[Reducing non-communicable diseases and health care costs: building a prevention alliance]

In Italy, as well as in most European Countries, the loss of almost 70% of the years of life is attributable to cerebro-cardiovascular diseases and cancers. Whereas the Italian population is expected to grow older, with a significant increase in the burden of chronic non-communicable diseases, the reduction in incidence of chronic diseases and the compression of morbidity are priorities. This is the reason why in Italy the implementation of the National Plan for Prevention and related regional plans becomes necessary, as it can promote the co-operation of multidisciplinary skills in several areas: political, health, economic, legal, sociological. In Piedmont (Northern Italy), it seems useful the creation of a regional Laboratory of prevention,which provides support for the development and implementation of the regional prevention plan, through actions and programmes based on cost-effectiveness analyses. The use of resources in prevention should not be exclusively interpreted as a cost, but as an investment, which, in some cases, can become an avoided cost. Using prevention policies makes it possible to gain years of healthy life and to potentially reduce the cost of healthcare system. The creation of the Laboratory of prevention is a multidisciplinary context, so it is an opportunity to involve the stakeholders in order to achieve the regional health objectives.

Bone substitutes in orthopaedic surgery: from basic science to clinical practice

Bone substitutes are being increasingly used in surgery as over two millions bone grafting procedures are performed worldwide per year. Autografts still represent the gold standard for bone substitution, though the morbidity and the inherent limited availability are the main limitations. Allografts, i.e. banked bone, are osteoconductive and weakly osteoinductive, though there are still concerns about the residual infective risks, costs and donor availability issues. As an alternative, xenograft substitutes are cheap, but their use provided contrasting results, so far. Ceramic-based synthetic bone substitutes are alternatively based on hydroxyapatite (HA) and tricalcium phosphates, and are widely used in the clinical practice. Indeed, despite being completely resorbable and weaker than cortical bone, they have exhaustively proved to be effective. Biomimetic HAs are the evolution of traditional HA and contains ions (carbonates, Si, Sr, Fl, Mg) that mimic natural HA (biomimetic HA). Injectable cements represent another evolution, enabling mininvasive techniques. Bone morphogenetic proteins (namely BMP2 and 7) are the only bone inducing growth factors approved for human use in spine surgery and for the treatment of tibial nonunion. Demineralized bone matrix and platelet rich plasma did not prove to be effective and their use as bone substitutes remains controversial. Experimental cell-based approaches are considered the best suitable emerging strategies in several regenerative medicine application, including bone regeneration. In some cases, cells have been used as bioactive vehicles delivering osteoinductive genes locally to achieve bone regeneration. In particular, mesenchymal stem cells have been widely exploited for this purpose, being multipotent cells capable of efficient osteogenic potential. Here we intend to review and update the alternative available techniques used for bone fusion, along with some hints on the advancements achieved through the experimental research in this field.

The economic burden of caregiving on families of children and adolescents with cancer: a population-based assessment

BACKGROUND

Childhood cancer represents a relevant economic burden on families. The preferred tool to investigate family expenditure is the retrospective questionnaire, which is subject to recall errors and selection bias. Therefore, in the present study the economic burden of caregiving on families of children and adolescents (0-19 years of age) with cancer was analysed using administrative data as an alternative to retrospective questionnaires.

PROCEDURE

Incident cases of cancer diagnosed in children and adolescents in 2000-2005 (N = 917) were identified from the Piedmont Childhood Cancer Registry and linked to available administrative databases to identify episodes of care during the 3 years after diagnosis (N = 13,433). The opportunity cost of informal caregiving was estimated as the value of the time spent by one of the parents, and was assumed to be equal to the number of days during which the child received inpatient care, day-care or outpatient radiotherapy. Factors affecting the level of economic burden of caregiving on families were analysed in a multivariable model.

RESULTS

The economic burden of caregiving increased when care was supplied at the Regional Referral Centre, or when treatment complexity was high. Families with younger children had a higher level of economic burden of caregiving. Leukaemia required a higher family commitment than any other cancer considered.

