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Hammitt JK, Tunçel T. Monetary values of increasing life expectancy: Sensitivity to shifts of the survival curve. JOURNAL OF RISK AND UNCERTAINTY 2023:1-31. [PMID: 37360985 PMCID: PMC10171170 DOI: 10.1007/s11166-023-09406-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 06/28/2023]
Abstract
Individuals' monetary values of decreases in mortality risk depend on the magnitude and timing of the risk reduction. We elicited stated preferences among three time paths of risk reduction yielding the same increase in life expectancy (decreasing risk for the next decade, subtracting a constant from or multiplying risk by a constant in all future years) and willingness to pay (WTP) for risk reductions differing in timing and life-expectancy gain. Respondents exhibited heterogeneous preferences over the alternative time paths, with almost 90 percent reporting transitive orderings. WTP is statistically significantly associated with life-expectancy gain (between about 7 and 28 days) and with respondents' stated preferences over the alternative time paths. Estimated value per statistical life year (VSLY) can differ by time path and averages about $500,000, roughly consistent with conventional estimates obtained by dividing estimated value per statistical life by discounted life expectancy.
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Affiliation(s)
- James K. Hammitt
- Center for Risk Analysis, Harvard University, Cambridge, MA USA
- Toulouse School of Economics, University of Toulouse Capitole, Toulouse, France
| | - Tuba Tunçel
- Florida State University, Tallahassee, FL USA
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2
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Woolley AE, Gandhi AR, Jones ML, Kim JJ, Mallidi HR, Givertz MM, Baden LR, Mehra MR, Neilan AAM. The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients. Transplantation 2023; 107:961-969. [PMID: 36525554 PMCID: PMC10065819 DOI: 10.1097/tp.0000000000004378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/29/2022] [Accepted: 08/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy. METHODS We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY). RESULTS Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs. CONCLUSIONS Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.
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Affiliation(s)
- Ann E Woolley
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aditya R Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Michelle L Jones
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Hari R Mallidi
- Harvard Medical School, Boston, MA
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael M Givertz
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lindsey R Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Mandeep R Mehra
- Harvard Medical School, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - And Anne M Neilan
- Harvard Medical School, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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3
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Williams EE, Katz JN, Leifer VP, Collins JE, Neogi T, Suter LG, Levy B, Farid A, Safran‐Norton CE, Paltiel AD, Losina E. Cost-Effectiveness of Arthroscopic Partial Meniscectomy and Physical Therapy for Degenerative Meniscal Tear. ACR Open Rheumatol 2022; 4:853-862. [PMID: 35866194 PMCID: PMC9555200 DOI: 10.1002/acr2.11480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We examined the cost-effectiveness of treatment strategies for concomitant meniscal tear and knee osteoarthritis (OA) involving arthroscopic partial meniscectomy surgery and physical therapy (PT). METHODS We used the Osteoarthritis Policy Model, a validated Monte Carlo microsimulation, to compare three strategies, 1) PT-only, 2) immediate surgery, and 3) PT + optional surgery, for participants whose pain persists following initial PT. We modeled a cohort with baseline meniscal tear, OA, and demographics from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of arthroscopic partial meniscectomy versus PT. We estimated risks and costs of arthroscopic partial meniscectomy complications and accounted for heightened OA progression post surgery using published data. We estimated surgery use rates and treatment efficacies using MeTeOR data. We considered a 5-year time horizon, discounted costs, and quality-adjusted life-years (QALYs) 3% per year and conducted sensitivity analyses. We report incremental cost-effectiveness ratios. RESULTS Relative to PT-only, PT + optional surgery added 0.0651 QALY and $2,010 over 5 years (incremental cost-effectiveness ratio = $30,900 per QALY). Relative to PT + optional surgery, immediate surgery added 0.0065 QALY and $3080 (incremental cost-effectiveness ratio = $473,800 per QALY). Incremental cost-effectiveness ratios were sensitive to optional surgery efficacy in the PT + optional surgery strategy. In the probabilistic sensitivity analysis, PT + optional surgery was cost-effective in 51% of simulations at willingness-to-pay thresholds of both $50,000 per QALY and $100,000 per QALY. CONCLUSION First-line arthroscopic partial meniscectomy has a prohibitively high incremental cost-effectiveness ratio. Under base case assumptions, second-line arthroscopic partial meniscectomy offered to participants with persistent pain following initial PT is cost-effective at willingness-to-pay thresholds between $31,000 and $473,000 per QALY. Our analyses suggest that arthroscopic partial meniscectomy can be a high-value treatment option for patients with meniscal tear and OA when performed following an initial PT course and should remain a covered treatment option.
