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Khalid N, Muhammad H, Ahmed A, Ahmad SA. Editorial: Shedding light on the "smoker's paradox". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00592-X. [PMID: 39095291 DOI: 10.1016/j.carrev.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Nauman Khalid
- Section of Inerventional Cardiology, St. Francis Medical Center, Monroe, LA, USA.
| | - Haris Muhammad
- Section of Internal Medicine, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Aliza Ahmed
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Sarah Aftab Ahmad
- Section of Cardiothoracic Surgery, St. Francis Medical Center, Monroe, LA, USA
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Muoghalu CG, Ekong N, Wyns W, Ofoegbu CC, Newell M, Ebirim DA, Alex-Ojei ST. A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries. Cureus 2023; 15:e44125. [PMID: 37750155 PMCID: PMC10518219 DOI: 10.7759/cureus.44125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/27/2023] Open
Abstract
Myocardial infarction (MI) is a significant cause of morbidity and mortality in low- and middle-income countries. Fibrinolytic agents and percutaneous coronary intervention (PCI) are the main approaches for the recanalization and reperfusion of the myocardium following MI. Many studies have shown that PCI is superior to thrombolytics due to better outcomes and decreased mortality. Nevertheless, PCI's mortality gain over thrombolysis decreases as the time between presentation and PCI procedure increases. Furthermore, PCI is not widely available in most developing countries; thus, it cannot be delivered promptly. Most patients in developing countries cannot afford the cost of PCI. Thus, thrombolytic therapy remains essential to managing MI in developing countries and should not be disregarded. Tenecteplase (TNK) and streptokinase (SK) are the two most widely used fibrinolytics in managing MI in underdeveloped nations. Despite their widespread availability, comparative studies on them have been inconclusive. This study aims to review the available literature on the effectiveness and safety of TNK versus SK in managing MI in resource-poor nations. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search for studies comparing TNK and STK was conducted on EMBASE, Cochrane Library, Web of Science, CINAHL, Scopus, Google Scholar, and Ovid version of MEDLINE databases. A reference list of the eligible articles and systematic reviews was also screened. A narrative synthesis of the available data was done by representing the data on the effect direction plot, followed by vote counting. Of the 2284 references retrieved from the databases, only 17 studies met the inclusion criteria and were selected for final analysis. The study suggested that TNK is more effective in complete ST-segment resolution (80% vs 10% on the effect direction plot) and symptom relief (80% vs 20%) than SK. SK and TNK were comparable in achieving successful fibrinolysis (50% vs 50%). For the safety parameters, TNK is associated with a lesser risk of major bleeding than SK (88.9% vs 11.1%) and minor bleeding (25% vs 75%). SK was linked with a higher risk of hypotension/shock (77.8% vs 11.1%) and anaphylaxis/allergy (100% vs 0%). Long-term mortality was higher in the SK arm (100% vs 0%). In-hospital mortality is comparable between the two agents (37.5% vs 37.5%). There is conflicting evidence regarding other safety and efficacy endpoints. Compared to SK, TNK results in better complete ST-segment resolution and symptom relief. A higher risk of long-term mortality, increased risk of major and minor bleeding, hypotension, and allergy/anaphylaxis was observed in patients who received SK. Both agents were comparable in terms of in-hospital mortality and successful fibrinolysis. Controversy exists regarding which agent is linked with increased risk of 30-35-day mortality benefit and stroke. Randomized controlled trials (RCTs) with large sample sizes are needed to establish TNK vs SK superiority in efficacy and safety. The long-term duration of follow-up of the mortality rate of the two agents is also essential, as most patients in these regions cannot afford the recommended PCI post-fibrinolysis.
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Affiliation(s)
| | - Ndianabasi Ekong
- Department of Medicine, Medical Center, Akwa Ibom State College of Education, Afaha Nsit, NGA
| | - William Wyns
- Department of Medicine, University of Galway, Galway, IRL
| | | | - Micheal Newell
- Department of Surgery, University of Galway, Galway, IRL
| | | | - Sandra T Alex-Ojei
- Department of Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, NGA
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Robertson DS, Choodari-Oskooei B, Dimairo M, Flight L, Pallmann P, Jaki T. Point estimation for adaptive trial designs II: Practical considerations and guidance. Stat Med 2023; 42:2496-2520. [PMID: 37021359 PMCID: PMC7614609 DOI: 10.1002/sim.9734] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/20/2023] [Accepted: 03/18/2023] [Indexed: 04/07/2023]
Abstract
In adaptive clinical trials, the conventional end-of-trial point estimate of a treatment effect is prone to bias, that is, a systematic tendency to deviate from its true value. As stated in recent FDA guidance on adaptive designs, it is desirable to report estimates of treatment effects that reduce or remove this bias. However, it may be unclear which of the available estimators are preferable, and their use remains rare in practice. This article is the second in a two-part series that studies the issue of bias in point estimation for adaptive trials. Part I provided a methodological review of approaches to remove or reduce the potential bias in point estimation for adaptive designs. In part II, we discuss how bias can affect standard estimators and assess the negative impact this can have. We review current practice for reporting point estimates and illustrate the computation of different estimators using a real adaptive trial example (including code), which we use as a basis for a simulation study. We show that while on average the values of these estimators can be similar, for a particular trial realization they can give noticeably different values for the estimated treatment effect. Finally, we propose guidelines for researchers around the choice of estimators and the reporting of estimates following an adaptive design. The issue of bias should be considered throughout the whole lifecycle of an adaptive design, with the estimation strategy prespecified in the statistical analysis plan. When available, unbiased or bias-reduced estimates are to be preferred.
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Affiliation(s)
| | - Babak Choodari-Oskooei
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Munya Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Faculty of Informatics and Data Science, University of Regensburg, Regensburg, Germany
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Trerayapiwat K, Jinatongthai P, Vathesatogkit P, Sritara P, Paengsai N, Dilokthornsakul P, Nathisuwan S, Le LM, Chaiyakunapruk N. Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100503. [PMID: 35789828 PMCID: PMC9250039 DOI: 10.1016/j.lanwpc.2022.100503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown. METHODS Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed. FINDINGS From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK. INTERPRETATION In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase. FUNDING None.
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Affiliation(s)
- Krittimeth Trerayapiwat
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Peerawat Jinatongthai
- Pharmacy practice division, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Ninutcha Paengsai
- National Health Security Office (NHSO), Fund Management Unit, Bangkok, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Lan My Le
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, United States of America
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Grewal SK, Hedrick AL, Man L, Sharma AM, Desai KR, Khaja MS. A Brief Review of Thrombolytics for Venous Interventions. Semin Intervent Radiol 2022; 39:394-399. [PMID: 36406029 PMCID: PMC9671688 DOI: 10.1055/s-0042-1757318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Anticoagulation continues to be the mainstay of therapy for the management of venous thromboembolism. However, anticoagulation does not lead to the breakdown or dissolving of the thrombus. In an acute pulmonary embolism, extensive thrombus burden can be associated with a high risk for early decompensation, and in acute deep venous thrombosis, it can be associated with an increased risk for phlegmasia. In addition, residual thrombosis can be associated with chronic thromboembolic pulmonary hypertension and postthrombotic syndrome in a chronic setting. Thrombolytic therapy is a crucial therapeutic choice in treating venous thromboembolism for thrombus resolution. Historically, it was administered systemically and was associated with high bleeding rates, particularly major bleeding, including intracranial bleeding. In the last two decades, there has been a significant increase in catheter-based therapies with and without ultrasound, where lower doses of thrombolytic agents are utilized, potentially reducing the risk for major bleeding events and improving the odds of reducing the thrombus burden. In this article, we provide an overview of several thrombolytic therapies, including delivery methods, doses, and outcomes.