CONCLUSIONS

Estimates of the economic burden of caregiving on families of children and adolescents with cancer derived from administrative data should be considered a minimum burden. The estimated effect of the covariates is informative for healthcare decision-makers in planning support programmes.

Role of multidimensional assessment of frailty in predicting short-term outcomes in hospitalized cancer patients: results of a prospective cohort study

AIMS AND BACKGROUND

The study analyzed the value of physical and psychosocial frailty assessment in predicting the need for supportive care and the risk of short-term failures after discharge in hospitalized cancer patients.

METHODS AND STUDY DESIGN

Frailty was assessed in 350 consecutive patients using a multidimensional tool. Patients were followed for 4 months after discharge to record the occurrence of chemotherapy interruption, urgent hospital readmission or death. The association between patient characteristics and the outcomes were analyzed with either logistic or Cox multivariable models.

RESULTS

About 40% of patients were classified as frail, with a higher prevalence of clinical frailty (alone or together with psychosocial frailty). Psychosocial frailty was positively associated with the need for supportive care at discharge (adjusted OR, 3.46; 95% CI, 1.55-7.76) but did not predict a worse prognosis when other important clinical factors were considered. However, the need for supportive care at discharge, in addition to advanced disease and reduced performance status, was a strong predictor of short-term hospital readmission or death (HR 7.50; 95% CI, 3.12-18.02).

CONCLUSIONS

A more comprehensive assessment of frailty in cancer patients can aid in the timely identification of the need for supportive care after hospital discharge and improves the prediction of the short-term risk of hospital readmission or death.

Prediction of mortality and macrovascular complications in type 2 diabetes: validation of the UKPDS Outcomes Model in the Casale Monferrato Survey, Italy

AIMS/HYPOTHESIS

The United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model can be used to estimate the lifetime occurrence of major diabetes-related complications in order to calculate health economic outcomes. The aim of the study was to assess the performance of the model by comparing the predicted and observed mortality and the incidence of macrovascular complications in an Italian population-based cohort with type 2 diabetes.

METHODS

We used data from the Casale Monferrato Survey, a cohort enrolled in 1988 and surveyed in 1991 (n = 1,967) to assess the prevalence of cardiovascular risk factors. In 2000, a new survey included all the members of the original cohort who were still alive (n = 860), and in addition all individuals identified with a new diagnosis of type 2 diabetes since 1993 (n = 2,389). We compared the mortality predicted by the model for the 1991 survey over the subsequent 17-year period with the observed risk. The following outcomes were analysed in the 2000 survey: myocardial infarction (MI), other ischaemic heart disease, stroke, congestive heart failure (CHF) and amputation.

RESULTS

For all-cause mortality, the predictions from the model at 5 and 10 years (23% and 47%, respectively) were identical to the observed risks. At 15 years, the risk of death was slightly overestimated (an estimate of 67% vs 64% observed, 95% CI 61%, 66%). The performance of the model was best for patients with a recent history of disease (duration <6 years). Among the complications, the predicted cumulative incidences of MI and CHF were very close to those observed.

CONCLUSIONS/INTERPRETATION

External validation is essential to assess the accuracy of simulation models. The UKPDS Outcomes Model satisfactorily predicted a set of actual incidences of mortality and complications in an Italian diabetes cohort up to a duration of approximately 12 years. The longer term performance of such models should be carefully evaluated.

Compliance with clinical practice guidelines for breast cancer treatment: a population-based study of quality-of-care indicators in Italy

Background

It has been documented that variations exist in breast cancer treatment despite wide dissemination of clinical practice guidelines. The aim of this population-based study was to evaluate the impact of regional guidelines (Piedmont guidelines, PGL) for breast cancer diagnosis and treatment on quality-of-care indicators in the Northwestern Italian region of Piedmont.

