1
|
Silva A, Lalani J, James L, O'Donnell S, Amar-Zifkin A, Shemie SD, Zavalkoff S. Donor audits in deceased organ donation: a scoping review. Can J Anaesth 2024; 71:143-151. [PMID: 37910334 PMCID: PMC10858122 DOI: 10.1007/s12630-023-02613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance. SOURCE We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement. PRINCIPAL FINDINGS The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD. CONCLUSION Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.
Collapse
Affiliation(s)
- Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
- CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
| | - Jehan Lalani
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Lee James
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Shauna O'Donnell
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Sam D Shemie
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Samara Zavalkoff
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| |
Collapse
|
2
|
Burstein D, Kimmel S, Putt M, Rossano J, VanderPluym C, Ankola A, Lorts A, Maeda K, O'Connor M, Edelson J, Lin K, Buchholz H, Conway J. Cost-effectiveness of bivalirudin in pediatric ventricular assist devices. J Heart Lung Transplant 2023; 42:390-397. [PMID: 36333207 DOI: 10.1016/j.healun.2022.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/14/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Despite recent data suggesting improved outcomes with bivalirudin vs heparin in pediatric Ventricular assist devices (VAD), higher costs remain a barrier. This study quantified trends in bivalirudin use and compared outcomes, resource utilization, and cost-effectiveness associated with bivalirudin vs heparin. METHODS Children age 0 to 6 year who received VAD from 2009 to 2021 were identified in Pediatric Health Information System. Bivalirudin use was evaluated using trend analysis and outcomes were compared using Fine-Gray subdistrubtion hazard ratios (SHR). Daily-level hospital costs were compared due to differences in length of stay. Cost-effectiveness was evaluated using incremental cost-effectiveness ratio (ICER). RESULTS Of 691 pediatric VAD recipients (median age 1 year, IQR 0-2), 304 (44%) received bivalirudin with 90% receiving bivalirudin in 2021 (trend p-value <0.01). Bivalirudin had lower hospital mortality (26% vs 32%; adjusted SHR 0.57, 95% CI 0.40-0.83) driven by lower VAD mortality (20% vs 27%; adjusted SHR 0.46, 95% CI 0.32-0.77) after adjusting for year, age, diagnosis, and center VAD volume. Post-VAD length of stay was longer for bivalirudin than heparin (median 91 vs 64 days, respectively, p < 0.001). Median daily-level costs were lower among bivalirudin (cost ratio 0.87, 95% CI 0.79-0.96) with higher pharmacy costs offset by lower imaging, laboratory, supply, and room/board costs. Estimated ICER for bivalirudin vs heparin was $61,192 per quality-adjusted life year gained with a range of $27,673 to $131,243. CONCLUSIONS Bivalirudin use significantly increased over the past decade and is now used in 90% young pediatric VAD recipients. Bivalirudin was associated with significantly lower hospital mortality and an ICER <$65,000, making it a cost-effective therapy for pediatric VAD recipients.
Collapse
Affiliation(s)
- Danielle Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Stephen Kimmel
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainsville, Florida
| | - Mary Putt
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ashish Ankola
- Division of Cardiology, Texas Children's Hospital, Houston, Texas
| | - Angela Lorts
- Division of Cardiology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan Edelson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberly Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holger Buchholz
- Division of Cardiothoracic Surgery, University of Alberta, Edmonton, Alberta, California
| | - Jennifer Conway
- Division of Cardiology, University of Alberta, Edmonton, Alberta, California
| |
Collapse
|
3
|
Pathophysiology of heart failure and an overview of therapies. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
4
|
Silva E Silva V, Schirmer J, Roza BD, de Oliveira PC, Dhanani S, Almost J, Schafer M, Tranmer J. Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review. Can J Kidney Health Dis 2021; 8:2054358121992921. [PMID: 33680483 PMCID: PMC7897821 DOI: 10.1177/2054358121992921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/22/2020] [Indexed: 12/19/2022] Open
Abstract
Background Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes. Objective To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes. Design Scoping Review using a mixed methods approach for data extraction. Setting Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused. Sample Organ donation programs or processes. Methods We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results. Results A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%). Limitations Consistent with scoping review methodology, the methodological quality of included studies was not assessed. Conclusions This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically. Trial Registration Not applicable.
Collapse
Affiliation(s)
| | | | | | | | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Joan Almost
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Markus Schafer
- Department of Sociology, University of Toronto, ON, Canada
| | - Joan Tranmer
- School of Nursing, Queen's University, Kingston, ON, Canada
| |
Collapse
|
5
|
Evers PD, Villa C, Wittekind SG, Hobing R, Morales DLS, Lorts A. Cost-utility of continuous-flow ventricular assist devices as bridge to transplant in pediatrics. Pediatr Transplant 2019; 23:e13576. [PMID: 31535775 DOI: 10.1111/petr.13576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/02/2019] [Accepted: 08/09/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The initial costs of a CF-VAD exceed those of a PF-VAD. However, the safety profile of CF-VAD is superior and the possibility of outpatient device support may justify the additional initial costs. This study analyzed the cost-utility of CF-VAD use in the pediatric population. METHODS A Markov-state transition model was constructed for the clinical course of the two VAD subtypes from implantation until death with variables extracted from internal financial records and the published literature. The modeled population consisted of pediatric heart failure patients who met indications for VAD implant (INTERMACS profile 1 or 2) and were size-eligible for either a PF-VAD or CF-VAD. RESULTS The cost-utility analysis illustrated that CF-VAD is both more effective and less costly compared to PF-VAD at base-case conditions. Sensitivity analyses demonstrated that only in extreme conditions did a CF-VAD strategy not meet criteria for cost-effectiveness (if readmission rate >20% weekly, neurologic event rate >8% weekly, or CF-VAD discharge rates <18% in a month) or VAD support duration shortens to ≤12 weeks. CONCLUSION While the implantation costs of a CF-VAD exceed those of a PF-VAD, after 12 weeks of device support CF-VAD becomes the more cost-effective strategy if the anticipated outpatient device care is sufficiently long. The cost efficacy of the CF-VAD will be further heightened as initiatives that result in earlier and safer discharges, as well as reductions in readmission rates continue to be successful.
Collapse
Affiliation(s)
- Patrick D Evers
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Chet Villa
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel G Wittekind
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rebecca Hobing
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Angela Lorts
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
6
|
Evers PD, Anderson JB, Ryan TD, Czosek RJ, Knilans TK, Spar DS. Wearable cardioverter-defibrillators in pediatric cardiomyopathy: A cost-utility analysis. Heart Rhythm 2019; 17:287-293. [PMID: 31476408 DOI: 10.1016/j.hrthm.2019.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization. OBJECTIVE The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement. METHODS A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year. RESULTS The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions. CONCLUSION Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.
