Leukaemia at Queen Elizabeth Central Hospital in Blantyre, Malawi

OBJECTIVES

To determine the patterns of leukaemias seen in Malawians at Queen Elizabeth Central Hospital (QECH) and to compare the findings with those from elsewhere. An overview of the problems encountered in the management of leukaemia in developing countries especially those in sub-Saharan Africa are highlighted.

DESIGN

Retrospective descriptive analysis of consecutive leukaemia cases seen from January 1994 through December 1998.

RESULTS

Of the 95 leukaemia patients diagnosed during the study period, childhood (0-15 years) leukaemia occurred in 27 (28.4%) patients while adulthood (above 15 years) leukaemia accounted for 68 (71.6%) patients. The main leukaemia types were: acute lymphoblastic leukaemia (ALL) 14 (14.7%), acute myeloblastic leukaemia (AML) 25 (26.3%), chronic myeloid (granulocytic) leukaemia (CML) 32 (33.7%), chronic lymphocytic (lymphatic) leukaemia (CLL) 22 (23.2%) and hairy cell leukaemia (HCL) two (2.1%) patients. Most of the acute leukaemia (AL) cases occurred in the six to 15 year age bracket with a male preponderance. In ALL, lymphadenopathy was the commonest presenting feature followed by pallor (92.9%) while in the AML group, pallor occurred in 80% of cases. Abdominal swelling (87.5%) due to splenomegaly (81.3%) were the main clinical features in the CML group whereas lymphadenopathy (63.6%) followed by splenomegaly (59.1%) were the dominant presenting features in CLL. Haematologically, although leucocytosis characterised both acute and chronic leukaemias, most cases of acute leukaemia presented with more severe anaemia (Hb < 7 g/dl) and marked thrombocytopenia (Platelet count < 50 x 10(9)/l) than the chronic leukaemias.

CONCLUSIONS AND RECOMMENDATIONS

The study shows that leukaemias are not rare in Malawi and cases which were diagnosed in this series probably only represent the tip of the iceberg. While there is need to increase diagnostic awareness among clinicians and laboratory staff, the severe chronic shortage of cytotoxic drugs and lack of supportive care facilities commonly encountered in developing countries should be realistically addressed through cost-sharing, cost recovery, adequate government subvention and donations from charitable organisations.

Asian Pacific cooperative study of allogeneic bone marrow transplantation

The first cooperative study of the Asian Pacific bone marrow transplantation group included 75 patients with early leukemia who received human leukocyte antigen-matched sibling bone marrow transplants and were randomized into granulocyte colony-stimulating factor and control groups. The selected patients were registered from 10 centers in six countries and areas within Asia (Beijing, Taipei, Hong Kong, Japan, Korea, and Malaysia). The incidence of grades II-IV acute graft-vs.-host disease was 22.2%, and the 2-year survival rate was 62.7%. The period of protective isolation (27.1-66.7 days), period of hospitalization (38.6-130.5 days), and medical costs for 4 months (US $10,300-US $80,803) varied considerably. Good cooperation, i.e., low rate of protocol violation or rapid and precise presentation of case reports, was obtained.

Retrospective survival analysis and cost-effectiveness evaluation of second allogeneic bone marrow transplantation in patients with acute leukemia. Gruppo Italiano Trapianto di Midollo Osseo

The therapeutic options for patients with acute leukemia who relapse after the initial transplant include second bone marrow transplantation (2BMT) and conventional chemotherapy (CC). In this work, we conducted an analysis of published survival data and we evaluated the cost-effectiveness of 2BMT in comparison with CC. We retrieved survival information on 167 patients treated with 2BMT and 299 patients treated with CC. Survival figures were derived from individual patient data and were compared between 2BMT and CC. The mean lifetime survival (MLS) was estimated for each of the two patient cohorts using standard techniques of survival-curve extrapolation. The cost data of patients given 2BMT or CC were estimated from published data. Our analysis of individual survival data showed that 2BMT improved survival at levels of statistical significance (survival gain = 19.6 months per patient). Using an incremental cost of $90000 per patient, the cost-effectiveness ratio of 2BMT in comparison with CC was calculated as $52215 discounted dollars per discounted life year gained. Our results indicate that, in patients with acute leukemia who relapse after their first transplant, 2BMT significantly prolongs survival in comparison with CC and seems to have an acceptable cost-effectiveness profile.