Methods

We included two samples of women aged 50–69 years with incident breast cancer treated in Piedmont before and after the introduction of PGL: 600 in 2002 (pre-PGL) and 621 in 2004 (post-PGL). Patients were randomly selected among all incident breast cancer cases identified through the hospital discharge records database. We extracted clinical data on breast cancer cases from medical charts and ascertained vital status through linkage with town offices. We assessed compliance with 14 quality-of-care indicators from PGL recommendations, before and after their introduction in clinical practice.

Results

Among patients with invasive lesions, 77.1% (N = 368) and 77.5% (N = 383) in the pre-PGL and post-PGL groups, respectively, received breast conservative surgery (BCS) as a first-line treatment. Following BCS, 87.7% received radiotherapy in 2002, compared to 87.9% in 2004. Of all patients at medium-to-high risk of distant metastasis, 65.5% (N = 268) and 63.6% (N = 252) received chemotherapy in 2002 and in 2004, respectively. Among the 117 patients with invasive lesions and negative estrogen receptor status in 2002, hormonal therapy was prescribed in 23 of them (19.6%). The incorrect prescription of hormonal therapy decreased to 10.8% (N = 10) among the 92 estrogen receptor-negative patients in 2004 (p < 0.01).

Compliance with PGL recommendations was already high in the pre-PGL group, although some quality-of-care indicators did not reach the standard. In the pre/post analysis, 8 out of 14 quality-of-care indicators showed an improvement from 2002 to 2004, but only 4 out of 14 reached statistical significance. We did not find any change in the risk of mortality in the post-PGL versus the pre-PGL group (adjusted hazard ratio 0.94, 95%CI 0.56–1.56).

Conclusions

These results highlight the need to continue to improve breast cancer care and to measure adherence to PGL.

Hospital factors and patient characteristics in the treatment of colorectal cancer: a population based study

BACKGROUND

The present study focuses on the analysis of social, clinical and hospital characteristics that can lead to disparities in the management and outcome of care. To that end, indicators of the quality of initial treatment delivered to newly-diagnosed colorectal cancer patients in a North-Western Region of Italy, were investigated using administrative data.

METHODS

The cohort includes all incident colorectal cancer patients (N = 24,187) selected by a validated algorithm from the Piedmont Hospital Discharge Record system over an 8-year period (2000-2007).Three indicators of quality of care in this population-based cohort were evaluated: the proportion of preoperative radiotherapy (RT) and of abdominoperineal (AP) resection in rectal cancer patients, and the proportion of postoperative in-hospital mortality in colorectal cancer patients.

RESULTS

Among rectal cancers, older patients were less likely to have preoperative RT, and more likely to receive an AP resection compared to younger patients. The probability of undergoing preoperative RT and AP resection was reduced in females compared to males (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64-0.93 and OR 0.78, 95%CI 0.69-0.89, respectively). However, there was a trend of increasing RT over time (p for trend <0.01). The probability of undergoing AP resection was increased in less-educated patients and in hospitals with a low caseload.A higher risk of postoperative in-hospital mortality was found among colorectal cancer patients who were older, male, (female versus male OR 0.71, 95%CI 0.60-0.84), unmarried (OR 1.32, 95%CI 1.09-1.59) or with unknown marital status.

CONCLUSIONS

The study provides evidence of the importance of social, clinical and hospital characteristics on the equity and quality of care in a Southern European country with an open-access public health care system.

Variation in gynecological oncology follow-up practice: attributable to cancer centers or to patient characteristics? A Piedmont Regional Oncology Network Study

AIMS AND BACKGROUND

Although guidelines recommend minimalist follow-up, there is wide variability in gynecological oncology practice. The aims of this study were to describe between-center differences in the follow-up of endometrial, ovarian, and uterine cervical cancer; to identify the determinants of test prescription; to estimate the related costs; and to assess the weight of center habits and patient characteristics as sources of unexplained variability.