Collapse
Affiliation(s)
- Patrick D Evers
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey B Anderson
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Thomas D Ryan
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard J Czosek
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Timothy K Knilans
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Spar
- Children's Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
7
|
Kramer AH, Hornby K, Doig CJ, Armstrong D, Grantham L, Kashuba S, Couillard PL, Kutsogiannis DJ. Deceased organ donation potential in Canada: a review of consecutive deaths in Alberta. Can J Anaesth 2019; 66:1347-1355. [PMID: 31240610 DOI: 10.1007/s12630-019-01437-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/22/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Transplantation is the most effective treatment for many patients with end-stage organ failure. There is a gap between the number of patients who would benefit from transplantation and availability of organs. We assessed maximum potential for deceased donation in Alberta and barriers to increasing the donation rate. METHODS All deaths that occurred in Alberta in 2015 in areas where mechanical ventilation could be provided were retrospectively identified using administrative data. Medical records were reviewed by donation coordinators and critical care physicians with expertise in donation, using a standardized tool to determine whether deceased patients could potentially have been organ donors. RESULTS There were 2,706 deaths occurring in either an intensive care unit or emergency department, of which 1,252 were attributable to a non-neurologic cause: 946 involved cardiac arrests with unsuccessful resuscitation, and 57 were not mechanically ventilated. Of the remaining 451 deaths, 117 (28 donors per million population [dpmp]) either were, or could potentially have been, organ donors after neurologic determination of death (NDD). Of these, 19 (4.5 dpmp) were not appropriately identified or referred, and 45 approached families (10.8 dpmp) did not provide consent. Non-identified NDD cases accounted for a larger proportion of deaths due to neurologic causes in emergency departments (18%) than in intensive care units (2%) (P < 0.0001) and in rural (9%) compared with urban centres (3%) (P = 0.05). If routinely available, donation after circulatory death (DCD) could potentially have been possible in as many as 113 (27 dpmp) cases. CONCLUSIONS Maximum deceased organ donation potential in Alberta is approximately 55 dpmp. The current donation rate has potential to increase with more widespread availability of DCD and a higher consent rate.
Collapse
Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine & Clinical Neurosciences, University of Calgary, 3132 Hospital Drive NW, Calgary, AB, Canada.
| | - Karen Hornby
- Research Support Services Program, Trillium Gift of Life Network, Toronto, ON, Canada
| | - Christopher J Doig
- Departments of Critical Care Medicine & Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Laura Grantham
- Alberta Organ & Tissue Donation Program, Calgary, AB, Canada
| | - Sherri Kashuba
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Philippe L Couillard
- Departments of Critical Care Medicine & Clinical Neurosciences, University of Calgary, 3132 Hospital Drive NW, Calgary, AB, Canada
| | | |
Collapse
|
8
|
Burch M, Nallagangula TK, Nic Lochlainn E, Severin T, Thakur L, Jaecklin T, George AT, Solar-Yohay S, Rossano JW, Shaddy RE. Systematic literature review on the economic, humanistic, and societal burden of heart failure in children and adolescents. Expert Rev Pharmacoecon Outcomes Res 2019; 19:397-408. [PMID: 30747011 DOI: 10.1080/14737167.2019.1579645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Unlike the adult heart failure (HF) patient population, there is scarce information on the overall burden of HF in the pediatric population across geographies and within different age groups. AREAS COVERED A systematic review aims to describe and quantify the economic, humanistic, and societal burden of pediatric (age <18 years) HF on patients and caregivers. Eighteen published studies over a period of 10 years (1 January 2006-20 May 2016) were identified through Embase, Medline, Cochrane Library and selected congresses. Studies from the US reported higher HF-related hospitalization-rates in infants aged <1 year (49.3%-63.9%) versus children aged 1-12 years (18.7%-30.9%) in HF diagnosed patients. Across the studies, the average length of hospital stay was 15 days, increasing to 26 days for infants. Average annual hospital charges were higher for infants (US$176,000) versus children aged 1-10 years (US$132,000) in the US. In Germany, diagnosis-related group (DRG)-based hospital-allowances per HF-case increased from €3,498 in 1995 to €4,250 in 2009. EXPERT OPINION To our knowledge, this is the first systematic review, which provides valuable insights into the burden of HF in children and adolescents, and strengthens current knowledge of pediatric HF. However, there is a need for larger population-based studies with wider geographical coverage.
Collapse
Affiliation(s)
- Michael Burch
- a Cardiorespiratory Division , Great Ormond Street Hospital for Children , London , UK
| | | | | | - Thomas Severin
- d Cardio-Metabolic Development Unit , Novartis Pharma AG , Basel , Switzerland
| | - Lalit Thakur
- b Health Economics and Outcomes Research , Novartis Healthcare Pvt. Ltd , Hyderabad , India
| | - Thomas Jaecklin
- e Global Clinical Development , Mirum Pharmaceuticals AG , Basel , Switzerland
| | - Aneesh Thomas George
- b Health Economics and Outcomes Research , Novartis Healthcare Pvt. Ltd , Hyderabad , India
| | - Susan Solar-Yohay
- f Cardio-Metabolic Development Unit , Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | - Joseph W Rossano
- g Pediatric Cardiology, Children's Hospital of Philadelphia , University of Pennsylvania Perelman School of Medicine , Philadelphia, PA , USA
| | - Robert E Shaddy
- h Pediatric Cardiology , Children's Hospital Los Angeles and Keck School of Medicine of USC , Los Angeles, CA , USA
| |
Collapse
|
9
|
Godown J, Thurm C, Hall M, Dodd DA, Feingold B, Soslow JH, Mettler BA, Smith AH, Bearl DW, Schumacher KR. Center Variation in Hospital Costs for Pediatric Heart Transplantation: The Relationship Between Cost and Outcomes. Pediatr Cardiol 2019; 40:357-365. [PMID: 30343331 PMCID: PMC6494458 DOI: 10.1007/s00246-018-2011-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022]
Abstract
There are limited published data addressing the costs associated with pediatric heart transplantation and no studies evaluating the variation in costs across centers. We aimed to describe center variation in pediatric heart transplant costs and assess the association of transplant hospitalization costs with patient outcomes. Using a linkage between the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases, hospital costs were assessed for patients (< 18 years of age) undergoing heart transplantation (2007-2016). Severity-adjusted patient costs were calculated using generalized linear mixed-effects models with a random hospital intercept. Center variation in hospital cost was described after adjusting for the predicted risk of in-hospital mortality. Post-transplant survival was compared between low- and high-cost centers using Cox proportional hazard models. A total of 2156 patients were included from 24 centers. There was 3.7-fold variation in transplant hospitalization costs across centers, ranging from $329,477 to $1,226,507. Patients transplanted at high-cost centers have a higher predicted risk of in-hospital mortality (8.1% vs. 6.1%, p < 0.001). Both early (p = 0.008) and long-term (p = 0.003) post-transplant survival were better in patients transplanted at low-cost centers. Transplant at low-cost centers was associated with improved post-transplant survival, independent of patient-specific risk (adjusted hazard ratio 0.72; 95%CI 0.57-0.92, p = 0.008). There is wide variation in cost for pediatric heart transplant inpatient care among U.S. centers with low-cost centers demonstrating the best patient survival. Differences in patient populations likely contribute to these findings, but cannot account for all the variation seen. This suggests that variability in the delivery of care across centers may influence post-transplant survival.