Pharmacoeconomic considerations in treating patients with acute leukaemia

Whereas individual cost-effectiveness analyses of new agents for acute leukaemia should be performed in target populations, any meaningful pharmacoeconomic evaluation of treatment options for this condition should include the many types of costs and outcomes in unselected, representative groups of patients. Both direct costs (e.g. costs for medication and hospitalisation) and indirect costs (e.g. lost productivity costs and reduced quality of life) are important parameters to assess, as are the costs of chronic adverse effects, research and development costs for new agents, and costs of procedure-related deaths. Complete remission, cure and survival are the 'success' response criteria for acute leukaemia treatments, in addition to prolonged life with acceptable quality of life for patients with incurable acute leukaemia. Death is 'failure', caused either by resistant disease (relapse and progressive disease) inspite of optimal chemotherapy or, sometimes, by insufficient treatment. All of these parameters should be taken into account when a pharmacoeconomic evaluation is performed (either for administrative or scientific purposes) in order to ensure a comprehensive and reliable background for the evaluation in question. Treatment of acute leukaemia is expensive with a total cost of about $US3000 per patient per day during the induction. Although 80% of children with acute leukaemia are cured, only less than 50% of adults are cured. Thus, a great cost is associated with death during treatment and only optimal medical treatment with full-scale combination chemotherapy and full supportive treatment can keep the number of deaths to a minimum.

Cost analysis of 2 empiric antibacterial regimens containing glycopeptides for the treatment of febrile neutropenia in patients with acute leukaemia

OBJECTIVE

Patients with cancer-associated neutropenia are at high risk of developing severe infections which can be fatal if treatment is not promptly administered. For this reason, fever is treated as soon as possible with broad spectrum antibacterial therapy. The objective of this study was to conduct a cost analysis in Italy comparing 2 empiric glycoprotein-containing antibacterial regimens for the treatment of febrile neutropenia in patients with acute leukaemia.

DESIGN AND SETTING

A retrospective cost analysis was conducted, using the records of 527 febrile neutropenic patients with acute leukaemia who participated in an 18-month multicentre (29 Italian haematological units) randomised trial during 1991. All patients received either of the following 2 empiric intravenous regimens, each containing 3 antibacterial agents: ceftazidime (2 g, 3 times daily) and amikacin (15 mg/kg/day, in 3 separate doses) plus teicoplanin (6 mg/kg, in a single dose) or vancomycin (30 mg/kg/day, in 2 separate doses). Economic analyses were carried out from a hospital perspective. Only the direct costs per patient, i.e. mean antibacterial treatment and management cost, mean overall treatment failure cost and mean cost of adverse effects, were included.

MAIN OUTCOME MEASURES AND RESULTS

No differences were found in the clinical response, defined as the improvement in the rate of fever or infection (if documented), between the 2 regimens. However, tolerability, defined as the incidence of adverse effects probably or definitely related to the assigned treatment, was reported to be better with the teicoplanin-rather than the vancomycin-containing regimen.

CONCLUSIONS

Thus retrospective cost analysis showed that despite the higher acquisition cost of teicoplanin relative to vancomycin, the lower incidence of adverse effects associated with teicoplanin and its ease of administration (single daily dose) resulted in equivalent overall treatment costs between teicoplanin- and vancomycin containing regimens.

High cost factors for leukaemia and lymphoma patients: a new analysis of costs within these diagnosis related groups

STUDY OBJECTIVE

To determine high cost factors to help managers and clinicians to analyse the reasons of adverse costs and provide indications for financial negotiation.

DESIGN

To locate high cost or long stay patients, the analysis was designed on the basis of a mixture of Weibull distributions. In this new model, the proportion of high cost patients was expressed according to the multinomial logistic regression, permitting the determination of high cost factors.