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Affiliation(s)
- Sukhdeep K. Grewal
- Department of Radiology and Medical Imaging, Vascular and Interventional Radiology, University of Virginia Health, Charlottesville, Virginia
| | - Amanda L. Hedrick
- Department of Medicine, Critical Care Pharmacology, University of Virginia Health, Charlottesville, Virginia
| | - Louise Man
- Department of Medicine, Hematology and Oncology, University of Virginia Health, Charlottesville, Virginia
| | - Aditya M. Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, Virginia
| | - Kush R. Desai
- Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Minhaj S. Khaja
- Department of Radiology and Medical Imaging, Vascular and Interventional Radiology, University of Virginia Health, Charlottesville, Virginia
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6
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The Telecardiology Revolution: From Emergency Management to Daily Clinical Practice. J Clin Med 2022; 11:jcm11071920. [PMID: 35407529 PMCID: PMC8999803 DOI: 10.3390/jcm11071920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/16/2022] Open
Abstract
AIMS Telecardiology is one of the most widespread applications of telemedicine. We aimed to report the design and development of a telecardiology system in the sanitary district of Cosenza, one of the largest in Italy, with a complex orography, and healthcare reorganization needs, for the management of the emergency network and daily clinical practice. METHODS Our telecardiology network connects 8 hospitals, 9 first aid centers, 20 local 118-EMS stations, 1 helicopter station, 8 hospital emergency departments, 59 hospital departments, and 3 catheterization laboratories. All data are centralized on a dedicated server, accessible from any location for real-time assessment. The quality, source, and timing of the electrocardiograms transmitted were evaluated. RESULTS From October 2015 to December 2019, a total of 389,970 ECGs were transmitted. The quality of ECGs was optimal in 52%, acceptable in 42%, and poor in 6% of the cases. The number of poor-quality ECGs was only 3% in the last 2 years. Out of the total, 145,097 (37.2%) were transmitted from the emergency departments and 5318 (1.4%) from the 118-EMS. Of interest, a sizable part of the ECG was related to routine clinical practice, comprising 110,556 (28.3%) from the cardiology department and 79,256 (20.3%) from other noncardiovascular departments. Finally, the average reporting time was significantly decreased compared to reporting times without a telecardiology system (5-10 vs. 45-90 min). CONCLUSION Our telecardiology system provides efficient cardiology assistance for all types, settings, and phases of cardiovascular diseases.
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Lazzaro C, Castagna L, Lanza F, Laszlo D, Milone G, Pierelli L, Saccardi R. Chemotherapy-based versus chemotherapy-free stem cell mobilization (± plerixafor) in multiple myeloma patients: an Italian cost-effectiveness analysis. Bone Marrow Transplant 2021; 56:1876-1887. [PMID: 33753907 PMCID: PMC8338551 DOI: 10.1038/s41409-021-01251-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 02/03/2021] [Accepted: 02/18/2021] [Indexed: 12/21/2022]
Abstract
Given the availability and efficacy of the mobilizing agent plerixafor in augmenting hematopoietic progenitor cell mobilization with granulocyte colony-stimulating factor (G-CSF), there is a strong case for comparing the cost-effectiveness of mobilization with G-CSF + cyclophosphamide versus G-CSF alone. This study investigated the cost and effectiveness (i.e., successful 4 million-CD34+ collection) of G-CSF alone versus high-dose cyclophosphamide (4 g/m2) + G-CSF mobilization (± on-demand plerixafor) in patients with multiple myeloma (MM) eligible for autograft in Italy. A decision tree-supported cost-effectiveness analysis (CEA) model in MM patients was developed from the societal perspective. The CEA model compared G-CSF alone with cyclophosphamide 4 g/m2 + G-CSF (± on-demand plerixafor) and was populated with demographic, healthcare and non-healthcare resource utilization data collected from a questionnaire administered to six Italian oncohematologists. Costs were expressed in Euro (€) 2019. The CEA model showed that G-CSF alone was strongly dominant versus cyclophosphamide + G-CSF ( ± on-demand plerixafor), with incremental savings of €1198.59 and an incremental probability of a successful 4 million-CD34+ apheresis (+0.052). Sensitivity analyses confirmed the robustness of the base-case results. In conclusion, chemotherapy-free mobilization (± on-demand plerixafor) is a “good value for money” option for MM patients eligible for autograft.
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Affiliation(s)
- Carlo Lazzaro
- Health Economist and Research Director, Studio di Economia Sanitaria, Milan, Italy.
| | - Luca Castagna
- Oncology and Haematology Unit, BMT section, Istituto Clinico Humanitas, Rozzano, Italy
| | - Francesco Lanza
- Hematology Section, Romagna Transplant Network, University Hospital "Santa Maria delle Croci", Ravenna, Italy
| | - Daniele Laszlo
- Stem Cell Mobilization and Collection Unit, IEO IRCCS, Milan, Italy
| | - Giuseppe Milone
- Hematology and BMT Unit, Azienda Policlinico Vittorio Emanuele, Catania, Italy
| | - Luca Pierelli
- Department of Experimental Medicine, University "Sapienza", Rome, Immune-hematology and Transfusion Medicine Unit, Azienda Ospedaliera San Camillo, Rome, Italy
| | - Riccardo Saccardi
- Department of Cellular Therapy and Transfusion Medicine, Careggi University Hospital, Florence, Italy
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8
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DelaCruz JJ, Giannikos C, Kakolyris A, Utzinger RC, Karpiak SE. Cost-Effectiveness Analysis Combining Medical and Mental Health Services for Older Adults with HIV in New York City. ATLANTIC ECONOMIC JOURNAL : AEJ 2021; 49:43-56. [PMID: 34040269 PMCID: PMC8143031 DOI: 10.1007/s11293-021-09697-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Older adults with the human immunodeficiency virus or HIV (OAWH), people 50 years and older, are aging with the disease and experience low quality of life. Mental health disorders trigger and worsen health inequalities with larger impacts on the quality of life of OAWH. This paper evaluated two rival health interventions using a standard decision-analytic model and quantified the cost per quality-adjusted life-years (QALY) to understand the differential in cost and effectiveness of an additional unit of perfect health. HIV medical care was compared with a combined strategy that includes both HIV medical and behavioral care. Primary data from a convenience sample (n=139) collected in New York City and outcomes for healthy older adults from the literature were used in this study. The incremental cost-effectiveness ratio (ICER) evaluating the economic cost and health benefits of the new intervention was $36,166 per QALY, which is less than the willingness to pay ($75,000). The ICER for Hispanics was $35,325 and for White/Caucasians was $40,499. Integrated medical plus behavioral care is cost-effective and improves quality of life among OAWH. Given the high rates of mental health disorders along with an underutilization of behavioral care among OAWH, timely and effective mental health programs are paramount to increase quality of life.
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Affiliation(s)
- Juan J DelaCruz
- Lehman College - City University of New York 250 Bedford Park Blvd W, Bronx, NY
| | - Christos Giannikos
- The Graduate Center - City University of New York 365 Fifth Avenue, New York, NY
| | - Andreas Kakolyris
- Manhattan College 4513 Manhattan College Parkway, Room DLS 505, Bronx, NY
| | - Robert C Utzinger
- Graduate Center - City University of New York365 Fifth Avenue, New York, NY
| | - Stephen E Karpiak
- ACRIA Center on HIV and Aging at GMHC & NYU-College of Nursing 307 West 38th Street, New York, NY
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9
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Levaggi R, Pertile P. Which valued-based price when patients are heterogeneous? HEALTH ECONOMICS 2020; 29:923-935. [PMID: 32537816 DOI: 10.1002/hec.4033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 03/09/2020] [Accepted: 04/22/2020] [Indexed: 06/11/2023]
Abstract
We use a simple model to study the static and dynamic efficiency of alternative regulation regimes for the reimbursement of medical innovations when responses to a new treatment (effectiveness) are heterogeneous across the eligible population. When the rational behavior of profit-maximizing firms is taken into account, only average value-based prices can ensure both static and dynamic efficiency, but they imply higher expenditure and lower consumer surplus. Ignoring dynamic efficiency, if patients' responses are sufficiently homogeneous, marginal value-based prices may dominate from the payer's perspective. We also present a refinement of average value-based prices that could reverse this result. Overall, the cost of ensuring static and dynamic efficiency is increasing in the degree of heterogeneity. A real-world example is used to illustrate these results.
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Affiliation(s)
- Rosella Levaggi
- Department of Economics and Management, University of Brescia, Brescia, Italy
| | - Paolo Pertile
- Department of Economics, University of Verona, Verona, Italy
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10
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Bishu KG, Lekoubou A, Kirkland E, Schumann SO, Schreiner A, Heincelman M, Moran WP, Mauldin PD. Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data. Am J Med Sci 2020; 359:257-265. [PMID: 32265010 DOI: 10.1016/j.amjms.2020.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/21/2019] [Accepted: 02/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.