Collapse
Affiliation(s)
- Justin Godown
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA.
| | - Cary Thurm
- Children's Hospital Association, Lenexa, KS, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Debra A Dodd
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Brian Feingold
- Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan H Soslow
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Bret A Mettler
- Pediatric Cardiothoracic Surgery, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Andrew H Smith
- Pediatric Critical Care, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - David W Bearl
- Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, TN, USA
| | - Kurt R Schumacher
- Pediatric Cardiology, C.S. Mott Children's Hospital, The University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
10
|
Ye XT, Parker A, Brink J, Weintraub RG, Konstantinov IE. Cost-effectiveness of the National Pediatric Heart Transplantation Program in Australia. J Thorac Cardiovasc Surg 2018; 157:1158-1166.e2. [PMID: 30578063 DOI: 10.1016/j.jtcvs.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/26/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Cost data for pediatric heart transplantation are scarce. We examined hospital cost of the national pediatric heart transplantation program in Australia and assessed factors associated with increased costs. METHODS The hospital cost of all children who underwent heart transplantation at a national referral center between January 2003 and June 2015 and were followed more than 1 year was retrospectively analyzed. Lifetime follow-up costs were adjusted for quality of life and projected to life expectancy. All costs were reported in 2016 US dollars. RESULTS Of 70 children who underwent heart transplantation in the study period, 61 were followed more than 1 year after transplantation (mean, 4.3 ± 2.5 years). Mean cost of primary heart transplantation was $278,480 (95% confidence interval, 219,282-337,679) and did not change over time. Pretransplant mechanical circulatory support was required in 36% (22/61) of children. On multivariable analysis, greater admission costs were associated with ventricular assist device and pretransplant length of stay. Mean annual follow-up cost after discharge was $55,823 (95% confidence interval, 47,631-64,015) in the first year and $12,119 (95% confidence interval, 8578-15,661) thereafter. Increased first-year follow-up costs were associated with endomyocardial biopsies and length of readmissions. Cost per quality-adjusted life-year gained varied from $29,161 to $44,481 on sensitivity analysis. Freedom from treated rejections was 65.5% at 1 year, 63.2% at 3 years, and 59.5% at 5 years. Endomyocardial biopsies contributed to 52% of first-year follow-up costs. CONCLUSIONS Primary pediatric heart transplantation in Australia is cost-effective for long-term survivors, even for those supported by ventricular assist device. Surveillance endomyocardial biopsy was a major contributor to post-transplantation costs. Selective targeting of surveillance biopsies may be cost-saving.
Collapse
Affiliation(s)
- Xin Tao Ye
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Alice Parker
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Johann Brink
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Robert G Weintraub
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Department of Cardiology, Royal Children's Hospital, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| |
Collapse
|
11
|
Sharma D, Xing S, Hung YT, Caskey RN, Dowell ML, Touchette DR. Cost-effectiveness analysis of lumacaftor and ivacaftor combination for the treatment of patients with cystic fibrosis in the United States. Orphanet J Rare Dis 2018; 13:172. [PMID: 30268148 PMCID: PMC6162947 DOI: 10.1186/s13023-018-0914-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/12/2018] [Indexed: 01/12/2023] Open
Abstract
Background Lumacaftor/ivacaftor was approved by the Food and Drug Administration (FDA) as a combination treatment for Cystic Fibrosis (CF) patients who are homozygous for the F508del mutation. The objective of this study was to assess the cost-effectiveness of lumacaftor/ivacaftor combination for the treatment of CF homozygous for F508del CF Transmembrane Conductance Regulator (CFTR) mutation. Methods A Markov-state transition model following a cohort of 12 year-old CF patients homozygous for F508del CFTR mutation in the United States (US) over two, four, six, eight and ten years from a payer’s perspective was developed using TreeAge Pro 2016. Markov states included: mild (percentage of predicted forced expiratory volume in 1 s or FEV1 > 70%), moderate (FEV1 40–70%), severe (FEV1 < 40%) disease, post-transplant, and death. Pulmonary exacerbation and lung transplant were included as transition states. All the input parameters were estimated from the literature. A 1-year cycle length and 3% discount rate were applied. To assess uncertainty in long-term treatment effects, several scenarios were modelled: 100% long-term effectiveness (base-case), defined as improvement in FEV1 in the first year followed by no annual FEV1 decline and a constant reduction in pulmonary exacerbations throughout, 75%, 50%, 25% and 0% (worst case) long-term effectiveness, where treatment effects were intermediate from the second year of treatment until the end of the time horizon. Other scenarios included changing the starting age of the cohort to 6 and 25 years. Primary outcome included incremental cost-effectiveness ratio (ICER) in terms of cost per quality adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were performed to determine uncertainty. Results Under the base-case, Lumacaftor/ivacaftor resulted in higher QALYs (7.29 vs 6.84) but at a very high cost ($1,778,920.88) compared to usual care ($116,155.76) over a 10-year period. The ICER for base-case and worst-case scenarios were $3,655,352 / QALY, and $8,480,265/QALY gained, respectively. In the base-case, lumacaftor/ivacaftor was cost-effective at a threshold of $150,000/QALY-gained when annual drug costs were lower than $4153. The results were not substantially affected by the sensitivity analyses. Conclusions The intervention produces large QALY gains but at an extremely high cost, resulting in an ICER that would not typically be covered by any insurer. Lumacaftor/ivacaftor’s status as an orphan drug complicates coverage decisions.
Collapse
Affiliation(s)
- Dolly Sharma
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Shan Xing
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Yu-Ting Hung
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Rachel N Caskey
- Departments of Internal Medicine and Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
| | - Maria L Dowell
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, The University of Chicago, Chicago, IL, USA
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
| |
Collapse
|
12
|
Boucek DM, Lal AK, Eckhauser AW, Weng HYC, Sheng X, Wilkes JF, Pinto NM, Menon SC. Resource Utilization for Initial Hospitalization in Pediatric Heart Transplantation in the United States. Am J Cardiol 2018. [PMID: 29523228 DOI: 10.1016/j.amjcard.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pediatric heart transplantation (HT) is resource intensive. Event-driven pediatric databases do not capture data on resource use. The objective of this study was to evaluate resource utilization and identify associated factors during initial hospitalization for pediatric HT. This multicenter retrospective cohort study utilized the Pediatric Health Information Systems database (43 children's hospitals in the United States) of children ≤19 years of age who underwent transplant between January 2007 and July 2013. Demographic variables including site, payer, distance and time to center, clinical pre- and post-transplant variables, mortality, cost, and charge were the data collected. Total length of stay (LOS) and charge for the initial hospitalization were used as surrogates for resource use. Charges were inflation adjusted to 2013 dollars. Of 1,629 subjects, 54% were male, and the median age at HT was 5 years (IQR [interquartile range] 0 to 13). The median total and intensive care unit LOS were 51 (IQR 23 to 98) and 23 (IQR 9 to 58) days, respectively. Total charge and cost for hospitalization were $852,713 ($464,900 to $1,609,300) and $383,600 ($214,900 to $681,000) respectively. Younger age, lower volume center, southern region, and co-morbidities before transplant were associated with higher resource use. In later years, charges increased despite shorter LOS. In conclusion, this large multicenter study provides novel insight into factors associated with resource use in pediatric patients having HT. Peritransplant morbidities are associated with increased cost and LOS. Reducing costs in line with LOS will improve health-care value. Regional and center volume differences need further investigation for optimizing value-based care and efficient use of scarce resources.
Collapse
|
13
|
West SC, Webber SA, Zeevi A, Miller SA, Morell VO, Feingold B. Charges and resource utilization for pediatric heart transplantation across a positive virtual and/or cytotoxicity crossmatch. Pediatr Transplant 2018; 22. [PMID: 29250877 DOI: 10.1111/petr.13095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2017] [Indexed: 02/06/2023]
Abstract
There is growing acceptance of transplantation across a positive crossmatch for highly allosensitized pediatric HT candidates. While survival may be similar to patients transplanted across a negative crossmatch, costs are unknown. Among 60 HT recipients at our center from 5/07 to 6/12, we analyzed hospital charges and length of stay from the day of HT to discharge and through the first year after transplant. Median age at HT was 6.2 years (15 days-20.5 years). Charges in the first year post-HT were greater for crossmatch-positive patients ($907 678 vs $549 754; P = .017), with a trend toward higher charges for the HT hospitalization ($537 640 vs $407 374; P = .07). Plasmapheresis was more common in crossmatch-positive patients during the HT hospitalization (80% vs 4%, P < .001). In the first year after HT, crossmatch-positive patients had a greater number of endomyocardial biopsies (10 vs 7.5, P = .03) and episodes of treated rejection (2 vs 0, P = .004). Pediatric HT across a positive crossmatch is associated with higher first-year costs, including increased use of plasmapheresis and care around an increased number of rejections. These novel data will help inform decision and policymaking regarding care practices for the growing population of highly sensitized pediatric HT candidates.