SETTING

The 1993 French reference database, constituted in the framework of the national study of DRG costs, conducted by the French Ministry of Health. The database of discharge abstracts recorded in 1993 in the Dijon public teaching hospital.

PARTICIPANTS

The analyses were based on 1352 abstracts from the French reference database and 368 from the Dijon database concerning patients, aged 18 and over, suffering from leukaemia and lymphoma.

MAIN RESULTS

High cost and long stay factors were the same: number of stays, death, transfer, acute leukaemia, neutropenia, septicaemia, high dose aplastic chemotherapy, central venous catheterisation, parenteral nutrition, protected or laminar airflow room, blood transfusion, and intravenous antibiotherapy.

CONCLUSIONS

Taking into account high cost predictive factors, as shown in the case of leukaemia and lymphoma patients, would help to reduce the adverse effects of a prospective payment system.

Safety and cost-effectiveness of outpatient total body irradiation in pediatric patients undergoing stem cell transplantation

PURPOSE

To determine the feasibility, safety, and cost of delivering total body irradiation (TBI) in an outpatient setting.

PATIENTS AND METHODS

The records of 33 pediatric patients with hematopoietic malignancies undergoing TBI in preparation for bone marrow transplantation (BMT) at the Children's Medical Center of Dallas between February 1992 and June 1997 were retrospectively reviewed. Seventeen children received TBI in an outpatient setting, including 7 patients younger than 8 years of age. All patients had a good performance status (Karnofsky index > 90%) and lived or were housed within a 50-mile radius of the hospital. Patients received 1200 cGy or 1350 cGy in 8 or 9 fractions twice daily over 4 to 5 days and were admitted for high-dose chemotherapy after the last TBI fraction. Mean age was 9 years (range 13 months to 16 years). Close contact was maintained with the BMT staff during outpatient TBI.

RESULTS

Eleven patients (65%) received oral ondansetron for nausea and vomiting, 6 received promethazine and ondansetron, and 3 required dexamethasone. Only 2 of the 17 children (12%) required admission during TBI for persistent vomiting and poor oral intake. Two other children (12%) required outpatient administration of intravenous fluids. The other 13 patients (76%) tolerated the outpatient TBI regimen well. Taking into account hospitalization and ambulance transport charges, outpatient TBI represented a savings of approximately $3250 per patient compared with inpatient TBI.

CONCLUSIONS

Fractionated TBI delivered in an outpatient setting to selected children of all ages is a safe and cost-effective practice.

[Modelling of length of stay and costs in 2 homogeneous groups of hematological and pneumological patients: clinical characterization of patients with long-stay and high costs]

After the implementation of the Medicare Prospective Payment System (PPS) in the USA, many European countries like France have introduced DRGs to curb hospital overspending. However, there has been some reluctance from hospital actors, especially because of the heterogeneous nature of DRG's. To analyse this situation, we propose a method based on distribution modelization of length of stays and costs within DRGs. For each DRG, the model is based on a mixture of Poisson and Weibull distributions identified as subgroups. The subgroups are characterized by their means and their proportions which are estimated by maximization of data likelihood. For a particular DRG, the proportion of long stay or high-cost patients can be explained by the introduction of clinical variables in the model. First the model was applied to the DRG "leukemia and lymphoma" (HCFA V.3), using 133 discharge abstract files from the Dijon public teaching hospital which were classified into this DRG in 1993. Among the studies parameters only acute leukemia, neutropenia < 500 PNN/mm3, high dose aplastic chemotherapy, central venous catheterization, parenteral nutrition, use of protected or laminar air flow room, septicemia, large spectrum intravenous antibiotherapy, and blood transfusion had a significant influence on the distribution of the patients in the long stay or costly subgroup. Second, for DRG "chronic bronchopneumopathies" (n = 220) the significant parameters were mechanical ventilation, antibiotherapy, post hospitalization medicalized care.