METHODS AND STUDY DESIGN

The medical records of patients treated between August 2004 and July 2005 for gynecological malignancies and followed up for the detection of recurrent disease were retrospectively collected from 29 centers of the Piedmont Oncology Network. Multivariate multilevel analyses were performed to study the determinants of test prescription and costs.

RESULTS

Analyses were performed on 351 patients (median follow-up: 578 days). The unexplained variability in computed tomography prescriptions (26%), ultrasound prescriptions (17%), and total cost of follow-up (15%) can be attributed to center habits, independenty of the clinical characteristics of the patients.

CONCLUSIONS

Much of the unexplained variability in the follow-up for gynecological malignancies is attributable to different habits of centers belonging to a cancer network. These results prompted us to design a multicenter randomized controlled trial to compare minimalist versus intensive follow-up programs in endometrial cancer.

Collatamp sponges in the management of open fractures

Open fractures are at high risk of infection and the prompt treatment of these injuries is critical to the success and is crucial to reduce the rate of complications. The basic steps of treatment include the immediate administration of systemic antibiotics, early surgical stabilization of the fracture associated with copious irrigation and radical debridement of the site of exposure, and when possible adequate soft tissue coverage. The systemic antibiotic therapy significantly improves the prognosis and reduces the occurrence of complications. However, in order to ensure adequate and sustained local concentration of antibiotic agent, high doses and for a long time are necessary. This increases the risk of side effects and bacterial resistance. The introduction of the antibiotic-loaded collagen sponges offers the advantages of a high local concentrations of antibiotic carrier delivering system with reduced systemic drug diffusion (less risk of side effects and resistance rate). Sponges are also biodegradable and fully resorbable and do not require additional surgery for their removal.

Impact of initial pattern of care on hospital costs in a cohort of incident lung cancer cases

RATIONALE, AIMS AND OBJECTIVES

Lung cancer is a disease with high consumption of health care resources. The aim of this study was to describe hospital costs due to lung cancer care from diagnosis until death or end of the study follow-up, in a cohort of incident cases, by using administrative data.

METHODS

Particular attention was given to the determinants of total costs and the impact of the initial treatment approach on the process of costs accumulation. Incident cases were identified by the local Cancer Registry (January 2000-December 2003) among the residents of Turin (Italy). Per patient hospital care has been determined from administrative databases (outpatient radiotherapy records and hospital discharge records). Costs determinants were identified via a multivariable generalized linear model (GLM), with a Gamma cost distribution and a logarithmic link function. To assess the time effect over the cost accumulation process for non-small-cell lung cancer cases, the same GLM Gamma model was repeated at different follow-up periods. Analyses were stratified by cancer histotype.

RESULTS

Results evidenced the relevant role of initial patterns of care on the cost accumulation process, with increased midterm costs associated with curative patterns of care.

CONCLUSION

The use of administrative data enabled hospital lung cancer care to be described, and related costs to be estimated.

[Results and cost evaluation of triage with high risk HPV test in cervical cancer screening. A pilot study in Piedmont (North-West Italy)]

OBJECTIVE

causal relation between high risk Papilloma virus and cervical carcinoma is definitely ascertained. HPV test is suggested both as primary screening test and as triage test for selecting women who should undergo colposcopy examination. Evidence is clear for triage after ASC-US cytology. A recent study suggested the implementation after LSIL cytology in women 35 or older but the issue is controversial.We present a pilot study on the implementation of HPV test triage in the framework of cervical cancer screening. The study was conducted in respect to: participation, predictive value, and cost analysis, separately for ASC-US and LSIL cytology.

DESIGN

HPV test was offered to women with Pap test result ASC-US or LSIL (35 and over), as an add-on to the "Prevenzione serena Screening Program" protocol. All samples were analyzed in the same specialized laboratory. HPV positive women were invited to colposcopy, negative will be invited at the scheduled interval for negative screening tests.