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Affiliation(s)
- Kinfe G Bishu
- Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina.
| | - Alain Lekoubou
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Kirkland
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Samuel O Schumann
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Andrew Schreiner
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Marc Heincelman
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - William P Moran
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Patrick D Mauldin
- Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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11
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Joner M, Cassese S. The "Smoker's Paradox": The Closer You Look, the Less You See. JACC Cardiovasc Interv 2019; 12:1951-1953. [PMID: 31521650 DOI: 10.1016/j.jcin.2019.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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12
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Thelengana A, Radhakrishnan DM, Prasad M, Kumar A, Prasad K. Tenecteplase versus alteplase in acute ischemic stroke: systematic review and meta-analysis. Acta Neurol Belg 2019; 119:359-367. [PMID: 29728903 DOI: 10.1007/s13760-018-0933-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
Tenecteplase is a product of genetic modification of recombinant tissue plasminogen activator with superior pharmacodynamic and pharmacokinetic properties. This meta-analysis was to determine whether intravenous thrombolysis with tenecteplase in patients with acute ischemic stroke has better efficacy and safety outcomes than with intravenous alteplase. PubMed, Cochrane Central Register of Controlled Trials, WHO International clinical trials registry platform (ICTRP), Australian New Zealand Clinical Trials Registry (ANZCTR), EU Clinical Trials Register (EU-CTR) and ClinicalTrials.gov were searched for trials comparing tenecteplase with alteplase in acute ischemic stroke. Functional outcomes (modified Rankin Scale at 90 days), early major neurological improvement, rates of any intracerebral haemorrhage, symptomatic intracerebral haemorrhage and mortality rate at 90 days were the outcomes compared. Four randomized controlled trials involving 1334 patients were included. The Tenecteplase group compared to the alteplase group had significantly better early major neurological improvement (RR = 1.56, 95% CI [1.00, 2.43], p = 0.05). There was no significant difference between tenecteplase and alteplase in excellent functional outcome at 90 days, good functional outcome at 90 days, any intracerebral haemorrhage, symptomatic intracerebral haemorrhage or mortality at 90 days. Our meta-analysis found tenecteplase to be significantly favouring one outcome: early major neurological improvement. Other outcomes did not differ between the tenecteplase and alteplase groups. Trials of cost-effective/benefit analysis comparing tenecteplase versus alteplase and tenecteplase versus endovascular treatment are necessary to reinforce the evidence for the potential cost advantage of tenecteplase.
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13
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Shrestha A, House DR, Welch JL. In Patients With ST-Segment Elevation Myocardial Infarction, Which Fibrinolytic Agent Is the Safest and Most Effective? Ann Emerg Med 2018; 72:670-671. [DOI: 10.1016/j.annemergmed.2018.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 11/25/2022]
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14
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Marschner IC, Schou IM. Underestimation of treatment effects in sequentially monitored clinical trials that did not stop early for benefit. Stat Methods Med Res 2018; 28:3027-3041. [PMID: 30132370 DOI: 10.1177/0962280218795320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, there has been a prominent discussion in the literature about the potential for overestimation of the treatment effect when a clinical trial stops at an interim analysis due to the experimental treatment showing a benefit over the control. However, there has been much less attention paid to the converse issue, namely, that sequentially monitored clinical trials which did not stop early for benefit tend to underestimate the treatment effect. In meta-analyses of many studies, these two sources of bias will tend to balance each other to produce an unbiased estimate of the treatment effect. However, for the interpretation of a single study in isolation, underestimation due to interim analysis may be an important consideration. In this paper, we discuss the nature of this underestimation, including theoretical and simulation results demonstrating that it can be substantial in some contexts. Furthermore, we show how a conditional approach to estimation, in which we condition on the study reaching its final analysis, may be used to validly inflate the observed treatment difference from a sequentially monitored clinical trial. Expressions for the conditional bias and information are derived, and these are used in supplied R code that computes the bias-adjusted estimate and an associated confidence interval. As well as simulation results demonstrating the validity of the methods, we present a data analysis example from a pivotal clinical trial in cardiovascular disease. The methods will be most useful when an unbiased treatment effect estimate is critical, such as in cost-effectiveness analysis or risk prediction.
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Affiliation(s)
- Ian C Marschner
- Department of Statistics, Macquarie University, NSW, Australia.,NHMRC Clinical Trials Centre, University of Sydney, NSW, Australia
| | - I Manjula Schou
- Department of Statistics, Macquarie University, NSW, Australia.,Janssen-Cilag Pty. Limited, NSW, Australia
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Shreibati JB, Manson JE, Margolis KL, Chlebowski RT, Stefanick ML, Hlatky MA. Impact of hormone therapy on Medicare spending in the Women's Health Initiative randomized clinical trials. Am Heart J 2018; 198:108-114. [PMID: 29653631 PMCID: PMC5901884 DOI: 10.1016/j.ahj.2017.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Randomized trials can compare economic as well as clinical outcomes, but economic data are difficult to collect. Linking clinical trial data with Medicare claims could provide novel information on health care utilization and cost. METHODS We linked data from Medicare claims of women ≥65 years old who had Medicare fee-for-service coverage with their clinical data from the Women's Health Initiative trials of conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) versus placebo and of CEE-alone versus placebo. The primary outcome was total Medicare spending during the intervention phase of the trial, and the secondary outcomes were spending on diseases hypothesized a priori to be sensitive to the effects of hormone therapy. RESULTS In the CEE+MPA trial, 4,557 participants ≥65 years old were included. Women randomly assigned to CEE+MPA had 4% higher mean Medicare spending overall ($45,690 vs $43,920, P = .08) but 0.5% lower spending for hormone-sensitive diseases ($3,526 vs $3,547, P = .07), with 73% higher spending for coronary heart disease (P = .045) and 122% higher spending for pulmonary embolism (P = .026). In the CEE-alone trial, 3,107 participants were included. Total spending among women randomly assigned to CEE was 3.3% higher ($75,411 vs $72,997, P = .16), and 1.7% higher spending for hormone-sensitive diseases ($5,213 vs $5,127, P = .57), but with 39% lower spending for hip fracture (p<0.03). CONCLUSIONS Menopausal hormone therapy increased spending for some diseases, but decreased spending for others. These offsetting effects led to modest (3%-4%), nonsignificant increases in overall spending among women aged 65 years and older.
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Affiliation(s)
| | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA.
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16
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Olchanski N, Cohen JT, Neumann PJ, Wong JB, Kent DM. Understanding the Value of Individualized Information: The Impact of Poor Calibration or Discrimination in Outcome Prediction Models. Med Decis Making 2017; 37:790-801. [PMID: 28399375 DOI: 10.1177/0272989x17704855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Risk prediction models allow for the incorporation of individualized risk and clinical effectiveness information to identify patients for whom therapy is most appropriate and cost-effective. This approach has the potential to identify inefficient (or harmful) care in subgroups at different risks, even when the overall results appear favorable. Here, we explore the value of personalized risk information and the factors that influence it. METHODS Using an expected value of individualized care (EVIC) framework, which monetizes the value of customizing care, we developed a general approach to calculate individualized incremental cost effectiveness ratios (ICERs) as a function of individual outcome risk. For a case study (tPA v. streptokinase to treat possible myocardial infarction), we used a simulation to explore how an EVIC is influenced by population outcome prevalence, model discrimination (c-statistic) and calibration, and willingness-to-pay (WTP) thresholds. RESULTS In our simulations, for well-calibrated models, which do not over- or underestimate predicted v. observed event risk, the EVIC ranged from $0 to $700 per person, with better discrimination (higher c-statistic values) yielding progressively higher EVIC values. For miscalibrated models, the EVIC ranged from -$600 to $600 in different simulated scenarios. The EVIC values decreased as discrimination improved from a c-statistic of 0.5 to 0.6, before becoming positive as the c-statistic reached values of ~0.8. CONCLUSIONS Individualizing treatment decisions using risk may produce substantial value but also has the potential for net harm. Good model calibration ensures a non-negative EVIC. Improvements in discrimination generally increase the EVIC; however, when models are miscalibrated, greater discriminating power can paradoxically reduce the EVIC under some circumstances.