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Affiliation(s)
| | - Jeffrey N. Katz
- Brigham and Women's Hospital and Harvard UniversityBostonMassachusetts
| | | | - Jamie E. Collins
- Brigham and Women's Hospital and Harvard UniversityBostonMassachusetts
| | - Tuhina Neogi
- Boston University School of MedicineBostonMassachusetts
| | - Lisa G. Suter
- Yale School of Medicine, New Haven, Connecticut, and West Haven Veterans Affairs Medical CenterWest HavenConnecticut
| | | | | | | | | | - Elena Losina
- Brigham and Women's Hospital, Harvard Medical School, and Boston University School of Public HealthBostonMassachusetts
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4
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Xie X, Li C, Tiggelaar S, Simbulan F, Falk L, Brophy JM. Developing a cross-validation tool for evaluating economic evidence in rapid literature reviews. J Comp Eff Res 2022; 11:1151-1160. [PMID: 36170031 DOI: 10.2217/cer-2021-0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Rapid economic reviews efficiently summarize economic evidence. However, reporting main findings without assessing quality and credibility can be misleading. The objective of this study was to develop a rapid cross-validation screening tool to evaluate economic evidence when conducting rapid economic literature reviews. Methods: This article outlines our reasoning and the theoretical concepts for developing the screening tool. Results: This cross-validation tool is a qualitative approach under a Bayesian framework that uses prior health economic evidence to gauge the credibility of the rapid economic review's findings. This article describes an application of this tool and highlights practical considerations for its development and deployment. Conclusion: This tool can provide a valuable screening instrument to evaluate the quality and credibility of the economic evidence.
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Affiliation(s)
- Xuanqian Xie
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Chunmei Li
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Sean Tiggelaar
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Frances Simbulan
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Lindsey Falk
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - James M Brophy
- Departments of Medicine & Epidemiology, Biostatistics, & Occupational Health, McGill University, Montreal, QC H3A 0G4, Canada
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5
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Ergun MA, Hajjar A, Alagoz O, Rampurwala M. Optimal breast cancer risk reduction policies tailored to personal risk level. Health Care Manag Sci 2022; 25:363-388. [PMID: 35687269 PMCID: PMC10445480 DOI: 10.1007/s10729-022-09596-2] [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: 02/14/2021] [Accepted: 03/17/2022] [Indexed: 11/04/2022]
Abstract
Depending on personal and hereditary factors, each woman has a different risk of developing breast cancer, one of the leading causes of death for women. For women with a high-risk of breast cancer, their risk can be reduced by two main therapeutic approaches: 1) preventive treatments such as hormonal therapies (i.e., tamoxifen, raloxifene, exemestane); or 2) a risk reduction surgery (i.e., mastectomy). Existing national clinical guidelines either fail to incorporate or have limited use of the personal risk of developing breast cancer in their proposed risk reduction strategies. As a result, they do not provide enough resolution on the benefit-risk trade-off of an intervention policy as personal risk changes. In addressing this problem, we develop a discrete-time, finite-horizon Markov decision process (MDP) model with the objective of maximizing the patient's total expected quality-adjusted life years. We find several useful insights some of which contradict the existing national breast cancer risk reduction recommendations. For example, we find that mastectomy is the optimal choice for the border-line high-risk women who are between ages 22 and 38. Additionally, in contrast to the National Comprehensive Cancer Network recommendations, we find that exemestane is a plausible, in fact, the best, option for high-risk postmenopausal women.
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Affiliation(s)
- Mehmet A Ergun
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3242 Mechanical Engineering Building, 1513 University Avenue, Madison, WI, 53706, USA
- Department of Industrial Engineering, Istanbul Technical University, Istanbul, Turkey
| | - Ali Hajjar
- Harvard Medical School, Boston, Massachusetts, Boston, USA
- Massachusetts General Hospital Institute for Technology Assessment, Boston, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3242 Mechanical Engineering Building, 1513 University Avenue, Madison, WI, 53706, USA.