SETTING AND PARTICIPANTS

Piedmont (NW Italy), LHAs of Novara and Verbano. In the 1-year study period 15,614 Pap tests were performed: 153 women were eligible for the triage.

MAIN OUTCOME MEASURES

Participation at HPV test, HPV test results, costs.

RESULTS

ninety two percent of women invited to HPV test actually participated: 66.9% of them were positive (52.8% after ASC-US and 82.8% after LSIL). Regarding colposcopy and histological results, CIN2+ were 9.4% of positive HPV tests in ASC-US group and 17.1% in LSIL group. Cost analysis showed limited differences between triage (offered after ASC-US and LSIL cytology) and traditional protocol. Triage is economically convenient when limited to women with ASC-US cytology.

CONCLUSION

the pilot study demonstrated the feasibility of adding a triage phase with HPV test in cervical cancer screening protocol. Additional cost is balanced by the saving due to the reduction in the number of colposcopy exams: the process is economically convenient when limited to women with ASC-US cytology. When extended to LSIL cytology the marginal cost increases because of the higher prevalence of HPV positive results and total cost of triage with HPV test is close to the cost of immediate colposcopy referral.

Bioplasty for vertebral fractures: preliminary results of a pre-clinical study on goats using autologous modified skin fibroblasts

The debate is still ongoing about the long term effects of the mininvasive vertebral augmentation techniques and their usefulness in treating more complex cases where a bone inducing effect more than a merely bone substitution would be suitable, such as the vertebral fractures in young patients. We previously developed a clinically relevant gene therapy approach using modified dermal fibroblasts for inducing bone healing and bone formation in different animal models. The aim of this study is to show the feasibility of a minimally invasive percutaneous intrasomatic ex vivo gene therapy approach to treat thoracolumbar vertebral fractures and anterior column bone defects in a goat model.

The use of collatamp in total hip arthroplasty

Total Hip Arthroplasty (THA) is one of the most common orthopedic operations in the world. The number of THA is expected to grow and with it the number of associated complications. Although improved surgical technique and the development of more scrupulous asepsis has decreased the incidence of periprosthetic joint infection (PJI), it remains one of the most feared complications of joint arthroplasty. The purpose of this study is to present the use of antibiotic-loaded collagen sponges (Collatamp EG) in the prophylaxis and treatment of PJI. For this scope a case report is described. The advantages offered by the antibiotic loaded sponges in terms of high and sustained concentration of antibiotic at the site of infection, diffused by the fully reabsorbable carrier, showed to be a an important adjuvant therapy in the treatment of PJI. Low systemic concentration of the drug and a wide versatility in surgical application are other advantages of this dispositive.

Regression models for analyzing costs and their determinants in health care: an introductory review

OBJECTIVE

This article aims to describe the various approaches in multivariable modelling of healthcare costs data and to synthesize the respective criticisms as proposed in the literature.

METHODS

We present regression methods suitable for the analysis of healthcare costs and then apply them to an experimental setting in cardiovascular treatment (COSTAMI study) and an observational setting in diabetes hospital care.

RESULTS

We show how methods can produce different results depending on the degree of matching between the underlying assumptions of each method and the specific characteristics of the healthcare problem.

CONCLUSIONS

The matching of healthcare cost models to the analytic objectives and characteristics of the data available to a study requires caution. The study results and interpretation can be heavily dependent on the choice of model with a real risk of spurious results and conclusions.

An economic evaluation of water birth: the cost-effectiveness of mother well-being

PURPOSE

To assess the cost-effectiveness of water compared with normal land delivery.

METHODS

A retrospective controlled study was conducted over a two-year period in a Northern Italian hospital. The cohort included all the 110 women who completed a water birth and 110 women who had a land birth during the same period. The two groups were compared with respect to labour duration, perineal tear and newborn's health status. The economic evaluation adopted a cost-effectiveness approach in relation to presence/absence of perineal tears.