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Affiliation(s)
- Natalia Olchanski
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - Joshua T Cohen
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - Peter J Neumann
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK).,Division of Clinical Decision Making, Tufts Medical Center, Boston, MA (JBW)
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
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van Klaveren D, Wong JB, Kent DM, Steyerberg EW. Biases in Individualized Cost-effectiveness Analysis: Influence of Choices in Modeling Short-Term, Trial-Based, Mortality Risk Reduction and Post-Trial Life Expectancy. Med Decis Making 2017; 37:770-778. [PMID: 28854143 DOI: 10.1177/0272989x17696994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefits and costs of a treatment are typically heterogeneous across individual patients. Randomized clinical trials permit the examination of individualized treatment benefits over the trial horizon but extrapolation to lifetime horizon usually involves combining trial-based individualized estimates of short-term risk reduction with less detailed (less granular) population life tables. However, the underlying assumption of equal post-trial life expectancy for low- and high-risk patients of the same sex and age is unrealistic. We aimed to study the influence of unequal granularity between models of short-term risk reduction and life expectancy on individualized estimates of cost-effectiveness of aggressive thrombolysis for patients with an acute myocardial infarction. METHODS To estimate life years gained, we multiplied individualized estimates of short-term risk reduction either with less granular and with equally granular post-trial life expectancy estimates. Estimates of short-term risk reduction were obtained from GUSTO trial data (30,510 patients) using logistic regression analysis with treatment, sex, and age as predictor variables. Life expectancy estimates were derived from sex- and age-specific US life tables. RESULTS Based on sex- and age-specific, short-term risk reductions but average population life expectancy (less granularity), we found that aggressive thrombolysis was cost-effective (incremental cost-effectiveness ratio below $50,000) for women above age 49 y and men above age 53 y (92% and 69% of the population, respectively). Considering sex- and age-specific short-term mortality risk reduction and correspondingly sex- and age-specific life expectancy (equal granularity), aggressive thrombolysis was cost-effective for men above age 45 y and women above age 50 y (95% and 76% of the population, respectively). CONCLUSIONS Failure to model short-term risk reduction and life expectancy at an equal level of granularity may bias our estimates of individualized cost-effectiveness and misallocate resources.
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Affiliation(s)
- David van Klaveren
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands (DVK, EWS).,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (DVK, JBW, DMK)
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (DVK, JBW, DMK).,Division of Clinical Decision Making, Tufts Medical Center, Boston, MA, USA (JBW)
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (DVK, JBW, DMK)
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands (DVK, EWS)
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18
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Wei CY, Quek RGW, Villa G, Gandra SR, Forbes CA, Ryder S, Armstrong N, Deshpande S, Duffy S, Kleijnen J, Lindgren P. A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies. PHARMACOECONOMICS 2017; 35:297-318. [PMID: 27785772 DOI: 10.1007/s40273-016-0464-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints. OBJECTIVE The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates. METHODS Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers. RESULTS Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal. CONCLUSIONS This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.
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Affiliation(s)
- Ching-Yun Wei
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK.
| | | | | | | | - Carol A Forbes
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Steve Ryder
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Nigel Armstrong
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Sohan Deshpande
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Steven Duffy
- Kleijnen Systematic Reviews Ltd., Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Jos Kleijnen
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Peter Lindgren
- IHE-Institutet för Hälso-och Sjukvårdsekonomi, Lund, Sweden
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20
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Kyeremanteng K, Wan C, D'Egidio G, Neilipovitz D. Approach to economic analysis in critical care. J Crit Care 2016; 36:92-96. [PMID: 27546754 DOI: 10.1016/j.jcrc.2016.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/06/2016] [Accepted: 07/01/2016] [Indexed: 12/30/2022]
Abstract
There are 4 general economic analyses used in health care: cost minimization, cost-benefit, cost-effectiveness, and cost utility. In this review, we provide an overview of each of these analyses and examine their appropriateness and effectiveness in assessing critical care costs. In the intensive care unit setting, it is particularly important to consider the patients' quality of life following the treatment of critical illness and to adopt a societal perspective when conducting economic analyses. Therefore, of the 4 economic analyses we cover, we recommend the use of cost-effectiveness and cost utility analyses.
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Affiliation(s)
| | - Cynthia Wan
- University of Ottawa, Ottawa, Ontario, Canada.
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21
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Hlatky MA. Considering Cost-Effectiveness in Cardiology Clinical Guidelines: Progress and Prospects. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:516-519. [PMID: 27565266 DOI: 10.1016/j.jval.2016.04.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Since the 1980s, when the American College of Cardiology (ACC) and the American Heart Association (AHA) established a joint task force to examine the use of cardiovascular procedures and therapies, cardiologists have been leaders in the development of clinical practice guidelines. The ACC/AHA guidelines development process has evolved considerably over the last 30 or more years. Guidelines now focus on clinical conditions, such as angina, instead of procedures, such as bypass surgery. There is a formal organizational structure, with dedicated staff, a standing committee on practice guidelines, and specific panels of volunteer experts on each topic. This process tightly manages conflicts of interest and strives for evidence-based, as opposed to opinion-based, guidelines, with a clear citation of the supporting evidence. Traditional clinical guidelines consider only what is best for the individual patient, and have explicitly not considered the cost to society. Nevertheless, in many guidelines development meetings, high cost was implicitly considered: if a procedure was extremely costly, the evidence needed to be very strong. The Guidelines Committee recognized that cost considerations ought to be made more transparent, and that the evidence on economic value should be explicitly cited when available. These considerations were formalized by a recent white paper on incorporating economic considerations into ACC/AHA guidelines. In considering value, it is necessary to assess the quality of the evidence as well as to define levels of value. The next ACC/AHA guideline will incorporate value as a part of its recommendations. This will be an evidence-based process in which published economic assessments relating to key questions will be reviewed.
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Affiliation(s)
- Mark A Hlatky
- Stanford University School of Medicine, Stanford, CA, USA.
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22
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Sinha AC, Singh PM, Bhat S. Are we operating too late? Mortality Analysis and Stochastic Simulation of Costs Associated with Bariatric Surgery: Reconsidering the BMI Threshold. Obes Surg 2015; 26:219-28. [DOI: 10.1007/s11695-015-1934-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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23
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Ramsey SD, Willke RJ, Glick H, Reed SD, Augustovski F, Jonsson B, Briggs A, Sullivan SD. Cost-effectiveness analysis alongside clinical trials II-An ISPOR Good Research Practices Task Force report. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:161-72. [PMID: 25773551 DOI: 10.1016/j.jval.2015.02.001] [Citation(s) in RCA: 501] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Clinical trials evaluating medicines, medical devices, and procedures now commonly assess the economic value of these interventions. The growing number of prospective clinical/economic trials reflects both widespread interest in economic information for new technologies and the regulatory and reimbursement requirements of many countries that now consider evidence of economic value along with clinical efficacy. As decision makers increasingly demand evidence of economic value for health care interventions, conducting high-quality economic analyses alongside clinical studies is desirable because they broaden the scope of information available on a particular intervention, and can efficiently provide timely information with high internal and, when designed and analyzed properly, reasonable external validity. In 2005, ISPOR published the Good Research Practices for Cost-Effectiveness Analysis Alongside Clinical Trials: The ISPOR RCT-CEA Task Force report. ISPOR initiated an update of the report in 2014 to include the methodological developments over the last 9 years. This report provides updated recommendations reflecting advances in several areas related to trial design, selecting data elements, database design and management, analysis, and reporting of results. Task force members note that trials should be designed to evaluate effectiveness (rather than efficacy) when possible, should include clinical outcome measures, and should obtain health resource use and health state utilities directly from study subjects. Collection of economic data should be fully integrated into the study. An incremental analysis should be conducted with an intention-to-treat approach, complemented by relevant subgroup analyses. Uncertainty should be characterized. Articles should adhere to established standards for reporting results of cost-effectiveness analyses. Economic studies alongside trials are complementary to other evaluations (e.g., modeling studies) as information for decision makers who consider evidence of economic value along with clinical efficacy when making resource allocation decisions.