Oncology case management linking structure and process with clinical and financial outcomes

Case management programs have emerged in a variety of models. Current literature about the structure and process of case management programs has not always clearly described linkages with outcomes. Therefore, the purpose of this article is to describe a case management program, apply the model with oncology patients, and then to clarify the structure and process that the authors believe are correlated strongly with both clinical and financial indicators of quality. Planning for the case management program involved interdisciplinary inpatient staff and personnel from the ambulatory oncology clinics. After program implementation, data on patients with a diagnosis of chemotherapy without acute leukemia (DRG 410) were collected throughout 1 year (March 1995-February 1996). Results indicated a reduction in length of stay and side effects of chemotherapy linked to the improvement in process. The primary recommendation to nurse managers who are considering a case management program is to carefully decide on a structure and process that can be formalized before the program is implemented.

Infection in immunocompromised patients with malignant blood disorders in a district general hospital

The pattern and management of infection in immunocompromised patients over a period of 3 years in a district general hospital has been studied. A total of 222 positive cultures was obtained in 607 episodes of suspected infection all involving patients with malignant blood disorders. Febrile episodes requiring intravenous antibiotics occurred in 248 instances involving 107 patients. The pattern of organisms cultured and the responses to various antibiotic regimes are reported. The costs of antibiotic therapy are considered in the light of the overall response. Of the patients studied, 54 died, infection having a likely causative or contributory part in 21 of them (less than 10% of infective episodes). We conclude that the infective complications of these disorders, particularly in older patients, can be efficiently managed in a district general hospital when full supportive facilities are available.

Cost-effective use of autologous bone marrow transplantation: few answers, many questions, and suggestions for future assessments

High dose chemotherapy with the support of autologous bone marrow transplantation (ABMT) or peripheral blood progenitor cells (PBPC) has been increasingly used in a variety of haematological and epithelial cancers over the last decade. The rationale of this approach is to overcome the chemotherapy resistance of tumour cells by increasing the dose of cytotoxic drugs. However, the clinical benefit of dose-intensification has been difficult to prove. Almost all studies of ABMT have been done without randomised comparisons with the standard form of therapy for a specific condition. From an economic perspective, the cost of ABMT has been steadily decreasing with improvements in supportive care primarily. Still, current ABMT cost estimates range from $US70 000 to $US150 000 for each uncomplicated procedure. Despite the lack of compelling evidence in support of dose-intensification, ABMT has become a default standard of care after relapse for many patients with lymphoma or leukaemia. We used a decision analysis model to estimate the cost effectiveness of the timing of ABMT in relapsed Hodgkin's disease. The model illustrates the difficulty of using available clinical trial data when follow-up of promising early reports is not available. The model showed that in most situations the optimal strategy is ABMT in second relapse despite growing consensus that immediate ABMT is the treatment of choice. ABMT for women with high-risk or early metastatic breast cancer is one of the most controversial areas in clinical oncology. In the US, several ongoing major randomised trials are addressing the role of ABMT in breast cancer. Using a Markov process we found that ABMT is the preferred strategy under almost all assumptions. The size of the benefit and cost effectiveness of ABMT varied markedly depending on the assumptions made. The model does not supplant the need for randomised trials that concurrently measure efficacy, quality of life, and resource utilisation. However, such analyses point out the critical areas where costs could be cut substantially without effecting efficacy. Drawing conclusions about the cost effectiveness of ABMT for all conditions is hampered by the lack of randomised comparisons of efficacy. Concurrent economic appraisals of selected phase III comparative trials should be considered since the supportive care costs associated with ABMT appear to be stabilising. However, the most important point is that randomised trials are the only mechanism for estimating the therapeutic effect of high dose chemotherapy.

[Chemotherapy and bone marrow transplantation for acute leukemia]

Chemotherapy (CT) and bone marrow transplantation (BMT) have made remarkable progress in recent years. The comparison of both treatment modalities has become an important issue. The methods of comparison, however, should be varied according to the subjects and purposes of comparison. For a general comparison of both CT and BMT, the registry data of both treatments, seems adequate. For the comparison of a CT regimen with a BMT regimen, a randomized control study seems most adequate. in order to get an overview. For the selection of treatment for a certain patient, comparison of CT and BMT data from the center in which the patient will be treated seems most important. As the latter comparison we have studied the rate of early death, the rate of long-term survival and medical costs in leukemia patients diagnosed and followed for 5 years, at the Center for Adult Diseases Osaka. The early death rate was similar in both groups of patients. The long-term survival rate was 78% in BMT and 28% in CT patients. Cost effectiveness was also favorable in BMT patients. Data on CT and BMT in each center should be prepared for the selection of treatment for patients at each center.