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6
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Ennezat PV, Alavi Z, Le Jemtel TH, Hansen MR. Consideration Regarding the Analysis of Randomized Controlled Trials in the Era of Evidence-based Medicine. J Cardiovasc Pharmacol 2022; 79:605-619. [PMID: 34983917 DOI: 10.1097/fjc.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/19/2021] [Indexed: 01/09/2023]
Abstract
ABSTRACT Analysis of randomized controlled trials (RCTs) is the cornerstone of evidence-based medicine, therapeutic guidelines and ultimately daily practice. However, 2 issues contribute to cloud the analysis of RCTs. Industry-sponsored RCTs aim at capturing as large indications as possible and clinicians rely excessively on P value statistical significance for the evaluation of the findings. To be most valuable to practitioners, analysis of RCTs needs to provide absolute risk reduction, number of patients needed to treat, fragility index along with the estimation of lost to follow-up patients, and outcome postponement (gain in survival time). We analyzed few major cardiovascular RCTs and assessed the robustness of their findings. Our suggested analytic parameters may be further used in future systematic reviews and meta-analyses.
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Affiliation(s)
- Pierre V Ennezat
- Department of Cardiology, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | - Zarrin Alavi
- INSERM, CIC 1412, Centre Hospitalier Universitaire de Brest, Brest, France
| | | | - Morten R Hansen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; and
- Department of Clinical Biochemistry and Pharmacology Odense University Hospital, Odense, Denmark
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7
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Nielsen JB, Kristiansen IS, Thapa S. Prolongation of disease-free life: When is the benefit sufficient to warrant the effort of taking a preventive medicine? Prev Med 2022; 154:106867. [PMID: 34740678 DOI: 10.1016/j.ypmed.2021.106867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/21/2021] [Accepted: 10/30/2021] [Indexed: 11/18/2022]
Abstract
The prolongation of disease-free life (PODL) required by people to be willing to accept an offer of a preventive treatment is unknown. Quantifying the required benefits could guide information and discussions about preventive treatment. In this study, we investigated how large the benefit in prolongation of a disease-free life (PODL) should be for individuals aged 50-80 years to accept a preventive treatment offer. We used a cross-sectional survey design based on a representative sample of 6847 Danish citizens aged 50-80 years. Data were collected in 2019 through a web-based standardized questionnaire administered by Statistics Denmark, and socio-demographic data were added from a national registry. We analyzed the data with chi-square tests and stepwise multinomial logistic regression. The results indicate that the required minimum benefit from the preventive treatment varied widely between individuals (1-week PODL = 14.8%, ≥4 years PODL = 39.2%), and that the majority of individuals (51.1%) required a PODL of ≥2 years. The multivariable analysis indicate that education and income were independently and negatively associated with requested minimum benefit, while age and smoking were independently and positively associated with requested minimum benefit to accept the preventive treatment. Most individuals aged 50-80 years required larger health benefits than most preventive medications on average can offer. The data support the need for educating patients and health care professionals on how to use average benefits when discussing treatment benefits, especially for primary prevention.
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Affiliation(s)
- Jesper B Nielsen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
| | - Ivar S Kristiansen
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark; Department of Health Management and Health Economics, University of Oslo, Norway.
| | - Subash Thapa
- Research Unit of General Practice, University of Southern Denmark, J.B. Winsløws Vej 9, 5000 Odense, Denmark.
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8
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Burman J. Delaying the inevitable: Are disease modifying drugs for progressive MS worthwhile? Mult Scler Relat Disord 2021; 54:103134. [PMID: 34247107 DOI: 10.1016/j.msard.2021.103134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/18/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
Ocrelizumab and siponimod have a scientifically proven effect in progressive MS and decrease the risk of disability in the short-term. The primary endpoints in the pivotal trials of ocrelizumab and siponimod were reported as a hazard ratio of 3-month confirmed disability progression, which was reported to be 0.76-0.79. Based on this, both drugs were subsequently licensed for use in patients with progressive multiple sclerosis. Hazard ratios are not easily communicated to patients and therefore the alternative endpoint average postponement of disability was calculated with data from the pivotal trials. After two years of treatment, the average postponement of disability was 16 days per year with ocrelizumab and 19 days with siponimod. Over time, the average postponement of disability reached a plateau, when further treatment added little value. Taken together, these data suggest that these interventions have a short-lived and limited clinical effect in patients with progressive MS.
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Affiliation(s)
- Joachim Burman
- Department of Neurology, Uppsala University, Uppsala, Sweden.