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Affiliation(s)
- Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Schools of Medicine and Pharmacy, University of Washington, Seattle, WA, USA.
| | - Richard J Willke
- Outcomes & Evidence Lead, CV/Metabolic, Pain, Urology, Gender Health, Global Health & Value, Pfizer, Inc., New York, NY, USA
| | - Henry Glick
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Federico Augustovski
- Institute for Clinical Effectiveness and Health Policy (IECS), University of Buenos Aires, Buenos Aires, Argentina
| | - Bengt Jonsson
- Department of Economics, Stockholm School of Economics, Stockholm, Sweden
| | - Andrew Briggs
- William R. Lindsay Chair of Health Economics, University of Glasgow, Glasgow, Scotland, UK
| | - Sean D Sullivan
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Schools of Medicine and Pharmacy, University of Washington, Seattle, WA, USA
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Application of Entropy-Based Attribute Reduction and an Artificial Neural Network in Medicine: A Case Study of Estimating Medical Care Costs Associated with Myocardial Infarction. ENTROPY 2014. [DOI: 10.3390/e16094788] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Ademi Z, Watts GF, Pang J, Sijbrands EJG, van Bockxmeer FM, O'Leary P, Geelhoed E, Liew D. Cascade screening based on genetic testing is cost-effective: evidence for the implementation of models of care for familial hypercholesterolemia. J Clin Lipidol 2014; 8:390-400. [PMID: 25110220 DOI: 10.1016/j.jacl.2014.05.008] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 05/06/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) imposes significant burden of premature coronary heart disease (CHD). OBJECTIVE This study aimed to determine the cost-effectiveness of FH detection based on genetic testing, supplemented with the measurement of plasma low-density lipoprotein cholesterol concentration, and treatment with statins. METHODS A Markov model with a 10-year time horizon was constructed to simulate the onset of first-ever CHD and death in close relatives of probands with genetically confirmed FH. The model comprised of 3 health states: "alive without CHD," "alive with CHD," and "dead." Decision-analysis compared the clinical consequences and costs of cascade-screening vs no-screening from an Australian health care perspective. The annual risk of CHD and benefits of treatment was estimated from a cohort study. The underlying prevalence of FH, sensitivity, specificity, cost of screening, treatment, and clinic follow-up visits were derived from a cascade screening service for FH in Western Australia. An annual discount rate of 5% was applied to costs and benefits. RESULTS The model estimated that screening for FH would reduce the 10-year incidence of CHD from 50.0% to 25.0% among people with FH. Of every 100 people screened, there was an overall gain of 24.95 life-years and 29.07 quality-adjusted life years (discounted). The incremental cost-effectiveness ratio was in Australian dollars, $4155 per years of life saved and $3565 per quality-adjusted life years gained. CONCLUSION This analysis within an Australian context, demonstrates that cascade screening for FH, using genetic testing supplemented with the measurement of plasma low-density lipoprotein cholesterol concentrations and treatment with statins, is a cost-effective means of preventing CHD in families at risk of FH.
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Affiliation(s)
- Zanfina Ademi
- Department of Medicine (RMH), Melbourne EpiCentre, The University of Melbourne and Melbourne Health, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia.
| | - Gerald F Watts
- Lipid Disorders Clinic, Metabolic Research Centre and Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, The University of Western Australia, Australia
| | - Jing Pang
- Lipid Disorders Clinic, Metabolic Research Centre and Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, The University of Western Australia, Australia
| | - Eric J G Sijbrands
- Section of Pharmacology, Vascular and Metabolic Diseases of the Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Peter O'Leary
- School of Surgery, The University of Western Australia, Crawley, Australia; Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia; School of Pathology & Laboratory Medicine, The University of Western Australia, Crawley, Australia
| | - Elizabeth Geelhoed
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Australia; School of Population Health, The University of Western Australia, Australia
| | - Danny Liew
- Department of Medicine (RMH), Melbourne EpiCentre, The University of Melbourne and Melbourne Health, Australia
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Brunetti ND, Dellegrottaglie G, Lopriore C, Di Giuseppe G, De Gennaro L, Lanzone S, Di Biase M. Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis. Clin Cardiol 2014; 37:140-5. [PMID: 24452666 DOI: 10.1002/clc.22234] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 11/27/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate. HYPOTHESIS Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs. METHODS An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist). RESULTS During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ - 2508 after correction for potential savings. CONCLUSIONS Prehospital EMS triage with telemedicine ECG in patients with suspected acute cardiac disease may reduce health-care costs.
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27
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Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res 2014; 8:165-78. [DOI: 10.1586/14737167.8.2.165] [Citation(s) in RCA: 487] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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28
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Marcucci M, Sinclair JC. A generalised model for individualising a treatment recommendation based on group-level evidence from randomised clinical trials. BMJ Open 2013; 3:bmjopen-2013-003143. [PMID: 23943775 PMCID: PMC3752048 DOI: 10.1136/bmjopen-2013-003143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Randomised controlled trials report group-level treatment effects. However, an individual patient confronting a treatment decision needs to know whether that person's expected treatment benefit will exceed the expected treatment harm. We describe a flexible model for individualising a treatment decision. It individualises group-level results from randomised trials using clinical prediction guides. METHODS We constructed models that estimate the size of individualised absolute risk reduction (ARR) for the target outcome that is required to offset individualised absolute risk increase (ARI) for the treatment harm. Inputs to the model include estimates for the individualised predicted absolute treatment benefit and harm, and the relative value assigned by the patient to harm/benefit. A decision rule recommends treatment when the predicted benefit exceeds the predicted harm, value-adjusted. We also derived expressions for the maximum treatment harm, or the maximum relative value for harm/benefit, above which treatment would not be recommended. RESULTS For the simpler model, including one kind of benefit and one kind of harm, the individualised ARR required to justify treatment was expressed as required ARRtarget(i)=ARIharm(i) × RVharm/target(i). A complex model was also developed, applicable to treatments causing multiple kinds of benefits and/or harms. We demonstrated the applicability of the models to treatments tested in superiority trials (either placebo or active control, either fixed harm or variable harm) and non-inferiority trials. CONCLUSIONS Individualised treatment recommendations can be derived using a model that applies clinical prediction guides to the results of randomised trials in order to identify which individual patients are likely to derive a clinically important benefit from the treatment. The resulting individualised prediction-based recommendations require validation by comparison with strategies of treat all or treat none.
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Affiliation(s)
- Maura Marcucci
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - John C Sinclair
- Departments of Pediatrics and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Lazzaro C, Bordonaro R, Cognetti F, Fabi A, De Placido S, Arpino G, Marchetti P, Botticelli A, Pronzato P, Martelli E. An Italian cost-effectiveness analysis of paclitaxel albumin (nab-paclitaxel) versus conventional paclitaxel for metastatic breast cancer patients: the COSTANza study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:125-35. [PMID: 23610525 PMCID: PMC3629871 DOI: 10.2147/ceor.s41850] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Paclitaxel albumin (nab-paclitaxel) is a nanoparticle albumin-bound paclitaxel formulation aimed at increasing therapeutic index in metastatic breast cancer. When compared to conventional paclitaxel, nab-paclitaxel has a reported longer time to progression, higher response, lower incidence of neutropenia, no need for premedication, shorter time of administration, and in pretreated metastatic breast cancer patients, extended overall survival. This study investigates the cost-effectiveness of nab-paclitaxel versus conventional paclitaxel for pretreated metastatic breast cancer patients in Italy. Materials and methods A Markov model with progression-free, progressed, and dead states was developed to estimate costs, outcomes, and quality adjusted life years over 5 years from the Italian National Health Service viewpoint. Patients were assumed to receive nab-paclitaxel 260 mg/m2 three times weekly or conventional paclitaxel 175 mg/m2 three times weekly. Data on health care resource consumption was collected from a convenience sample of five Italian centers. Resources were valued at Euro (€) 2011. Published utility weights were applied to health states to estimate the impact of response, disease progression, and adverse events on quality adjusted life years. Three sensitivity analyses tested the robustness of the base case incremental cost-effectiveness ratio (ICER). Results and conclusion Compared to conventional paclitaxel, nab-paclitaxel gains an extra 0.165 quality adjusted life years (0.265 life years saved) and incurs additional costs of €2506 per patient treated. This translates to an ICER of €15,189 (95% confidence interval: €11,891–€28,415). One-way sensitivity analysis underscores that ICER for nab-paclitaxel remains stable despite varying taxanes cost. Threshold analysis shows that ICER for nab-paclitaxel exceeds €40,000 only if cost per mg of conventional paclitaxel is set to zero. Probabilistic sensitivity analysis highlights that nab-paclitaxel has a 0.99 probability to be cost-effective for a threshold value of €40,000 and is the optimal alternative from a threshold value of €16,316 onwards. Based on these findings, nab-paclitaxel can be considered highly cost-effective when compared to the acceptability range for ICER proposed by the Italian Health Economics Association (€25,000–€40,000).