Collapse
Affiliation(s)
- Shawn C West
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Steven A Webber
- Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Adriana Zeevi
- Transplant Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan A Miller
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Victor O Morell
- Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Brian Feingold
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.,Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Godown J, Thurm C, Dodd DA, Soslow JH, Feingold B, Smith AH, Mettler BA, Thompson B, Hall M. A unique linkage of administrative and clinical registry databases to expand analytic possibilities in pediatric heart transplantation research. Am Heart J 2017; 194:9-15. [PMID: 29223439 DOI: 10.1016/j.ahj.2017.08.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Large clinical, research, and administrative databases are increasingly utilized to facilitate pediatric heart transplant (HTx) research. Linking databases has proven to be a robust strategy across multiple disciplines to expand the possible analyses that can be performed while leveraging the strengths of each dataset. We describe a unique linkage of the Scientific Registry of Transplant Recipients (SRTR) database and the Pediatric Health Information System (PHIS) administrative database to provide a platform to assess resource utilization in pediatric HTx. METHODS All pediatric patients (1999-2016) who underwent HTx at a hospital enrolled in the PHIS database were identified. A linkage was performed between the SRTR and PHIS databases in a stepwise approach using indirect identifiers. To determine the feasibility of using these linked data to assess resource utilization, total and post-HTx hospital costs were assessed. RESULTS A total of 3188 unique transplants were identified as being present in both databases and amenable to linkage. Linkage of SRTR and PHIS data was successful in 3057 (95.9%) patients, of whom 2896 (90.8%) had complete cost data. Median total and post-HTx hospital costs were $518,906 (IQR $324,199-$889,738), and $334,490 (IQR $235,506-$498,803) respectively with significant differences based on patient demographics and clinical characteristics at HTx. CONCLUSIONS Linkage of the SRTR and PHIS databases is feasible and provides an invaluable tool to assess resource utilization. Our analysis provides contemporary cost data for pediatric HTx from the largest US sample reported to date. It also provides a platform for expanded analyses in the pediatric HTx population.
Collapse
|
15
|
Nandi D, Rossano JW, Wang Y, Jerrell JM. Risk Factors for Heart Failure and Its Costs Among Children with Complex Congenital Heart Disease in a Medicaid Cohort. Pediatr Cardiol 2017; 38:1672-1679. [PMID: 28852817 DOI: 10.1007/s00246-017-1712-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/09/2017] [Indexed: 01/05/2023]
Abstract
Little research attention has been paid to the occurrence of heart failure (HF) in children with complex congenital heart diseases (CHDs). Herein, we describe the prevalence, risk factors, and costs associated with HF in complex CHD. Patients aged ≤17 years and diagnosed with a complex CHD on multiple service visits over a 15-year period in the SC Medicaid dataset (1996-2010) were tracked and analyzed. The cohort included 2999 unduplicated patients; 51.0% were male; 34.4% were African American. HF was diagnosed in 7.6%. Single ventricle lesions, genetic syndromes, and ventricular arrhythmia were significantly associated with an increased likelihood of being diagnosed with HF, controlling for development of comorbid pulmonary hypertension. Patients with HF received significantly more subspecialty care, more surgeries, more hospitalizations, more total days of inpatient care, and more emergency department care than those without HF. Patients with significantly higher total care costs paid by Medicaid had HF, more cardiac surgeries, and more specialized mechanical or other support procedures, controlling for diagnosed single ventricle CHD, a genetic syndrome, and number of non-cardiac surgeries. Complex CHD patients with HF incur significantly higher care costs but require multifaceted, intensive supports for management of incident complications and comorbid conditions.
Collapse
Affiliation(s)
- Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph W Rossano
- The Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yinding Wang
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Jeanette M Jerrell
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC, 29203, USA.
| |
Collapse
|
16
|
Wittlieb-Weber CA, Rossano JW, Weber DR, Lin KY, Ravishankar C, Mascio CE, Shaddy RE, O'Connor MJ. Emergency department utilization in pediatric heart transplant recipients. Pediatr Transplant 2017; 21. [PMID: 28455909 DOI: 10.1111/petr.12936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 11/28/2022]
Abstract
We used the NEDS database (2010) to evaluate ED utilization in PED HT recipients compared to other patient populations with focus on characteristics of ED visits, risk factors for admission, and charges. We analyzed 433 ED visits by PED HT recipients (median age 8 [range: 0-18] years). The most common primary diagnosis category was infectious (n=163, 37.6%), with pneumonia being the most common infectious etiology. When compared to all PED visits, HT visits were more likely to result in hospital admission (32.6% versus 3.9%, P<.001), had greater hospital LOS (median of 3 days [IQR 2-4] versus 2 days [IQR 1-4], P=.001), and accumulated greater total hospital charges (median $26 317 [IQR $11 438-$46 407] versus $12 332 [IQR $7092-$22 583], P<.001). When compared to visits by other SOT recipients, results varied with similar rates of hospital admission for HT, LUNGT, and KT visits and similar LOS for HT and KT visits but differing total hospital charges. Although PED HT recipients account for a small percentage of overall ED visits, they are more likely to be hospitalized and require greater resource utilization compared to the general PED population, but not when compared to other SOT recipients.
Collapse
Affiliation(s)
- Carol A Wittlieb-Weber
- Division of Pediatric Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Joseph W Rossano
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - David R Weber
- Division of Pediatric Endocrinology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kimberly Y Lin
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Shaddy
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew J O'Connor
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
17
|
Yam N, McMullan DM. Extracorporeal cardiopulmonary resuscitation. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:72. [PMID: 28275617 DOI: 10.21037/atm.2017.01.11] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Extracorporeal life support (ECLS) is used for patients in isolated or combined cardiopulmonary failures. The use of ECLS to rescue patients with cardiac arrest that is refractory to conventional cardiopulmonary resuscitation has been shown to improve survival in many patient populations. Increasing recognition of the survival benefit associated with extracorporeal cardiopulmonary resuscitation (ECPR) has led to increased use of ECPR during the past decade. This review provides an overview of ECPR utilization; population-based clinical outcomes, resource utilization and costs associated this advanced form of life support therapy.
Collapse
Affiliation(s)
- Nicholson Yam
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | | |
Collapse
|
18
|
Berthiaume J, Kirk J, Ranek M, Lyon R, Sheikh F, Jensen B, Hoit B, Butany J, Tolend M, Rao V, Willis M. Pathophysiology of Heart Failure and an Overview of Therapies. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00008-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
|
19
|
Abstract
Heart failure in children is a complex disease process, which can occur secondary to a variety of aetiologies, including CHD, cardiomyopathy, or acquired conditions as well. Although the overall incidence of disease is low, the associated morbidity and mortality are high. Mortality may have decreased slightly over the last decade, and this is likely due to our ability to shepherd patients through longer periods of significant morbidity, with lasting effects. Costs of heart failure are significant - on the order of $1 billion annually as hospital charges for inpatient admissions alone. The value, or benefit to patient life and quality of life at this cost, is not well delineated. Further research is needed to optimise not only outcomes for these patients but also the high costs associated with them.