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9
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Pan J, Wang Y, Cao L, Wang Y, Zhao Q, Tang S, Gong W, Guo L, Liu Z, Wen Z, Zheng B, Wang W. Impact of immunization programs on 11 childhood vaccine-preventable diseases in China: 1950-2018. Innovation (N Y) 2021; 2:100113. [PMID: 34557762 PMCID: PMC8454656 DOI: 10.1016/j.xinn.2021.100113] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/27/2021] [Indexed: 11/07/2022] Open
Abstract
To evaluate the achievements of China's immunization program between 1950 and 2018, we chose 11 vaccine-preventable diseases (VPDs) as representative notifiable diseases and used annual surveillance data obtained between 1950 and 2018 to derive disease incidence and mortality trends. Quasi-Poisson and polynomial regression models were used to estimate the impacts of specific vaccine programs, and life-table methods were used to calculate the loss of life expectancy, years of life lost, and loss of working years. The total notification number for the 11 VPDs was 211,866,000 from 1950 to 2018. The greatest number occurred in 1959, with a total incidence of 1,723 per million persons. From 1978 to 2018, a substantial decline was observed in the incidence of major infectious diseases. The incidence of pertussis fell 98% from 126.35 to 1.58 per million, and the incidences of measles, meningococcal meningitis, and Japanese encephalitis fell 99%, 99%, and 98%, respectively. The regression models showed that most of the 11 diseases exhibited dramatic declines in morbidity after their integration into the Expanded Program on Immunization (EPI), while varicella and paratyphoid fever, which were not integrated into the EPI, showed increased morbidity. From 1978 to 2018, the total life expectancy for the 11 VPDs increased by 0.79 years, and similar results were obtained for different age groups. China has had great success in controlling VPDs in recent decades, and improving vaccination coverage is a key aspect of controlling VPDs in China. 11 vaccine-preventable diseases (VPDs) were examined to measure the impact of the national immunization program Most of the 11 VPDs exhibited dramatic declines in morbidity rate after their integration into the Expanded Program on Immunization (EPI) From 1978 to 2018, the total life expectancy for the 11 VPDs increased by 0.79 years, and similar results were obtained for different age groups Improving vaccination coverage is a key aspect of controlling VPDs in China
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Affiliation(s)
- Jinhua Pan
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Yesheng Wang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Lingsheng Cao
- National Immunization Program, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Ying Wang
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai 200032, China
| | - Qi Zhao
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China.,School of Public Health, Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC 27708, USA
| | - Wenfeng Gong
- Bill and Melinda Gates Foundation, Seattle, WA 98109, USA
| | - Lei Guo
- Duke Global Health Institute, Duke University, Durham, NC 27708, USA
| | - Zhixi Liu
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Zexuan Wen
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Bo Zheng
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China
| | - Weibing Wang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai 200032, China.,School of Public Health, Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai 200032, China
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McCann NC, Cohn J, Flanagan C, Sacks E, Mukherjee S, Walensky RP, Adetunji O, Maeka KK, Panella C, Chadambuka A, Mafaune H, Odhiambo C, Freedberg KA, Ciaranello AL. Strengthening Existing Laboratory-Based Systems vs. Investing in Point-of-Care Assays for Early Infant Diagnosis of HIV: A Model-Based Cost-Effectiveness Analysis. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S12-S21. [PMID: 32520910 PMCID: PMC7302325 DOI: 10.1097/qai.0000000000002384] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: To improve early infant HIV diagnosis (EID) programs, options include replacing laboratory-based tests with point-of-care (POC) assays or investing in strengthened systems for sample transport and result return. Setting: We used the CEPAC-Pediatric model to examine clinical benefits and costs of 3 EID strategies in Zimbabwe for infants 6 weeks of age. Methods: We examined (1) laboratory-based EID (LAB), (2) strengthened laboratory-based EID (S-LAB), and (3) POC EID (POC). LAB/S-LAB and POC assays differed in sensitivity (LAB/S-LAB 100%, POC 96.9%) and specificity (LAB/S-LAB 99.6%, POC 99.9%). LAB/S-LAB/POC algorithms also differed in: probability of result return (79%/91%/98%), time until result return (61/53/1 days), probability of initiating antiretroviral therapy (ART) after positive result (52%/71%/86%), and total cost/test ($18.10/$30.47/$30.71). We projected life expectancy (LE) and average lifetime per-person cost for all HIV-exposed infants. We calculated incremental cost-effectiveness ratios (ICERs) from discounted (3%/year) LE and costs in $/year-of-life saved (YLS), defining cost effective as an ICER <$580/YLS (reflecting programs providing 2 vs. 1 ART regimens). In sensitivity analyses, we varied differences between S-LAB and POC in result return probability, result return time, ART initiation probability, and cost. Results: For infants who acquired HIV, LAB/S-LAB/POC led to projected one-year survival of 67.3%/69.9%/75.6% and undiscounted LE of 21.74/22.71/24.49 years. For all HIV-exposed infants, undiscounted LE was 63.35/63.38/63.43 years, at discounted lifetime costs of $200/220/240 per infant. In cost-effectiveness analysis, S-LAB was an inefficient use of resources; the ICER of POC vs. LAB was $830/YLS. Conclusions: Current EID programs will attain greater benefit from investing in POC EID rather than strengthening laboratory-based systems.