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Midorikawa Y, Takayama T, Shimada K, Nakayama H, Higaki T, Moriguchi M, Nara S, Tsuji S, Tanaka M. Marginal survival benefit in the treatment of early hepatocellular carcinoma. J Hepatol 2013; 58:306-11. [PMID: 23063418 DOI: 10.1016/j.jhep.2012.09.026] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 08/23/2012] [Accepted: 09/20/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Early treatment has been recommended for hepatocellular carcinoma (HCC) due to its high cure rate. However, the reported survival benefits of treating early HCC may be affected by lead time. METHODS Early HCC was defined as a well-differentiated cancer containing Glisson's triad (carcinoma in situ). We applied the concept of lead time to chronic liver disease, which is originally the length of time between screen-detected and symptom-detected disease. To evaluate prolongation of survival with treatment of early HCC, survivals of patients with early and overt HCCs smaller than 2.0 cm treated with liver resection were compared. To calculate lead time and survival benefit of liver resection, survivals of untreated early and overt HCC patients were compared. RESULTS After liver resection, median overall survival of 46 patients with early HCC (8.8 years; 95% CI, 7.2-11.2) was significantly longer than that of the 202 with overt HCC (6.8 years; 95% CI, 6.2-8.3, p = 0.0257). The prolongation in survival time with liver resection for early HCC was 34.7 (95% CI, 22.1-46.5) months. On the other hand, comparing liver resection and natural history, the survival benefits of surgery for 12 patients with early and 16 with overt HCC were 74.7 (95% CI, 51.9-97.4) and 73.4 (95% CI, 57.9-88.9) months, respectively. Consequently, the lead time and survival benefit with resection for early HCC were estimated as 33.4 (95% CI, 18.9-47.8) and 1.3 (95% CI, -22.1-24.7) months, respectively. CONCLUSIONS Survival benefit of resection for early HCC is marginal because of a long lead time, and early HCC is therefore not a target lesion for surgery.
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Affiliation(s)
- Yutaka Midorikawa
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-machi, Itabashi-ku, Tokyo 173-8610, Japan
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Ali S, Ronaldson S. Ordinal preference elicitation methods in health economics and health services research: using discrete choice experiments and ranking methods. Br Med Bull 2012; 103:21-44. [PMID: 22859714 DOI: 10.1093/bmb/lds020] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The predominant method of economic evaluation is cost-utility analysis, which uses cardinal preference elicitation methods, including the standard gamble and time trade-off. However, such approach is not suitable for understanding trade-offs between process attributes, non-health outcomes and health outcomes to evaluate current practices, develop new programmes and predict demand for services and products. Ordinal preference elicitation methods including discrete choice experiments and ranking methods are therefore commonly used in health economics and health service research. AREAS OF AGREEMENT Cardinal methods have been criticized on the grounds of cognitive complexity, difficulty of administration, contamination by risk and preference attitudes, and potential violation of underlying assumptions. Ordinal methods have gained popularity because of reduced cognitive burden, lower degree of abstract reasoning, reduced measurement error, ease of administration and ability to use both health and non-health outcomes. AREAS OF CONTROVERSY The underlying assumptions of ordinal methods may be violated when respondents use cognitive shortcuts, or cannot comprehend the ordinal task or interpret attributes and levels, or use 'irrational' choice behaviour or refuse to trade-off certain attributes. CURRENT USE AND GROWING AREAS: Ordinal methods are commonly used to evaluate preference for attributes of health services, products, practices, interventions, policies and, more recently, to estimate utility weights. AREAS FOR ON-GOING RESEARCH: There is growing research on developing optimal designs, evaluating the rationalization process, using qualitative tools for developing ordinal methods, evaluating consistency with utility theory, appropriate statistical methods for analysis, generalizability of results and comparing ordinal methods against each other and with cardinal measures.
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Affiliation(s)
- Shehzad Ali
- Department of Health Sciences, University of York, Heslington, York, UK.
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Abstract
Although clinical trials often provide "best evidence" comparing the effectiveness of alternative management strategies, such evidence can be limited in duration or in the results reported, causing clinicians and policy analysts to wonder "what if?" Models of the clinical prognosis-often spanning patients' lifetimes (the "long haul")-are perhaps weaker evidence, but can help answer questions about the management of individual patients and place that best evidence into the context of clinical reality.
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Te Ao BJ, Brown PM, Feigin VL, Anderson CS. Are stroke units cost effective? Evidence from a New Zealand stroke incidence and population-based study. Int J Stroke 2011; 7:623-30. [PMID: 22010968 DOI: 10.1111/j.1747-4949.2011.00632.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM Acute stroke units in hospitals are known to be more costly than standard care, but proponents claim that the health gains will justify the expense. Yet, despite widespread adoption of stroke units, the evidence on the cost effectiveness of stroke units has been mixed, due in part to differences in the pathway of care across hospitals. The purpose of this study is to compare costs and outcomes for patients admitted to a stroke unit with those admitted to a general ward. METHODS Data on 530 stroke sufferers from a large incidence study of stroke (the Auckland Regional Community Stroke Outcome Study) were used. Cost of health services, places of discharge were identified at one-, six- and 12 months poststroke and were linked with long-term cost and survival five-years poststroke. A decision analytical model was developed, including the relationship between waiting time for discharge and probability of admission to stroke unit. Cost effectiveness was determined using a willingness to pay threshold of NZ$20 000 (US$15 234). RESULTS Regression analysis suggested that there were no significant differences between patients admitted to a stroke unit and a general ward. The incremental cost-utility ratio for the first-year was NZ$42 813/quality-adjusted life year (US$32 610/quality-adjusted life year), but fell substantially to NZ$6747/quality-adjusted life year (US$5139/quality-adjusted life year) when lifetime costs and outcomes were considered. Probabilistic and one-way sensitivity analysis suggests that the results are robust to areas of uncertainty or delays in the pathway of care. CONCLUSION Stroke unit care was cost effective in Auckland, New Zealand.
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Affiliation(s)
- Braden J Te Ao
- National Institute for Stroke and Applied Neurosciences, School of Rehabilitation and Occupational Studies, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand.
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Abstract
John Ioannidis and Alan Garber discuss how to use incremental cost-effectiveness ratios (ICER) and related metrics so they can be useful for decision-making at the individual level, whether used by clinicians or individual patients.
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Affiliation(s)
- John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
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Hawkins N, Scott DA. Reimbursement and value-based pricing: stratified cost-effectiveness analysis may not be the last word. HEALTH ECONOMICS 2011; 20:688-698. [PMID: 20568075 DOI: 10.1002/hec.1625] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
During recent discussions, it has been argued that stratified cost-effectiveness analysis has a key role in reimbursement decision-making and value-based pricing (VBP). It has previously been shown that when manufacturers are price-takers, reimbursement decisions made in reference to stratified cost-effectiveness analysis lead to a more efficient allocation of resources than decisions based on whole-population cost-effectiveness analysis. However, we demonstrate that when manufacturers are price setters, reimbursement or VBP based on stratified cost-effectiveness analysis may not be optimal. Using two examples - one considering the choice of thrombolytic treatment for specific patient subgroups and the other considering the extension of coverage for a cancer treatment to include an additional indication - we show that combinations of extended coverage and reduced price can be identified that are advantageous to both payers and manufacturers. The benefits of a given extension in coverage and reduction in price depend both upon the average treatment benefit in the additional population and its size relative to the original population. Negotiation regarding trade-offs between price and coverage may lead to improved outcomes both for health-care systems and manufacturers compared with processes where coverage is determined conditional simply on stratified cost-effectiveness at a given price.
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Petrou S, Gray A. Economic evaluation alongside randomised controlled trials: design, conduct, analysis, and reporting. BMJ 2011; 342:d1548. [PMID: 21474510 PMCID: PMC3230107 DOI: 10.1136/bmj.d1548] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2011] [Indexed: 11/03/2022]
Affiliation(s)
- Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK.