Collapse
Affiliation(s)
- Deipanjan Nandi
- Cardiac Center, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Joseph W. Rossano
- Cardiac Center, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| |
Collapse
|
20
|
Feingold B, Webber SA, Bryce CL, Park SY, Tomko HE, West SC, Hart SA, Mahle WT, Smith KJ. Cost-effectiveness of pediatric heart transplantation across a positive crossmatch for high waitlist urgency candidates. Am J Transplant 2015; 15:2978-85. [PMID: 26082322 PMCID: PMC4876705 DOI: 10.1111/ajt.13342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/25/2015] [Accepted: 04/05/2015] [Indexed: 01/25/2023]
Abstract
Allosensitized children listed with a requirement for a negative prospective crossmatch have high mortality. Previously, we found that listing with the intent to accept the first suitable organ offer, regardless of the possibility of a positive crossmatch (TAKE strategy), results in a survival advantage from the time of listing compared to awaiting transplantation across a negative crossmatch (WAIT). The cost-effectiveness of these strategies is unknown. We used Markov modeling to compare cost-effectiveness between these waitlist strategies for allosensitized children listed urgently for heart transplantation. We used registry data to estimate costs and waitlist/posttransplant outcomes. We assumed patients remained in hospital after listing, no positive crossmatches for WAIT, and a base-case probability of a positive crossmatch of 47% for TAKE. Accepting the first suitable organ offer cost less ($405 904 vs. $534 035) and gained more quality-adjusted life years (3.71 vs. 2.79). In sensitivity analyses, including substitution of waitlist data from children with unacceptable antigens specified during listing, TAKE remained cost-saving or cost-effective. Our findings suggest acceptance of the first suitable organ offer for urgently listed allosensitized pediatric heart transplant candidates is cost-effective and transplantation should not be denied because of allosensitization status alone.
Collapse
Affiliation(s)
- B Feingold
- Pediatric Cardiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA,Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - SA Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - CL Bryce
- Health Policy Management, University of Pittsburgh School of Public Health. Pittsburgh, PA
| | - SY Park
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - HE Tomko
- Health Policy Management, University of Pittsburgh School of Public Health. Pittsburgh, PA
| | - SC West
- Pediatric Cardiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - SA Hart
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - WT Mahle
- Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - KJ Smith
- Section of Decision Sciences and Clinical Systems Modeling, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
21
|
A Novel Quality-of-Life Utility Index in Patients With Multilevel Cervical Degenerative Disc Disease: Comparison of Anterior Cervical Discectomy and Fusion With Total Disc Replacement. Spine (Phila Pa 1976) 2015; 40:1072-8. [PMID: 25811263 DOI: 10.1097/brs.0000000000000898] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Decision analysis from prior randomized controlled trial (RCT) data. OBJECTIVE To describe the importance of developing baseline utility indices while identifying effective treatment options for cervical spine disease. SUMMARY OF BACKGROUND DATA Cervical total disc replacement (CTDR) was developed to treat cervical spondylosis while preserving motion. Although anterior cervical discectomy and fusion (ACDF) has been the standard of care, a recent RCT suggested similar outcomes for 2-level disease. The quality-of-life benefit afforded by both CTDR and ACDF has never been fully elucidated. The purpose of our investigation was to better define the changes in utility and perceived value for patients undergoing these procedures. METHODS Data were derived from LDR's RCT comparing CTDR and ACDF for 2-level cervical disc disease. Using linear regression, we constructed health states on the basis of the stratification of clinical outcomes used in the RCT, namely, neck disability index and visual analogue scale. Data from SF-12 questionnaires, completed preoperatively and at each follow-up visit, were transformed into utilities using the SF-6D mapping algorithm. SAS v.9.3 was used for the analyses. RESULTS A strong correlation (R = 0.6864, P < 0.0001) was found between neck disability index and visual analogue scale. We constructed 5 distinct health states by projecting neck disability index intervals onto visual analogue scale. A poorer health state was associated with a lower mean utility value whereas a higher health state was associated with a higher mean utility value (P < 0.0001). The difference in preoperative utility between 2-level ACDF and CTDR was not significant (P = 0.1982), and yet, the difference in the postoperative utility between the cohorts was significant (P < 0.05) at every time point collected from 6 to 60 months. CONCLUSION This is the first instance in which distinct utility values have been derived for validated health states related to cervical spine disease. There is substantial potential for these to become baseline future indices for cost-utility analyses in similar populations. LEVEL OF EVIDENCE 1.
Collapse
|
22
|
Miller JR, Eghtesady P. Ventricular assist device use in congenital heart disease with a comparison to heart transplant. J Comp Eff Res 2015; 3:533-46. [PMID: 25350804 DOI: 10.2217/cer.14.42] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Despite advances in medical and surgical therapies, some children with congenital heart disease (CHD) are not able to be adequately treated or palliated, leading them to develop progressive heart failure. As these patients progress to end-stage heart failure they pose a unique set of challenges. Heart transplant remains the standard of care; the donor pool, however, remains limited. Following the experience from the adult realm, the pediatric ventricular assist device (VAD) has emerged as a valid treatment option as a bridge to transplant. Due to the infrequent necessity and the uniqueness of each case, the pediatric VAD in the CHD population remains a topic with limited information. Given the experience in the adult realm, we were tasked with reviewing pediatric VADs and their use in patients with CHD and comparing this therapy to heart transplantation when possible.
Collapse
Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO 63110, USA
| | | |
Collapse
|
23
|
Feingold B, Webber SA, Bryce CL, Park SY, Tomko HE, Comer DM, Mahle WT, Smith KJ. Comparison of listing strategies for allosensitized heart transplant candidates requiring transplant at high urgency: a decision model analysis. Am J Transplant 2015; 15:427-35. [PMID: 25612495 PMCID: PMC4888902 DOI: 10.1111/ajt.13071] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/11/2014] [Accepted: 09/21/2014] [Indexed: 01/25/2023]
Abstract
Allosensitized children who require a negative prospective crossmatch have a high risk of death awaiting heart transplantation. Accepting the first suitable organ offer, regardless of the possibility of a positive crossmatch, would improve waitlist outcomes but it is unclear whether it would result in improved survival at all times after listing, including posttransplant. We created a Markov decision model to compare survival after listing with a requirement for a negative prospective donor cell crossmatch (WAIT) versus acceptance of the first suitable offer (TAKE). Model parameters were derived from registry data on status 1A (highest urgency) pediatric heart transplant listings. We assumed no possibility of a positive crossmatch in the WAIT strategy and a base-case probability of a positive crossmatch in the TAKE strategy of 47%, as estimated from cohort data. Under base-case assumptions, TAKE showed an incremental survival benefit of 1.4 years over WAIT. In multiple sensitivity analyses, including variation of the probability of a positive crossmatch from 10% to 100%, TAKE was consistently favored. While model input data were less well suited to comparing survival when awaiting transplantation across a negative virtual crossmatch, our analysis suggests that taking the first suitable organ offer under these circumstances is also favored.
