cancer is shown in Table 3. Assuming a 25% relative risk reduction afforded by treatment, if the cost of finasteride was reduced from its current cost of $62 per month to $15 per month, the cost per LYS would fall to $65,000 for a population at high risk (prevalence ≥30% for men age 50 and older) of developing prostate cancer. On the other hand, at a cost of $62/month, a relative risk reduction of 50% targeted at a population with a prostate cancer prevalence of &gt;40% after age 50 would be required to obtain a cost of $100,000 per LYS.Graphic representations of two-way sensitivity analyses are shown in Figs. 2 and 3. Figure 2 shows that disease prevalence and the prostate cancer risk reduction significantly affect the costeffectiveness of finasteride. At a cost of $62 per month, the cost per LYS is &gt;$100,000 unless the prevalence is &gt;40% and the risk reduction is &gt;50%. In Figure 3, cost-effectiveness is based on varying drug costs and disease prevalences. At low drug costs, chemoprevention results in less than $100,000 per LYS even at low disease prevalence. An additional analysis was performed to bias towards an increased cost of prostate cancer treatment. We assumed a quarter of men with prostate cancer diagnosis received salvage therapy following recurrence and one-half of men with metastatic disease received chemotherapy. This resulted in a decrease in the cost-effectiveness ratio by 3.9%.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches. In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data. From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained. We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.

Cost-Effectiveness of Environmental–Structural Communication Interventions for HIV Prevention in the Female Sex Industry in the Dominican Republic

Behavior change communication often focuses on individual-level variables such as knowledge, perceived risk, self-efficacy, and behavior. A growing body of evidence suggests, however, that structural interventions to change the policy environment and environmental interventions designed to modify the physical and social environment further bolster impact. Little is known about the cost-effectiveness of such comprehensive intervention programs. In this study we use standard cost analysis methods to examine the incremental cost-effectiveness of two such interventions conducted in the Dominican Republic in sex establishments. In Santo Domingo the intervention was environmental; in Puerto Plata it was both environmental and structural (levying financial sanctions on sex establishment owners who failed to follow the intervention). The interventions in both sites included elements found in more conventional behavior change communication (BCC) programs (e.g., community mobilization, peer education, educational materials, promotional stickers). One key aim was to examine whether the addition of policy regulation was cost-effective. Data for the analysis were gleaned from structured behavioral questionnaires administered to female sex workers and their male regular paying partners in 41 sex establishments conducted pre- and postintervention (1 year follow-up); data from HIV sentinel surveillance, STI screening results conducted for the intervention; and detailed cost data we collected. We estimated the number of HIV infections averted from each of the two intervention models and converted these estimates to the number of disability life years saved as compared with no intervention. One-way, two-way, three-way, and multivariate sensitivity analysis were conducted on model parameters. We examine a discount rate of 0%, 3% (base case), and 6% for future costs and benefits. The intervention conducted in Santo Domingo (community mobilization, promotional media, and interpersonal communication) was estimated to avert 64 HIV infections per 10,000 clients reached, and resulted in a cost per disability-adjusted life year (DALY) saved of $1,186. In Puerto Plata a policy/regulatory intervention was added, which resulted in 162 HIV infections averted per 10,000 clients reached, and yielded a cost per DALY saved of $457. Cost-effectiveness estimates were most correlated to the discount rate used and base rates of sexually transmitted infection (which affects the HIV transmission rate). Both intervention models resulted in cost-effective outcomes; however, the intervention that included policy regulation resulted in a substantially more cost-effective outcome.

Complete daVinci™ versus Laparoscopic Pyeloplasty: Cost Analysis

Computer-assisted pyeloplasty with the daVinci system is an emerging technique to treat ureteropelvic junction (UPJ) obstruction. A relative cost analysis was performed assessing this technology in comparison with purely laparoscopic pyeloplasty. Eight patients underwent computer-assisted (daVinci) dismembered pyeloplasty (CP) via a transperitoneal four-port approach. They were compared with 13 patients who underwent purely laparoscopic pyeloplasty (LP). All patients had a primary UPJ obstruction and were matched for age, sex, and body mass index. The cost of equipment and capital depreciation for both procedures, as well as assessment of room set-up time, takedown time, and personnel were analyzed. Surgeons and nursing staff for both groups were experienced in both laparoscopy and daVinci procedures. One- and two-way financial analysis was performed to assess relative costs. The mean set-up and takedown time was 71 minutes for CP and 49 minutes for LP. The mean length of stay was 2.3 days for CP and 2.5 days for LP. The mean operating room (OR) times for CP and LP were 176 and 210 minutes, respectively. There were no complications in either group. One-way cost analysis with an economic model showed that LP is more cost effective than CP at our hospital if LP OR time is <338 minutes. With adjustment to a volume of 500 daVinci cases/year, CP is still not as cost effective as LP. Two-way sensitivity analysis shows that in-room time must still be <130 minutes and yearly cases must be >500 to obtain cost equivalence for CP. Perioperative parameters for CP are encouraging. However, the costs are a clear disadvantage. In our hospital, it is more cost effective to teach and perform LP than to perform CP.