[High-cost therapy. Ethical principles of allocation of scarce resources]

This article raises some ethical problems concerning high-cost therapy for malignant haematological diseases. The problem of setting priorities is discussed within the framework of utilitarianism, right-based theories and the contractarian theory of John Rawls. It is argued that utilitarianism can provide precise answers, based on the principle of allocative efficiency. However, this is not the only objective of a public health care system. The right-based approach is discussed, but sufficiently precise definitions seem hard to formulate. The contractarian approach is regarded as interesting, since it tries to address the question of trade-offs between objectives of allocative efficiency and distributive fairness.

[Cost of leukemia treatment]

Medical cost has increasingly become an important problem in the medical practice. As one of the useful fields of computer in the hospital, we have analyzed the costs of chemotherapy and bone marrow transplantation in patients with leukemia who were diagnosed between 1983 and 1986 and followed up till Dec. 1989. For CML the difference in the cost was 5 million yen and a survival rate was 75% and was higher in BMT than in chemotherapy. For Acute leukemia the difference of the costs was 8 million yen and survival rates were 89% and 30%. These data may show that BMT is a very effective and economical treatment for leukemia. In this study we have analyzed only the direct medical cost paid by the governmental insurance, however there seems necessary many other costs which are not covered by the insurance such as the cost for the family members, the cost for cryopreservation of cells and sterilization tentatively covered by the hospital or the cost of blood or marrow bank which are covered or should be covered by the government. Evaluation of the treatment outcome by the parameters such as length and quality of life, productivity of the patient, prevention of the loss of social investment including education on the patient, seemed also necessary for justification of the medical cost.

Costs of bone marrow transplants using unrelated donors

Bone marrow transplantation is an expensive treatment, rationed primarily by the availability of donors. Recruiting potential unrelated bone marrow donors to a register would add not only to the cost, but also to the volume, of transplantation. Proposals to establish such registries have thus been subject to rigorous financial scrutiny. In Australia, 3 alternative estimates suggest that approximately 200 patients, otherwise suitable for bone marrow transplantation, do not receive transplants because they have no suitable related donor. The population of Australia is approximately 16 million. The alternatives for these patients are thus chemotherapy or unrelated bone marrow transplantation. The costs of chemotherapy and transplantation have been directly compared in 1 trial of treatment for acute nonlymphoblastic leukaemia. The cost per year of life saved was approximately the same for the 2 treatments, with better patient survival from transplantation. The estimated cost difference in both the United States and Australia, between the policy extremes of no patients transplanted, and all transplanted, was between 1.3-2.4% of the total costs of managing these patients. The cost of searching existing registers for unrelated donors for Australian patients, averages A$24,000-28,000 to the point of a successful donor procedure. The cost of establishing and maintaining an Australian Register of a size predicted to find donors for half of the potential recipients, has been estimated at A$ 10,000 per donor procedure. The decision to proceed with unrelated bone marrow transplantation commits resources that are currently used by the alternative therapies. It is thus important to monitor both the costs and effects of the new approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis, cost and effectiveness of therapy of infections caused by gram-positive organisms in neutropenic children