Collapse
Affiliation(s)
- Brian Feingold
- Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC,Clinical and Translational Research, University of Pittsburgh
| | - Steven A. Webber
- Department of Pediatrics, Vanderbilt University School of Medicine
| | - Cindy L. Bryce
- Health Policy Management, University of Pittsburgh School of Public Health
| | | | - Heather E. Tomko
- Health Policy Management, University of Pittsburgh School of Public Health
| | - Diane M. Comer
- Center for Research on Health Care Data Center, University of Pittsburgh
| | - William T. Mahle
- Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine
| | - Kenneth J. Smith
- Section of Decision Sciences and Clinical Systems Modeling, Department of Medicine, University of Pittsburgh School of Medicine
| |
Collapse
|
24
|
Partridge JC, Robertson KR, Rogers EE, Landman GO, Allen AJ, Caughey AB. Resuscitation of neonates at 23 weeks' gestational age: a cost-effectiveness analysis. J Matern Fetal Neonatal Med 2014; 28:121-30. [PMID: 24684658 DOI: 10.3109/14767058.2014.909803] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation. DESIGN Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100 000/QALY was utilized. RESULTS Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127 844 mQALYs) than universal resuscitation ($1.2 billion; 126 574 mQALYs) or selective resuscitation ($845 million; 125 966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22 256 and 15 134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95. CONCLUSIONS Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.
Collapse
Affiliation(s)
- J Colin Partridge
- Department of Pediatrics, Center for Clinical and Policy Perinatal Research, University of California San Francisco , San Francisco, CA , USA
| | | | | | | | | | | |
Collapse
|
25
|
Luk A, Ross HJ. "Please Sir, I want some more?"… Charles Dickens, Oliver Twist. J Heart Lung Transplant 2014; 33:231-2. [PMID: 24559942 DOI: 10.1016/j.healun.2013.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022] Open
Affiliation(s)
- Adriana Luk
- Department of Medicine, Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Heather J Ross
- Department of Medicine, Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| |
Collapse
|
26
|
Ament JD, Greene KR, Flores I, Capobianco F, Salas G, Uriona MI, Weaver JP, Moser R. Health impact and economic analysis of NGO-supported neurosurgery in Bolivia. J Neurosurg Spine 2014; 20:436-42. [PMID: 24527825 DOI: 10.3171/2014.1.spine1228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Bolivia, one of the poorest countries in the world, ranks 108th on the 2013 Human Development Index. With approximately 1 neurosurgeon per 200,000 people, access to neurosurgery in Bolivia is a growing health concern. Furthermore, neurosurgery in nonindustrialized countries has been considered both cost-prohibitive and lacking in outcomes evaluation. A non-governmental organization (NGO) supports spinal procedures in Bolivia (Solidarity Bridge), and the authors sought to determine its impact and cost-effectiveness. METHODS In a retrospective review of prospectively collected data, 19 patients were identified prior to spinal instrumentation and followed over 12 months. For inclusion, patients required interviewing prior to surgery and during at least 2 follow-up visits. All causes of spinal pathology were included. Sixteen patients met inclusion criteria and were therefore part of the analysis. Outcomes measured included assessment of activities of daily living, pain, ambulation, return to work/school, and satisfaction. Cost-effectiveness was determined by cost-utility analysis. Utilities were derived using the Health Utilities Index. Complications were incorporated into an expected value decision tree. RESULTS Median (± SD) preoperative satisfaction was 2.0 ± 0.3 (on a scale of 0-10), while 6-month postoperative satisfaction was 7 ± 1.4 (p < 0.0001). Ambulation, pain, and emotional disability data suggested marked improvement (56%, 69%, and 63%, respectively; p = 0.035, 0.003, and 0.006). Total discounted incremental quality-adjusted life year (QALY) gain was 0.771. The total discounted cost equaled $9036 (95% CI $8561-$10,740) at 2 years. Computing the incremental cost-effectiveness ratio resulted in a value of $11,720/QALY, ranging from $9220 to $15,473/QALY in a univariate sensitivity analysis. CONCLUSIONS This NGO-supported spinal instrumentation program in Bolivia appears to be cost-effective, especially when compared with the conventional $50,000/QALY benchmark and the WHO endorsed country-specific threshold of $16,026/QALY. However, with a gross domestic product per capita in Bolivia equaling $4800 per year and 30.3% of the population living on less than $2 per day, this cost continues to appear unrealistic. Additionally, the study has several significant limitations, namely its limited sample size, follow-up period, the assumption that patients not receiving surgical intervention would not make any clinical improvement, the reliance on the NGO for patient selection and sustainable practices such as follow-up care and ancillary services, and the lack of a randomized prospective design. These limitations, as well as an unclear understanding of Bolivian willingness-to-pay data, affect the generalizability of the study findings and impede widespread economic policy reform. Because cost-effectiveness research may inevitably direct care decisions and prove that an effort such as this can be cost saving, a prospective, properly controlled investigation is now warranted.
Collapse
Affiliation(s)
- Jared D Ament
- University of Massachusetts Medical Center, Worcester, Massachusetts
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
Dilated cardiomyopathy is a serious and life-threatening disorder in children. It is the most common form of pediatric cardiomyopathy. Therapy for this condition has varied little over the last several decades and mortality continues to be high. Currently, children with dilated cardiomyopathy are treated with pharmacological agents and mechanical support, but most require heart transplantation and survival rates are not optimal. The lack of common treatment guidelines and inadequate survival rates after transplantation necessitates more therapeutic clinical trials. Stem cell and cell-based therapies offer an innovative approach to restore cardiac structure and function towards normal, possibly reducing the need for aggressive therapies and cardiac transplantation. Mesenchymal stem cells and cardiac stem cells may be the most promising cell types for treating children with dilated cardiomyopathy. The medical community must begin a systematic investigation of the benefits of current and novel treatments such as stem cell therapies for treating pediatric dilated cardiomyopathy.
Collapse
Affiliation(s)
- Sarah M Selem
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Biomedical Research Building/Room 908, PO Box 016960 (R-125), Miami, FL 33101, USA
| | | | | |
Collapse
|
28
|
Abstract
This review seeks to introduce the concept of cost-utility analysis in neurosurgery and to highlight its essential components. It also includes a suggested approach to standardization, which would help bring more credence to this research and potentially affect management choices, reimbursement, and policy.
Collapse
Affiliation(s)
- Jared D Ament
- Department of Neurosurgery, University of California-Davis, CA 95817, USA.
| | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Organ transplant is a resource-intensive service that has been subjected to increasing scrutiny in this era of cost containment. A detailed understanding of the economic (societal) and financial (transplant provider) implications of organ quality, recipient characteristics, and allocation policy is vital for the transplant professionals. RECENT FINDINGS Prior studies of kidney transplant economics demonstrate significant cost savings achieved by eliminating the need for long-term dialysis. However, transplant providers are experiencing higher financial costs because of changes in recipient characteristics and broader use of marginal organs. Liver transplantation economics are also more challenging because of the severity of illness-based organ allocation. Furthermore, the use of more allografts recovered from donors after cardiac death has been demonstrated to increase costs with minimal benefits. Finally, successful long-term mechanical support devices have fundamentally changed the economic implications of advanced heart failure care. SUMMARY Although care for end-stage organ failure through transplant is one of the landmark accomplishments of 20th century medicine, maintaining or expanding access to transplant care is threatened by the high cost of care. Novel strategies are vital to reduce the financial burden faced by the centers that transplant high-risk patients and utilize lower quality organs.
Collapse
|
30
|
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.