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Affiliation(s)
- Nicole C McCann
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.,Division of Infectious Disease, University of Pennsylvania, Philadelphia, PA
| | - Clare Flanagan
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | | | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | | | - Kenneth K Maeka
- Early Infant Diagnosis Department, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - Christopher Panella
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | | | - Haurovi Mafaune
- Elizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe; and
| | | | - Kenneth A Freedberg
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Andrea L Ciaranello
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
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11
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Dunning L, Gandhi AR, Penazzato M, Soeteman DI, Revill P, Frank S, Phillips A, Dugdale C, Abrams E, Weinstein MC, Newell M, Collins IJ, Doherty M, Vojnov L, Fassinou Ekouévi P, Myer L, Mushavi A, Freedberg KA, Ciaranello AL. Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25651. [PMID: 33474817 PMCID: PMC8992471 DOI: 10.1002/jia2.25651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. METHODS Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). RESULTS With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. CONCLUSIONS Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
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Affiliation(s)
- Lorna Dunning
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Aditya R Gandhi
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Martina Penazzato
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Djøra I Soeteman
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Simone Frank
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Caitlin Dugdale
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Elaine Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew York CityNYUSA
| | - Milton C Weinstein
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Marie‐Louise Newell
- Institute for Development StudiesHuman Development and HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- School of Public HealthFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
| | - Intira J Collins
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Meg Doherty
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Lara Vojnov
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Andrea L Ciaranello
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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12
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Kang SK, Mali RD, Braithwaite RS, Kerr AR, McDevitt J. Point-of-care characterization and risk-based management of oral lesions in primary dental clinics: A simulation model. PLoS One 2020; 15:e0244446. [PMID: 33382762 PMCID: PMC7774939 DOI: 10.1371/journal.pone.0244446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/09/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Oral potentially malignant disorders (OPMDs) encompass histologically benign, dysplastic, and cancerous lesions that are often indistinguishable by appearance and inconsistently managed. We assessed the potential impact of test-and-treat pathways enabled by a point-of-care test for OPMD characterization. MATERIALS AND METHODS We constructed a decision-analytic model to compare life expectancy of test-treat strategies for 60-year-old patients with OPMDs in the primary dental setting, based on a trial for a point-of-care cytopathology tool (POCOCT). Eight strategies of OPMD detection and evaluation were compared, involving deferred evaluation (no further characterization), prompt OPMD characterization using POCOCT measurements, or the commonly recommended usual care strategy of routine referral for scalpel biopsy. POCOCT pathways differed in threshold for additional intervention, including surgery for any dysplasia or malignancy, or for only moderate or severe dysplasia or cancer. Strategies with initial referral for biopsy also reflected varied treatment thresholds in current practice between surgery and surveillance of mild dysplasia. Sensitivity analysis was performed to assess the impact of variation in parameter values on model results. RESULTS Requisite referral for scalpel biopsy offered the highest life expectancy of 20.92 life-years compared with deferred evaluation (+0.30 life-years), though this outcome was driven by baseline assumptions of limited patient adherence to surveillance using POCOCT. POCOCT characterization and surveillance offered only 0.02 life-years less than the most biopsy-intensive strategy, while resulting in 27% fewer biopsies. When the probability of adherence to surveillance and confirmatory biopsy was ≥ 0.88, or when metastasis rates were lower than reported, POCOCT characterization extended life-years (+0.04 life-years) than prompt specialist referral. CONCLUSION Risk-based OPMD management through point-of-care cytology may offer a reasonable alternative to routine referral for specialist evaluation and scalpel biopsy, with far fewer biopsies. In patients who adhere to surveillance protocols, POCOCT surveillance may extend life expectancy beyond biopsy and follow up visual-tactile inspection.