RESULTS

In the water delivery group 58 women (52.7%) experienced at least one perineal tear versus 80 (72.7%) in the traditional delivery group. The mean duration of labour was similar in the two groups. Neonatal well-being, expressed as Apgar score, did not differ significantly among the two groups at the first minute (9.48 vs. 9.28) and was slightly higher at 5 minutes in the water delivery group (9.95 vs. 9.84; P = 0.0269). Water delivery was found to be both more costly [ΔC = €279; 95% confidence interval (CI): 262-296] and more effective in terms of avoided perineal tears. The incremental health care cost per avoided perineal tear because of water delivery was estimated of €1395.7 (95% CI: 1049.2-3608.5).

CONCLUSION

Water birth, as compared with traditional delivery, allows for an increase in maternal well-being and is cost-effective.

Impact of advanced exercise ECG analysis on cost of coronary artery disease management

BACKGROUND

Conventional analysis of exercise electrocardiogram (EX-ECG) has limited accuracy. This study aims to evaluate the potential impact of improving EX-ECG accuracy on costs of diagnosis and number of misdiagnoses of coronary artery disease (CAD).

METHODS

A decision-tree model was simulated including sequential application of diagnostic procedures for suspected CAD. The model was structured in two main branches (presence or absence of CAD). A probabilistic sensitivity analysis was then performed for several combinations of improvement in test sensitivity and specificity.

RESULTS

A clear trend in cost reduction was observed at improving EX-ECG specificity (about 8-8.5 million dollars, corresponding to a 5.6-7.6% reduction according to the prevalence level). Wrong diagnoses counted for 9-13% of test. Improvements in test parameters lead to reductions in wrong diagnoses, especially when increasing specificity (8.8-12.5%).

CONCLUSIONS

A proper improvement in EX-ECG sensitivity and specificity would have a relevant impact on the costs of CAD management, while reducing the number of misdiagnoses.

Factors affecting pattern of care and survival in a population-based cohort of non-small-cell lung cancer incident cases

OBJECTIVE

To analyze the role of sociodemographic factors as determinants of the initial pattern of care and survival in incident NSCLC cases.

METHODS

We linked 2298 incident NSCLC cases, identified by the Piedmont Cancer Registry of Turin (PCRT) with administrative health records to identify the initial pattern of care. Because stage of disease strongly influences pattern of care and prognosis of NSCLC, all the analyses were stratified according to stage (early and advanced). The association between the set of patient's characteristics and the probability of accessing a specific pattern of care was analysed with a multivariable multinomial logistic regression model. Survival was analysed with the Cox proportional hazard model.

RESULTS

In the early stage group, presence of comorbidities, older age and low educational level were all associated with a lower probability of receiving surgery. These same factors, as well as being unmarried, were associated with higher probability of receiving other non-curative care only. The effects of comorbidities and low educational level as barriers to receiving more effective patterns of care were not relevant in the advanced stage group. When controlling for initial patterns of care, in the early stage group, an age older than 75 years and being unmarried were negative prognostic factors, while survival was completely independent from educational level. Among patients with an advanced stage of disease, only comorbidities had a negative impact on survival.

CONCLUSION

Appropriate lung cancer care is affected by sociodemographic factors. Greater attention to social and health programs is recommended to improve the timeliness of diagnosis, the staging of potentially resectable patients, and to implement more comprehensive multidisciplinary evaluations of those who may benefit from curative treatments.

Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial

CONTEXT

Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.

OBJECTIVE

To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.

INTERVENTION

Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).

MAIN OUTCOME MEASURES

The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.

RESULTS

Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).

CONCLUSION

Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00262431.

[Methodological aspects in valuing loss of production and informal care in cost-of-illness studies]

Estimating costs of illness in social terms requires the consideration of the loss of production costs due to absence from work. Costs related to informal care should also be counted. Costs due to the loss of production are valued through the human capital method and the frictional costs method. Opportunity cost and proxy good methods are utilized for the informal care. Our study highlights practical issues about the use of a variety of methods and points out their main limits.