Collapse
Affiliation(s)
- Luis E Rohde
- Postgraduate Program in Cardiovascular Science, Universidade Federal do Rio Grande do Sul, National Institute for Health Technology Assessment (IATS), CNPq, Av. Bento Gonçalves 9500, Porto Alegre, RS, Brazil
| | | | | | | |
Collapse
|
31
|
Abstract
A healthy 14-year-old presented to an emergency department in Alaska, complaining of shortness of breath, chest pain, and 72 hours of malaise and headache. On admission, her blood pressure was 80/50 mm Hg, and she had cool extremities. Electrocardiography revealed wide-complex ventricular tachycardia. She underwent synchronized electrical cardioversion. Although she initially converted to sinus rhythm, she subsequently became pulseless, with electrocardiographic evidence of ventricular tachycardia. Despite cardiopulmonary resuscitation, she failed to achieve a perfusing rhythm. Cardiovascular surgery consultation was obtained, and she was placed on partial cardiopulmonary bypass during 2 hours of ongoing chest compressions. Cardiopulmonary bypass flow was limited by the small size of her femoral arteries. She remained in refractory ventricular tachycardia. The cardiopulmonary bypass circuit was modified for transportation of the patient via air ambulance 1500 miles to a tertiary medical center that specializes in pediatric heart failure and mechanical cardiopulmonary support. Upon arrival at the tertiary medical center, she underwent carotid artery cannulation to improve total cardiopulmonary support and percutaneous balloon atrial septostomy to facilitate left ventricular decompression. Intravenous immunoglobulin and steroids were administered to treat presumed acute fulminant viral myocarditis. Extracorporeal life support was support was successfully discontinued after 14 days, but she experienced a thromboembolic stroke. The patient was discharged on hospital day 65 with moderate generalized left-sided weakness, but she was able to ambulate with minimal assistance. She subsequently returned to school and is progressing appropriately with her peers. Cardiac function has normalized, and she remains in normal sinus rhythm.
Collapse
Affiliation(s)
- D Michael McMullan
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, WA 98105-0371, USA.
| |
Collapse
|
32
|
Law SP, Kim JJ, Decker JA, Price JF, Cabrera AG, Graves DE, Morales DL, Heinle JS, Denfield SW, Dreyer WJ, Rossano JW. Hospital charges for pediatric heart transplant hospitalizations in the United States from 1997 to 2006. J Heart Lung Transplant 2012; 31:485-91. [DOI: 10.1016/j.healun.2011.12.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/27/2011] [Accepted: 12/18/2011] [Indexed: 11/30/2022] Open
|
33
|
Partridge JC, Sendowski MD, Martinez AM, Caughey AB. Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act. Am J Obstet Gynecol 2012; 206:49.e1-49.e10. [PMID: 22051817 DOI: 10.1016/j.ajog.2011.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 08/08/2011] [Accepted: 09/20/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation. STUDY DESIGN We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios. RESULTS Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled. CONCLUSION Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.
Collapse
Affiliation(s)
- John Colin Partridge
- Division of Neonatology, Department of Pediatrics, University of California, School of Medicine, San Francisco, USA
| | | | | | | |
Collapse
|
34
|
van Litsenburg RRL, Uyl-de Groot CA, Raat H, Kaspers GJL, Gemke RJBJ. Cost-effectiveness of treatment of childhood acute lymphoblastic leukemia with chemotherapy only: the influence of new medication and diagnostic technology. Pediatr Blood Cancer 2011; 57:1005-10. [PMID: 21618420 DOI: 10.1002/pbc.23197] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 04/18/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Survival for childhood acute lymphoblastic leukemia (ALL) has reached 80-90%. Future improvement in treatment success will involve new technologies and medication, adding to the pressure on limited financial resources. Therefore a retrospective cost-effectiveness analysis of ALL treatment with chemotherapy only according to the two most recent Dutch Childhood Oncology Group treatment protocols was performed. The most recent protocol ALL10 included more expensive medication (pegasparaginase) and implemented a new diagnostic technique (minimal residual disease levels) compared to the previous ALL9 protocol. PROCEDURE Fifty children from a single center cohort were included. All direct medical costs made during treatment, including those in satellite hospitals, were determined. Costs per life year saved (LYS) were calculated. The cost-effectiveness ratio of the most recent treatment protocol was determined. LYS were calculated based on national 5-year event-free survival. RESULTS Mean total costs were between $115,858 (ALL9) and $163,350 (ALL10) per patient. Hospital admissions (57%) and medication (11-17%) were important drivers of overall costs, and were higher in the most recent protocol ALL10. Costs per LYS were $1,962 (ALL9) and $2,655 (ALL10) and the cost-effectiveness ratio was $8,215. CONCLUSION Treatment of childhood ALL with chemotherapy only is well within accepted ranges of cost-effectiveness. The use of new technology and more expensive medication in the most recent protocol ALL10 lead to higher costs but more LYS. In future (ALL) treatment protocols, costs in relation to effects should be taken into account in order to establish more cost-effective disease management without jeopardizing survival and quality of life.
Collapse
|
35
|
Use of Internal Stent, External Transanastomotic Stent or No Stent During Pediatric Pyeloplasty: A Decision Tree Cost-Effectiveness Analysis. J Urol 2011; 185:673-80. [DOI: 10.1016/j.juro.2010.09.118] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Indexed: 11/19/2022]
|
36
|
Abstract
PURPOSE Despite demonstrated cost effectiveness, not all corneal disorders are amenable to type I Boston keratoprosthesis (KPro) implantation. This includes patients with autoimmune diseases, such as Stevens-Johnson syndrome/toxic epidermal necrolysis. Type II KPro is implanted through the eyelids in severe dry eye and cicatricial diseases, and its cost effectiveness was sought. PATIENTS AND METHODS In a retrospective chart review, 29 patients who underwent type II KPro surgery at the Massachusetts Eye and Ear Infirmary between the years 2000 and 2009 were identified. A total of 11 patients had 5-year follow-up data. Average cost effectiveness was determined by cost-utility analysis, comparing type II KPro surgery with no further intervention. RESULTS Using the current parameters, the cost utility of KPro from third-party insurer (Medicare) perspective was 63,196 $/quality-adjusted life year . CONCLUSION Efforts to refer those less likely to benefit from traditional corneal transplantation or type I KPro, for type II KPro surgery, may decrease both patient and societal costs.
Collapse
|
37
|
Feingold B, Arora G, Webber SA, Smith KJ. Cost-effectiveness of implantable cardioverter-defibrillators in children with dilated cardiomyopathy. J Card Fail 2010; 16:734-41. [PMID: 20797597 DOI: 10.1016/j.cardfail.2010.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 04/02/2010] [Accepted: 04/26/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) improve survival and are cost-effective in adults with poor left ventricular function. Because of differences in heart failure etiology, sudden death rates, and ICD complication rates, these findings may not be applicable to children. METHODS AND RESULTS We developed a Markov model to compare typical management of childhood dilated cardiomyopathy with symptomatic heart failure to prophylactic ICD implantation plus typical management. Model costs included costs of outpatient care, medications, complications, and transplantation. Time horizon was up to 20 years from model entry. Total costs were $433,000 (ICD strategy) and $355,000 (typical management). Although quality adjusted survival was greater in the ICD group (6.78 versus 6.43 quality adjusted life-years [QALY]), the incremental cost-utility ratio was $281,622/QALY saved with the ICD strategy. In sensitivity analyses, the ICD strategy cost less than the $100,000/QALY benchmark for cost-effectiveness only when the annual probability of sudden death exceeded 13% or when strong, sustained benefits in quality of life from the ICD were assumed. CONCLUSIONS Prophylactic ICD use in children with dilated cardiomyopathy, poor ventricular function, and symptomatic heart failure does not appear to be cost-effective. This is likely due to lower sudden death rates in this population.