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Affiliation(s)
- Stella K. Kang
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Rahul D. Mali
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - R. Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Alexander R. Kerr
- Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, New York University College of Dentistry, New York, New York, United States of America
| | - John McDevitt
- Department of Biomaterials, New York University College of Dentistry, New York, New York, United States of America
- Chemical and Biomolecular Engineering, Tandon School of Engineering, New York University, Brooklyn, New York, United States of America
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13
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Carlsson LMS, Sjöholm K, Jacobson P, Andersson-Assarsson JC, Svensson PA, Taube M, Carlsson B, Peltonen M. Life Expectancy after Bariatric Surgery in the Swedish Obese Subjects Study. N Engl J Med 2020; 383:1535-1543. [PMID: 33053284 PMCID: PMC7580786 DOI: 10.1056/nejmoa2002449] [Citation(s) in RCA: 241] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Obesity shortens life expectancy. Bariatric surgery is known to reduce the long-term relative risk of death, but its effect on life expectancy is unclear. METHODS We used the Gompertz proportional hazards regression model to compare mortality and life expectancy among patients treated with either bariatric surgery (surgery group) or usual obesity care (control group) in the prospective, controlled Swedish Obese Subjects (SOS) study and participants in the SOS reference study (reference cohort), a random sample from the general population. RESULTS In total, 2007 and 2040 patients were included in the surgery group and the control group, respectively, and 1135 participants were included in the reference cohort. At the time of the analysis (December 31, 2018), the median duration of follow-up for mortality was 24 years (interquartile range, 22 to 27) in the surgery group and 22 years (interquartile range, 21 to 27) in the control group; data on mortality were available for 99.9% of patients in the study. In the SOS reference cohort, the median duration of follow-up was 20 years (interquartile range, 19 to 21), and data on mortality were available for 100% of participants. In total, 457 patients (22.8%) in the surgery group and 539 patients (26.4%) in the control group died (hazard ratio, 0.77; 95% confidence interval [CI], 0.68 to 0.87; P<0.001). The corresponding hazard ratio was 0.70 (95% CI, 0.57 to 0.85) for death from cardiovascular disease and 0.77 (95% CI, 0.61 to 0.96) for death from cancer. The adjusted median life expectancy in the surgery group was 3.0 years (95% CI, 1.8 to 4.2) longer than in the control group but 5.5 years shorter than in the general population. The 90-day postoperative mortality was 0.2%, and 2.9% of the patients in the surgery group underwent repeat surgery. CONCLUSIONS Among patients with obesity, bariatric surgery was associated with longer life expectancy than usual obesity care. Mortality remained higher in both groups than in the general population. (Funded by the Swedish Research Council and others; SOS ClinicalTrials.gov number, NCT01479452.).
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Affiliation(s)
- Lena M S Carlsson
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Kajsa Sjöholm
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Peter Jacobson
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Johanna C Andersson-Assarsson
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Per-Arne Svensson
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Magdalena Taube
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Björn Carlsson
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
| | - Markku Peltonen
- From the Institutes of Medicine (L.M.S.C., K.S., P.J., J.C.A.-A., P.-A.S., M.T., B.C.) and Health and Care Sciences (P.-A.S.), Sahlgrenska Academy at the University of Gothenburg, and Early Cardiovascular, Renal, and Metabolism (CVRM), Biopharmaceuticals Research and Development, AstraZeneca (B.C.), Gothenburg, and the Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna (M.P.) - both in Sweden; and the Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki (M.P.)
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14
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Hird AE, Magee DE, Cheung DC, Sander B, Sridhar S, Nam RK, Kulkarni GS. Neoadjuvant Versus Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Microsimulation Model. Clin Genitourin Cancer 2020; 19:e135-e147. [PMID: 33168398 DOI: 10.1016/j.clgc.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Upper tract urothelial carcinoma (UTUC) is clinically understudied, and there are no definitive recommendations regarding timing of perioperative chemotherapy. The objective of this study was to compare 3 treatment pathways in UTUC: nephroureterectomy (NU) alone, neoadjuvant chemotherapy (NAC), and adjuvant chemotherapy (AC) using a microsimulation model. PATIENTS AND METHODS An individual-level state transition model was constructed using TreeAgePro software to compare treatment strategies for patients with newly diagnosed UTUC. The base case was that of a 70-year-old patient with a radiographically localized upper tract tumor. Primary outcome was quality-adjusted life expectancy. Secondary outcomes included crude overall survival, rates of adverse events, and bladder cancer diagnoses. RESULTS A total of 100,000 patients were simulated. NAC was preferred, with an estimated quality-adjusted life expectancy of 7.50 years versus 6.79 years with NU alone and 7.23 years with AC. Median crude overall survival was 123 months with NAC, 96 months with NU only, and 111 months with AC. Overall, 40.0% of patients in the AC group with invasive pathology completed chemotherapy. In the NAC group, 83.3% of patients completed chemotherapy. In the NAC group, 37.5% of patients experienced an adverse chemotherapy event compared to 15.1% of patients in the AC group. Bladder cancer recurrence rates were 64.9%, 65.9%, and 67.4% over the patient's lifetime for the NU, NAC, and AC strategies, respectively. CONCLUSION This study supports the increased use of NAC in UTUC until robust randomized trials are completed. The ultimate choice should be based on patient and tumor factors.