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Abstract
BACKGROUND The societal costs and health benefits of tissue plasminogen activator (tPA) for ischemic stroke can be modeled and extended to the US population. Similarly, the societal impact of new thrombolytics with improved efficacy or safety or extending eligibility can also be modeled. METHODS We previously modeled the impact of tPA on societal costs and health in the United States. Pertinent publications on utilization, societal cost, and health impact were identified by systematic review, updated to include studies describing the impact of extending the tPA time window. Information on utilization of tPA was integrated with published per-use data on costs and health impact (converted to 2004 dollars) to generate annual projections for the US population. Model inputs were modified to reflect various characteristics of new thrombolytics. RESULTS At its current price, tPA saves $6074 and adds 0.75 quality-adjusted life year (QALY) per use. If tPA were priced at $50,000/QALY, a standard benchmark for cost-effectiveness, it would cost $45,800 per dose and would be expected to generate $458 million in revenue annually for its manufacturer. Thrombolytics for stroke that extended the time window or improved efficacy could generate greater revenue if priced at an accepted level of cost-effectiveness. Given current clinical development costs, development of candidate drugs with 2.8% to 5.7% probability of ultimate FDA approval would be justified. CONCLUSIONS tPA produces substantial health and economic benefits in the United States. Better thrombolytics for stroke could have substantial impact on society, and potential returns to developers would appear to justify greater investment in new candidates.
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Affiliation(s)
- S Claiborne Johnston
- Department of Neurology, University of California, San Francisco, CA 94143-0114, USA.
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Thurston SJ, Heeg B, de Charro F, van Hout B. Cost-effectiveness of clopidogrel in STEMI patients in the Netherlands: a model based on the CLARITY trial. Curr Med Res Opin 2010; 26:641-51. [PMID: 20070142 DOI: 10.1185/03007990903529267] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study assesses the costs and effects of combination treatment with clopidogrel and aspirin in comparison to aspirin alone in patients with an ST-segment elevation myocardial infarction (STEMI) in a Dutch setting. METHODS A decision tree model is used to combine data from different sources about efficacy, epidemiology and costs. In the short-run, cost-effectiveness is based on efficacy data derived from the CLARITY trial. The cost-effectiveness of continued treatment is addressed by analysing which conditions need to be fulfilled to deem the strategy 'cost-effective', and discussing whether it is likely that it is. Estimates concerning the benefits of preventing events are derived from Swedish registries. Approximations of both direct and indirect costs are derived from the literature. Effects are expressed as life years gained and Quality Adjust Life Years (QALYs). Uncertainties are addressed by uni- and multivariate sensitivity analyses with and without taking account of the dependency between the separate ischaemic events. RESULTS A treatment regimen similar to that of the CLARITY trial, including patients similar to those in the trial, is estimated to result in 0.05 additional life years and 0.062 additional quality adjusted life years for a cost that is euro1929 lower than aspirin therapy. Continuation of treatment outside the trial period is expected to result in ICERs of below euro20,000 per QALY as long as the real risk reduction of combination treatment is greater than 0.487% per year. CONCLUSION The results indicate that clopidogrel therapy combined with aspirin, according to the regimen seen in CLARITY, and using data from Swedish registries to inform the model, is cost-effective. Sensitivity analyses suggest that the model is robust to a wide range of parameter estimates, including those based on data from Swedish registries. Continued treatment is very likely to be cost effective in light of all the indirect evidence.
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Logman JFS, Heeg BMS, Herlitz J, van Hout BA. Costs and consequences of clopidogrel versus aspirin for secondary prevention of ischaemic events in (high-risk) atherosclerotic patients in Sweden: a lifetime model based on the CAPRIE trial and high-risk CAPRIE subpopulations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2010; 8:251-265. [PMID: 20578780 DOI: 10.2165/11535520-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Antiplatelet therapy plays a central role in the prevention of atherothrombotic events. Both acetylsalicylic acid (aspirin) and clopidogrel have been shown to reduce the risk of recurrent cardiovascular events in various subgroups of patients with vascular disease. OBJECTIVE To estimate the cost effectiveness of clopidogrel versus aspirin in Sweden for the prevention of atherothrombotic events based on CAPRIE trial data. The focus of this study is on two high-risk subpopulations: (i) patients with pre-existing symptomatic atherosclerotic disease; and (ii) patients with polyvascular disease. METHODS A Markov model combining clinical, epidemiological and cost data was used to assess the economic value of clopidogrel compared with aspirin during a patient's lifetime. A societal perspective was used, with costs stated in Swedish kronor (SEK), year 2007 values. For the first 2 years, the clinical input for the model was based on the relevant subpopulations in the CAPRIE trial. Thereafter, transition probabilities were extrapolated, taking account of increased risks related to age and to a history of events. Cost effectiveness of 2 years of therapy is presented as cost per life-year gained (LYG) and as cost per QALY. Univariate and multivariate sensitivity analyses were performed to investigate robustness of results. RESULTS For patients resembling the total CAPRIE population, who were treated with clopidogrel, the expected cost per LYG was SEK217,806 and the cost per QALY was estimated at SEK169,154. For the high-risk CAPRIE subpopulations, costs per QALY were lowest for patients with pre-existing symptomatic atherosclerotic disease (SEK38,153). Using a 'willingness-to-pay' perspective indicated that treatment with clopidogrel instead of aspirin in high-risk patients is associated with a high probability for cost effectiveness; 81% using a threshold of SEK100,000 per QALY and 98% using a threshold of SEK500,000 per QALY. Overall, the results appeared to be robust over the sensitivity analyses performed. CONCLUSION When considering the cost-effectiveness categorization as proposed by the Swedish National Board of Health and Welfare, clopidogrel appears to be associated with costs per QALY that range from intermediate in the total CAPRIE population to low in high-risk atherosclerotic patients.
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Giraldez RR, Wiviott SD, Nicolau JC, Mohanavelu S, Morrow DA, Antman EM, Giugliano RP. Streptokinase and Enoxaparin as an Alternative to Fibrin-Specific Lytic-Based Regimens. Drugs 2009; 69:1433-43. [PMID: 19634922 DOI: 10.2165/00003495-200969110-00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Earnshaw SR, Wilson M, Mauskopf J, Joshi AV. Model-based cost-effectiveness analyses for the treatment of acute stroke events: a review and summary of challenges. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:507-520. [PMID: 19900253 DOI: 10.1111/j.1524-4733.2008.00467.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To summarize the methodological approaches used in published decision-analytic models evaluating interventions for acute stroke treatment, to highlight key components of decision-analytic models of stroke treatment, and to discuss challenges for developing stroke decision models. METHODS A review of the published literature was performed using Medline, to identify studies involving mathematical decision models to evaluate interventions for acute stroke treatment. Articles were analyzed to determine key components of a stroke model and to note areas in which data are lacking. RESULTS We identified 13 published models of acute stroke treatment. These models typically possessed a short-term treatment module and a long-term post-treatment module. The following aspects of economic modeling were found to be relevant for developing a stroke model: modeling approach and health state; health state transition probabilities; estimation of short-term, long-term, and indirect costs; health state utilities; poststroke mortality; time horizon; model validation; and estimation of parameter uncertainty. CONCLUSIONS Data gaps have limited the development of economic models in stroke to date. In order to more accurately assess the long-term incremental impact of a new treatment of stroke, future research is needed to address these data gaps. We recommend that the complexity of models for examining the cost-effectiveness of an acute stroke treatment be kept to a minimum such that it can incorporate the currently available data without making a large number of assumptions around the data.
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Messori A, Trippoli S, Bonacchi M, Sani G. Left ventricular assist device as destination therapy: application of the payment-by-results approach for the device reimbursement. J Thorac Cardiovasc Surg 2009; 138:480-5. [PMID: 19619799 DOI: 10.1016/j.jtcvs.2009.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 01/10/2009] [Accepted: 02/12/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Value-based methods are increasingly used to reimburse therapeutic innovation, and the payment-by-results approach has been proposed for handling interventions with limited therapeutic evidence. Because most left ventricular assist devices are supported by preliminary efficacy data, we examined the effectiveness data of the HeartMate (Thoratec Corp, Pleasanton, CA) device to explore the application of the payment-by-results approach to these devices and to develop a model for handling reimbursements. METHODS According to our model, after establishing the societal economic countervalue for each month of life saved, each patient treated with one such device is associated to the payment of this countervalue for every month of survival lived beyond the final date of estimated life expectancy without left ventricular assist devices. Our base-case analysis, which used the published data of 68 patients who received the HeartMate device, was run with a monthly countervalue of euro 5000, no adjustment for quality of life, and a baseline life expectancy of 150 days without left ventricular assist devices. Sensitivity analysis was aimed at testing the effect of quality of life adjustments and changes in life expectancy without device. RESULTS In our base-case analysis, the mean total reimbursement per patient was euro 82,426 (range, euro 0 to euro 250,000; N = 68) generated as the sum of monthly payments. This average value was close to the current price of the HeartMate device (euro 75,000). Sensitivity testing showed that the base-case reimbursement of euro 82,426 was little influenced by variations in life expectancy, whereas variations in utility had a more pronounced impact. CONCLUSION Our report delineates an innovative procedure for appropriately allocating economic resources in this area of invasive cardiology.