Collapse
Affiliation(s)
- Brian Feingold
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
| | | | | | | |
Collapse
|
38
|
Ament JD, Stryjewski TP, Ciolino JB, Todani A, Chodosh J, Dohlman CH. Cost-effectiveness of the Boston keratoprosthesis. Am J Ophthalmol 2010; 149:221-228.e2. [PMID: 19939347 DOI: 10.1016/j.ajo.2009.08.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 08/25/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To conduct a cost-utility analysis and determine the cost-effectiveness of the Boston Keratoprosthesis (Boston Kpro). DESIGN Retrospective cohort study. METHODS setting: The Massachusetts Eye and Ear Infirmary corneal service. patients: Inclusion required a minimum 2-year follow-up. Patients with autoimmune diseases and chemical burns were excluded. Eighty-two patients were included with various indications for surgery. intervention: The keratoprosthesis is a collar button-shaped polymethylmethacrylate (PMMA) device consisting of 2 curved plates sandwiched around a corneal donor (allo)graft. The device is assembled intraoperatively and sutured to a patient's eye after removing the diseased cornea. MAIN OUTCOME MEASURES Average cost-effectiveness of the keratoprosthesis was determined by cost-utility analysis, using expected-value calculations and time-tradeoff utilities. The comparative effectiveness, or gain in quality-adjusted life years (QALYs), was also sought. Cost-effectiveness was compared to recently published data on penetrating keratoplasty (PK). RESULTS A total discounted incremental QALY gain for the Boston Kpro of 0.763 correlated with a conferred QALY gain of 20.3% for the average patient. The average cost-effectiveness of the keratoprosthesis was $16 140 per QALY. CONCLUSIONS Comparable to corneal transplantation, with a cost-effectiveness between $12 000 and $16 000 per QALY, the keratoprosthesis can be considered highly cost-effective.
Collapse
|
39
|
Cost-effectiveness of homograft heart valve replacement surgery: an introductory study. Cell Tissue Bank 2009; 12:153-8. [DOI: 10.1007/s10561-009-9165-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 11/23/2009] [Indexed: 11/25/2022]
|
40
|
Does Cytomegalovirus Serology Impact Outcome After Pediatric Heart Transplantation? J Heart Lung Transplant 2009; 28:1299-305. [DOI: 10.1016/j.healun.2009.07.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 07/06/2009] [Accepted: 07/28/2009] [Indexed: 11/21/2022] Open
|
41
|
Cost utility evaluation of extracorporeal membrane oxygenation as a bridge to transplant for children with end-stage heart failure due to dilated cardiomyopathy. J Heart Lung Transplant 2008; 28:32-8. [PMID: 19134528 DOI: 10.1016/j.healun.2008.10.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/03/2008] [Accepted: 10/14/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) and cardiac transplantation are recognized to be expensive. METHODS We performed a cost utility evaluation with a decision model approach, including 75 children with dilated cardiomyopathy. A cohort of patients with end stage heart failure who were offered ECMO bridging was compared with a similar cohort offered only conventional intensive care. Outcome was measured in cost per quality adjusted life year (QALY). RESULTS Median follow-up was 4.39 years (interquartile range, 1.83-5.74 years), during which 50 children underwent transplantation, 16 had a period of recovery, and 25 died. ECMO bridging was highly effective (hazard ratio, 0.181; 95% confidence interval, 0.067-0.489; p = 0.001) but exceeded conventional criteria for cost-effectiveness. The reference incremental cost-effectiveness ratio (ICER) was pound65,645 per QALY and pound54,284 per life-year gained. Average life expectancy rose from 6.78 to 9.79 years and costs from pound146,398 to pound309,599 per patient with ECMO bridging. The ICER was sensitive to ECMO cost, the long-term transplant survival rate, and quality of life in transplant recipients. CONCLUSIONS ECMO bridging is effective but expensive. The eligible target population is small, nationally, positively influencing affordability. We strongly support our national policy of mechanical bridge to transplant for suitable children in end stage heart failure. Cost effectiveness could be optimized by: 1) increased availability of organ donors, 2) reduction in mechanical support costs possibly by alternate devices and 3) inclusion of patients most likely to benefit.
Collapse
|
42
|
Abstract
To discuss the indications for and outcomes of cardiac retransplantation in childhood. The major challenge of pediatric heart transplantation is graft failure. The major causes of graft failure include coronary allograft vasculopathy and chronic rejection. Retransplantation may be considered in children or young adults who develop graft failure following pediatric heart transplantation. Retransplantation now accounts for 7% of all pediatric transplants. Recent studies have demonstrated that cardiac retransplantation has a poorer outcome than primary heart transplantation. However, the interval from primary transplant to retransplantation appears to impact significantly the success of retransplantation. When children undergo retransplantation for early graft failure, the survival is quite poor and the appropriateness of this strategy is questionable. However, children who undergo retransplantation many years after primary transplantation have outcomes that are similar to primary transplantation. The decision to pursue retransplantation depends on the severity of graft failure and recent data suggest that identification of mild graft dysfunction or coronary allograft vasculopathy does not imply impending graft failure. Novel therapies to extend the life of the primary graft and to stratify those at risk of severe graft dysfunction will improve the allocation of scarce organs for pediatric patients who might be candidates for cardiac retransplantation. Retransplantation can extend the lives of children who develop graft failure after primary transplantation. However, not all patients who develop graft dysfunction should necessarily be listed for retransplantation.
Collapse
Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA 30322-1062, USA.
| |
Collapse
|
43
|
Bublik N, Alvarez JA, Lipshultz SE. Pediatric Cardiomyopathy as a Chronic Disease: A Perspective on Comprehensive Care Programs. PROGRESS IN PEDIATRIC CARDIOLOGY 2008; 25:103-111. [PMID: 19122765 DOI: 10.1016/j.ppedcard.2007.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Substantial numbers of children with cardiomyopathy are now surviving into adulthood, making it essentially a chronic disease. As a chronic condition, it may be best treated through comprehensive, multidisciplinary treatment programs. Such programs have improved health outcomes and reduced costs in managing other pediatric chronic diseases and heart failure in adults, but the treatment and cost implications of programs for managing pediatric cardiomyopathy are unknown. We investigated the treatment and cost implications of establishing such programs by reviewing cost-effectiveness studies of similar programs, estimating the current inpatient costs of this diagnosis, and interviewing experts in the field about the need and desirability of these programs. According to our findings, comprehensive pediatric heart failure programs do exist, but they have not been evaluated or even described in the literature. Consensus among experts in the field is that such programs are highly desirable, and similar programs have reported tremendous cost savings through early and intensive management: the return on investment has been as high as 22 to 1. Another study reported that mean length of stay decreased from 83.9 to 10.6 days, mean annual admissions decreased from 2,796 to 1,622, and median hospital charges decreased from $26.1 million to $14.6 million. In conclusion, limited experience and strong circumstantial evidence suggest that, despite substantial costs, comprehensive multidisciplinary pediatric heart failure programs would be highly cost-effective and beneficial to patients, families, and institutions alike.
Collapse
Affiliation(s)
- Natalya Bublik
- Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami
| | | | | |
Collapse
|
44
|
Ortega F, Valdés C, Ortega T. Quality of life after solid organ transplantation. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|