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Affiliation(s)
- Amanda E Hird
- Division of Urology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Diana E Magee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas C Cheung
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Srikala Sridhar
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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15
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Hansen MR, Hróbjartsson A, Pottegård A, Damkier P, Madsen KG, Pareek M, Olesen M, Hallas J. Postponement of cardiovascular outcomes by statin use: A systematic review and meta-analysis of randomized clinical trials. Basic Clin Pharmacol Toxicol 2020; 128:286-296. [PMID: 32896109 DOI: 10.1111/bcpt.13485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/01/2020] [Accepted: 09/01/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the average outcome postponement (gain in days to an event) for cardiovascular outcomes in a meta-analysis of randomized, controlled statin trials, including any myocardial infarction, any stroke and cardiovascular death. DESIGN Systematic review of large randomized, placebo-controlled trials of statin use, including a random-effects meta-analysis of all included trials. DATA SOURCES We searched MEDLINE (15 July 2019) and ClinicalTrials.gov (16 October 2019). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomized, placebo-controlled trials of statin use that included at least 1000 participants. We identified 15 cardiovascular outcomes that were reported in more than 2 trials. RESULTS We included 19 trials. The summary outcome postponements for the 15 cardiovascular outcomes varied between -1 and 38 days. For four major outcomes, the summary outcome postponement in days was as follows: cardiovascular mortality, 9.27 days (95% CI: 3.6 to 14.91; I2 = 72%; 9 trials) non-vascular and non-cardiovascular mortality, 1.5 days (95% CI: -2.2 to 5.3; I2 = 0%; 6 trials) any myocardial infarction 18.0 days (95% CI; 12.1 to 24.1; I2 = 92%; 15 trials); and any stroke, 6.1 days (95% CI; 2.86 to 9.39; I2 = 66%; 14 trials). CONCLUSION Statin treatment provided a small, average postponement of cardiovascular outcomes during trial duration.
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Affiliation(s)
- Morten Rix Hansen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Odense Explorative Patient Data Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kenneth Grønkjaer Madsen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark.,Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Morten Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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16
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Marchioni A, Andrisani D, Tonelli R, Piro R, Andreani A, Cappiello GF, Meschiari E, Dominici M, Bavieri M, Barbieri F, Taddei S, Casalini E, Falco F, Gozzi F, Bruzzi G, Fantini R, Tabbì L, Castaniere I, Facciolongo N, Clini E. Integrated intErventional bronchoscopy in the treatment of locally adVanced non-small lung cancER with central Malignant airway Obstructions: a multicentric REtrospective study (EVERMORE). Lung Cancer 2020; 148:40-47. [PMID: 32795722 DOI: 10.1016/j.lungcan.2020.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Despite new therapeutic perspectives, the presence of central airways occlusion (CAO) in patients with locally advanced non-small cell lung cancer (NSCLC) is associated with poor survival. There is no clear evidence on the clinical impact of interventional bronchoscopy as a part of an integrated treatment to cure these patients. MATERIALS AND METHODS This retrospective cohort study was conducted in two teaching hospitals over a 10 years period (January 2010-January 2020) comparing patients with NSCLC at stage IIIB and CAO at disease onset treated with chemotherapy/radiotherapy (standard therapy-ST) with those receiving interventional bronchoscopy plus ST (integrated treatment-IT). Primary outcome was 1-year survival. The onset of respiratory events, symptoms-free interval, hospitalization, need for palliation, and overall mortality served as secondary outcomes. RESULTS A total of 100 patients were included, 60 in the IT and 40 in the ST group. Unadjusted Kaplan-Meier estimates showed greater effect of IT compared to ST on 1-year survival (HR = 2.1 95%CI[1.1-4.8], p = 0.003). IT showed a significantly higher survival gain over ST in those patients showing KRAS mutation (7.6 VS 0.8 months,<0.0001), a lumen occlusion >65% (6.6 VS 2.9 months,<0.001), and lacking the involvement of left bronchus (7 VS 2.3 months,<0.0001). Compared to ST, IT also showed a favorable difference in terms of new hospitalizations (p = 0.03), symptom-free interval (p = 0.02), and onset of atelectasis (p = 0.01). CONCLUSIONS In patients with NSCLC stage IIIB and CAO, additional interventional bronchoscopy might impact on 1-year survival. Genetic and anatomic phenotyping might allow identifying those patients who may gain life expectancy from the endoscopic intervention.