Gram-positive infections are being reported with increasing frequency in children with haematological malignancies. Staphylococcus epidermidis, once considered a non-pathogenic skin contaminant, is emerging as a major cause of severe infection. However, in infants Gram-negative septicaemias are more frequent than in older children. A teicoplanin and ceftriaxone combination was assessed for use as empirical therapy of febrile episodes in neutropenic children with acute leukaemias. Of 47 patients, fever was of unknown origin in 21, and documented in 26 with 28 strains isolated; 19 Gram-positive (all sensitive to teicoplanin) and nine Gram-negative. Within 48 h, 41 patients became afebrile and the pathogen was cleared if initially present. Mean duration of treatment was 16 days. Febrile relapse occurred in 24 patients with eight documented superinfections. The need for prophylactic cover against Gram-positive organisms at the time of intravenous catheter insertion is questionable. We studied 71 patients who were randomly allocated to receive teicoplanin when the central line was inserted and if febrile, with added ceftriaxone and amikacin (arm A) or the tri-antibiotic regimen when fever occurred (arm B). In arm A a febrile episode occurred after ten days in 34/35 patients with only one Gram-positive organism isolated. In arm B a febrile episode occurred in all 36 patients after five days and ten Gram-positive strains were isolated. Those patients in arm A also received fluconazole. Amphotericin B was administered in cases of failure or relapses in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness analysis of paramedic emergency medical services in the treatment of prehospital cardiopulmonary arrest

STUDY OBJECTIVES

1) Identification of marginal costs associated with prehospital resuscitation of cardiopulmonary arrest; 2) Determination of cost effectiveness for such resuscitation; and 3) Comparison of cost effectiveness of paramedic care with selected other medical interventions.

DESIGN

Retrospective review of 190 cases of out-of-hospital cardiac arrest.

SETTING

City limits of a midsized southwestern city. The events studied took place outside of medical facilities.

TYPE OF PARTICIPANTS

Victims of out-of-hospital cardiac arrest for whom the EMS system was activated by a 911 telephone request for emergency medical assistance.

MEASUREMENTS AND MAIN RESULTS

The cost, including training, personnel, equipment, and response time maintenance, per year of life saved was found to be $8,886.00 for paramedic care. This result was compared with published cost-effectiveness figures for heart transplantation, liver transplantation, bone marrow transplantation, and chemotherapy for acute leukemia. Paramedic care was more cost effective, as measured by cost per year of life saved, than organ transplantation and chemotherapy for acute leukemia.

CONCLUSION

Out-of-hospital treatment by paramedics of cardiopulmonary arrest is more cost effective than heart, liver, bone marrow transplantation, or curative chemotherapy for acute leukemia.

Cost-benefit analysis of a plateletapheresis program

We determined costs and benefits of a community donor plateletapheresis program (CDPP) designed to provide HLA-matched platelet transfusions for patients who were refractory to random-donor platelets (RDPs). Costs of establishing and maintaining the CDPP were $127,520 for the first year (1982). Benefits were expressed as cost savings attributed to the CDPP. After the program began, the use of RDP in the community was 17,458 units less than projected. Estimates of net cost savings during the first year ranged from $177,570 to $272,253 (1982 dollars; cost-to-benefit ratios were 1:1.39 to 1:2.14.) In a matched cohort study of marrow transplant patients, CDPP platelet transfusions were as effective as those from family donors while total platelet and red cell use was unchanged. In patients with acute leukemia treated with chemotherapy, significant reduction in both platelet and red cell use was seen after institution of CDPP support. We conclude that the CDPP is a cost-effective approach to platelet support.

The use of Grade of Membership analysis to evaluate and modify diagnosis-related groups

A classification methodology is presented that can be used to evaluate the heterogeneity of reimbursement categories and service groups in multivariate terms. This methodology, called Grade of Membership analysis, has several properties that are particularly important in such assessments. First, simultaneously with the determination of the multivariate profile of characteristics that describe a group, the methodology determines the degree to which each case is described by that profile, which means that the model can explicitly represent the heterogeneity of individual cases in any derived classification scheme. Second, the estimates of the model's parameters are produced by maximum likelihood procedures; hence, the classification and group descriptions generated by the model can be statistically evaluated. Third, because of the way the group profiles are constructed, the results of the analysis will be reasonably robust to the selection of new samples. The analysis is illustrated using data on hospital discharges for the state of Maryland in 1981. The purpose of the analysis is to examine the association between the patterns of clinical and service attributes identified by the procedures with DRG category assignments.