A decision-tree model to estimate the impact on cost-effectiveness of a venous thromboembolism prophylaxis guideline

BACKGROUND AND OBJECTIVE

The impact of clinical guidelines (GL) on venous thromboembolism (VTE) prophylaxis was evaluated in a large Italian hospital with a before/after study. GL were effective in increasing the appropriateness of prophylaxis and in reducing VTE. Following this study, the aim was to estimate the impact of the adopted GL on costs and benefits through a cost-effectiveness analysis.

METHODS

A decision-tree model was used to compare prophylaxis costs and effects before and after GL implementation. All patients were classified into four risk profiles (low, moderate, high, very high). Outcomes considered were: no event, asymptomatic VTE, symptomatic VTE, fatal pulmonary embolism and major bleeding. Patient risks and the probability of receiving prophylaxis were defined using data from the previous study. Outcome probabilities were derived from the literature. Regional Drg reimbursements and hospital figures were used for costing the events.

RESULTS

Despite a marked increase in the number of patients receiving some form of prophylaxis, it was estimated that the introduction of GL reduced the average cost per patient related to VTE from euro210 to euro181 (-14%), with a parallel absolute decrease in VTE complications (-5%). Results are particularly relevant in the very-high-risk group. Sensitivity analysis confirmed the overall cost savings and gains in effectiveness.

CONCLUSIONS

The implementation of locally adapted GL on VTE prophylaxis may lead to a benefit in terms of both costs and effects, especially for the highest-risk patients.

[Bayesian approach for the cost-effectiveness evaluation of healthcare technologies]

The development of Bayesian statistical methods for the assessment of the cost-effectiveness of health care technologies is reviewed. Although many studies adopt a frequentist approach, several authors have advocated the use of Bayesian methods in health economics. Emphasis has been placed on the advantages of the Bayesian approach, which include: (i) the ability to make more intuitive and meaningful inferences; (ii) the ability to tackle complex problems, such as allowing for the inclusion of patients who generate no cost, thanks to the availability of powerful computational algorithms; (iii) the importance of a full use of quantitative and structural prior information to produce realistic inferences. Much literature comparing the cost-effectiveness of two treatments is based on the incremental cost-effectiveness ratio. However, new methods are arising with the purpose of decision making. These methods are based on a net benefits approach. In the present context, the cost-effectiveness acceptability curves have been pointed out to be intrinsically Bayesian in their formulation. They plot the probability of a positive net benefit against the threshold cost of a unit increase in efficacy.A case study is presented in order to illustrate the Bayesian statistics in the cost-effectiveness analysis. Emphasis is placed on the cost-effectiveness acceptability curves. Advantages and disadvantages of the method described in this paper have been compared to frequentist methods and discussed.

A biological role for the gonadotrophin-releasing hormone (GnRH) metabolite, GnRH-(1-5)

Gonadotrophin-releasing hormone (GnRH) was first isolated in the mammal and shown to be the primary regulator of the reproductive system through its initiation of pituitary gonadotrophin release. Subsequent to its discovery, this form of GnRH has been shown to be one of many structural variants found in the brain and peripheral tissues. Accordingly, the original form first discovered and cloned in the mammal is commonly referred to as GnRH-I. In addition to the complex regulation of GnRH-I synthesis, release and function, further evidence suggests that the processing of GnRH-I produces yet another layer of complexity in its activity. GnRH-I is processed by a zinc metalloendopeptidase EC 3.4.24.15 (EP24.15), which cleaves the hormone at the covalent bond between the fifth and sixth residue of the decapeptide (Tyr(5)-Gly(6)) to form GnRH-(1-5). It was previously thought that the cleavage of GnRH-I by EP24.15 represents the initiation of its degradation. Here, we review the evidence for the involvement of GnRH-(1-5), the metabolite of GnRH-I, in the regulation of GnRH-I synthesis, secretion and facilitation of reproductive behaviour.