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Affiliation(s)
- Andrea Messori
- Laboratory of Pharmacoeconomics, University Hospital of Careggi, Firenze, Italy.
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Levy WC, Mozaffarian D, Linker DT, Kenyon KW, Cleland JGF, Komajda M, Remme WJ, Torp-Pedersen C, Metra M, Poole-Wilson PA. Years-needed-to-treat to add 1 year of life: a new metric to estimate treatment effects in randomized trials. Eur J Heart Fail 2009; 11:256-63. [PMID: 19164422 PMCID: PMC2645057 DOI: 10.1093/eurjhf/hfn048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 11/11/2008] [Accepted: 11/11/2008] [Indexed: 01/13/2023] Open
Abstract
AIMS A standard metric to estimate absolute treatment effects is numbers-needed-to-treat (NNT), which implicitly assumes that all benefits reverse at trial-end. However, in-trial survival benefits typically do not reverse until long after trial-end, so that NNT will substantially underestimate lifetime benefits. METHODS AND RESULTS We developed a new concept, years-needed-to-treat (YNT) to add 1 year of life, that quantifies the expected average life expectancy for two treatments including the estimated years of life remaining post-trial. Numbers-needed-to-treat and YNT were calculated in the COMET trial, in which carvedilol vs. metoprolol tartrate resulted in 17% lower mortality over 4.8 years. A multivariate Cox model was used to predict survival. Remaining years of life were estimated using the mortality-life-table method. At trial-end, survival was 9% higher in the carvedilol arm. Assuming that patients remained on the same therapy post-trial, the average total years of life for carvedilol vs. metoprolol were 10.63 +/- 0.19 vs. 9.48 +/- 0.18 (P < 0.0001) or 1.15 (95% confidence interval 0.64-1.66) additional years of life. The YNT was 9.2, indicating that 9.2 person-years of treatment added 1 person-year of life, compared with NNT of 59. CONCLUSION Compared with NNT, the YNT method more accurately accounts for potential long-term benefits of interventions in randomized trials.
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Affiliation(s)
- Wayne C Levy
- Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA 98177, USA.
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Young N, Kinsella S, Raio CC, Nelson M, Chiricolo G, Johnson A, Malcolm G, Drumheller BC, Ward MF, Sama A. Economic impact of additional radiographic studies after registered diagnostic medical sonographer (RDMS)-certified emergency physician-performed identification of cholecystitis by ultrasound. J Emerg Med 2009; 38:645-51. [PMID: 19251389 DOI: 10.1016/j.jemermed.2008.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 08/06/2008] [Accepted: 10/09/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care. OBJECTIVE To determine the economic "opportunity" costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel. METHODS A retrospective analysis of a consecutive sample of patients with "positive" focused ED ultrasounds of the RUQ that were significant for cholecystitis, who presented from June 1, 2005 through February 30, 2006. Cost analysis was performed using standard Medicare compensation indices for radiological examinations of the abdomen/hepatobiliary system. RESULTS There were 37 patients enrolled; 32 patients exhibited RUQ pain with a focused ED ultrasound significant for cholecystitis. Eight (25%) patients received no further radiographic tests and exhibited positive pathology. Twenty-four (75%) patients had additional diagnostic examinations; 22 (92%) showed positive pathology. Based upon Medicare compensation indices, an opportunity cost of $6885.34 was incurred at our institution over 9 months due to additional examinations. Using nationally comparable indices, this was extrapolated to an opportunity cost of $63 million (95% confidence interval $48.3-$78.9 million) per year across the nation, assuming that 50% of patients with cholecystitis present to the ED and receive an ultrasound examination by an RDMS-certified Emergency Physician. CONCLUSIONS In this small sample, additional radiological testing after ED ultrasounds significant for acute cholecystitis led to sizable economic costs on a local and national level. Formal cost-benefit analyses are needed to evaluate the full economic and patient care implications of ED ultrasound use in this setting.
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Affiliation(s)
- Nicholas Young
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York 11030, USA
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Nelson CL, Sun JL, Tsiatis AA, Mark DB. Empirical estimation of life expectancy from large clinical trials: use of left-truncated, right-censored survival analysis methodology. Stat Med 2009; 27:5525-55. [PMID: 18613251 DOI: 10.1002/sim.3355] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In the current era of ever-increasing health care costs, economic analyses are an essential component in the comprehensive evaluation of new medical interventions. Cost-effectiveness analysis (CEA)--the most common form of economic analysis used in medicine--aids policy-makers in determining how to allocate finite health care dollars among possible alternative therapies. CEA relates the incremental benefits of a new technology to its incremental costs in a cost-effectiveness (CE) ratio. Although the generally agreed-upon standard of presentation for the CE ratio is the lifetime perspective (incremental lifetime cost to add one life year), this perspective presents an obvious challenge to the statistical analyst. Most large clinical trials collect limited follow-up data, and yet their findings form the basis of therapeutic recommendations that often extend far beyond the limits of the empirical data. Although clinical practice guidelines do not yet require explicit modeling to examine the long-term implications of their recommendations, health policy analyses routinely rely upon such extrapolations. This paper describes methods for using empirical patient-level data to extrapolate survival in large clinical trials and cohorts beyond a limited follow-up period in which most patients remain alive in order to estimate the entire survival distribution for a cohort of patients. We accomplish this task through a novel combination of models that estimate the hazard rate not only as a function of time but also as a function of patient age. Extrapolation of survival beyond a limited time frame is made possible by capitalizing on the extensive latitude of survival information available across the range of ages represented in the data. Variations in approach are presented, and issues arising in these analyses are discussed. The proposed methodology is developed, applied, and evaluated in both a large clinical trial cohort with 5-year follow-up on over 23,000 patients and a large observational database with long-term follow-up on over 4000 patients.
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Affiliation(s)
- Charlotte L Nelson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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Abstract
This randomized, double-blind trial in 311 patients with acute myocardial infarction has shown that very early therapy with anistreplase outside the hospital is not only feasible, but provides a major survival advantage. The difference in the median delay to treatment between the group treated in the hospital and those treated earlier was 2 1/4 h. After 30 months, mortality in the early group was less than half that in the later group, so that every hour of delay beyond 2 h resulted in almost 7 additional deaths per 100 patients treated. This is a greater percentage loss of life than would have resulted from a similar delay in the provision of resuscitation for the prehospital cardiac arrest. Multivariate analysis showed that age, treatment delay, and time of presentation were significant risk factors, with patients presenting at 1 h having more than twice the mortality of those presenting at 4 h; the sicker the patient, the earlier the presentation. By 5 years, prehospital administration of anistreplase, by saving 2 h, resulted in an additional 57% of a year's survival per patient. This compares favorably with the projected 14% of a year survival per patient reported with TPA versus streptokinase in GUSTO. Prehospital therapy with anistreplase was highly cost effective when compared with streptokinase given in hospital, and the marginal cost-effectiveness ratio was much lower than that for TPA versus streptokinase derived from GUSTO.
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Affiliation(s)
- J M Rawles
- Medicines Assessment Research Unit, University of Aberdeen, Foresterhill, Scotland, UK
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49
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Tan JM, Macario A. How to evaluate whether a new technology in the operating room is cost-effective from society's viewpoint. Anesthesiol Clin 2009; 26:745-64, viii. [PMID: 19041627 DOI: 10.1016/j.anclin.2008.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The hospital operating room is one of the most important and costly environments in health care. Given the current reductions in reimbursement and limited resources, hospital administrators and operating room managers have to be careful about adopting new technologies into the operating room. Operating rooms must balance the improved care a new technology can provide with its additional costs. Economic analysis provides systematic methods to guide decisions by quantitatively assessing the value of a new technology.
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Affiliation(s)
- Jonathan M Tan
- Stony Brook University School of Medicine, Health Sciences Center, Level 4, Stony Brook, NY 11794-2113, USA.
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50
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Lazzaro C, Bianchi C, Peracino L, Zacchetti P, Uccelli A. Economic evaluation of treating clinically isolated syndrome and subsequent multiple sclerosis with interferon β-1b. Neurol Sci 2009; 30:21-31. [DOI: 10.1007/s10072-009-0015-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 12/09/2008] [Indexed: 10/21/2022]
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