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Affiliation(s)
- Alessandro Marchioni
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Dario Andrisani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy.
| | - Roberto Tonelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy.
| | - Roberto Piro
- Respiratory Diseases Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Alessandro Andreani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Gaia Francesca Cappiello
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Emmanuela Meschiari
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Massimo Dominici
- University Hospital of Modena, Oncology Unit, University of Modena Reggio Emilia, Modena, Italy.
| | - Mario Bavieri
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Fausto Barbieri
- University Hospital of Modena, Oncology Unit, University of Modena Reggio Emilia, Modena, Italy.
| | - Sofia Taddei
- Respiratory Diseases Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Eleonora Casalini
- Respiratory Diseases Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Francesco Falco
- Respiratory Diseases Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Filippo Gozzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Giulia Bruzzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Riccardo Fantini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Luca Tabbì
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Ivana Castaniere
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy.
| | - Nicola Facciolongo
- Respiratory Diseases Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.
| | - Enrico Clini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
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Hansen MR, Hróbjartsson A, Videbæk L, Ennis ZN, Pareek M, Paulsen NH, Broe M, Olesen M, Pottegård A, Damkier P, Hallas J. Postponement of Death by Pharmacological Heart Failure Treatment: A Meta-Analysis of Randomized Clinical Trials. Am J Med 2020; 133:e280-e289. [PMID: 32173347 DOI: 10.1016/j.amjmed.2019.11.015] [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: 10/18/2019] [Revised: 11/02/2019] [Accepted: 11/03/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outcome postponement has been proposed as an effect measure for preventive drug treatment. It describes the average delay of the investigated unwanted clinical event, achieved by taking medication. The objective was to estimate postponement of death for the following heart failure medications compared to placebo: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), ARB added to ACE inhibitors, aldosterone antagonists, ivabradine, and renin antagonists. METHODS We searched Medline and Embase from inception of databases until October 2017. Eligibility criteria were randomized placebo-controlled heart failure trials, including at least 1000 participants, with survival as a prespecified outcome and a minimum trial duration of 1 year. We calculated the outcome postponement by modeling the area between survival curves. This area was modeled on the basis of the hazard ratio or relative risk, the rate of mortality in the placebo group, and the trial duration. All results were standardized to a 3-year trial duration to ensure comparability between treatments. RESULTS We identified 14 eligible trials, with a total of 52,014 patients. The results in terms of postponement of all-cause mortality was: beta-blockers 43.7 days (95% confidence interval [95% CI], 20.8-66.5), ACE inhibitors 41.0 days (95% CI, 18.8-63.3), and aldosterone-antagonists 41.3 days (95% CI, 14.3,68.4). CONCLUSION The modeled outcome postponement estimates reiterate beta-blockers, ACE inhibitors, and aldosterone antagonists as the mainstay of heart failure treatment. Furthermore, ivabradine or ARBs added to ACE inhibitors results in no statistically significant gain in survival.
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Affiliation(s)
- Morten Rix Hansen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark.
| | - Asbjørn Hróbjartsson
- Center for Evidence-Based Medicine, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Odense Explorative Patient Data Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Lars Videbæk
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Zandra Nymand Ennis
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Manan Pareek
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Department of Internal Medicine, Yale New Haven Hospital, New Haven, Conn
| | - Niels Herluf Paulsen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Martin Broe
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Morten Olesen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Per Damkier
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Xu W, Lau ZWX, Fulop T, Larbi A. The Aging of γδ T Cells. Cells 2020; 9:E1181. [PMID: 32397491 PMCID: PMC7290956 DOI: 10.3390/cells9051181] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/30/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022] Open
Abstract
In the coming decades, many developed countries in the world are expecting the "greying" of their populations. This phenomenon poses unprecedented challenges to healthcare systems. Aging is one of the most important risk factors for infections and a myriad of diseases such as cancer, cardiovascular and neurodegenerative diseases. A common denominator that is implicated in these diseases is the immune system. The immune system consists of the innate and adaptive arms that complement each other to provide the host with a holistic defense system. While the diverse interactions between multiple arms of the immune system are necessary for its function, this complexity is amplified in the aging immune system as each immune cell type is affected differently-resulting in a conundrum that is especially difficult to target. Furthermore, certain cell types, such as γδ T cells, do not fit categorically into the arms of innate or adaptive immunity. In this review, we will first introduce the human γδ T cell family and its ligands before discussing parallels in mice. By covering the ontogeny and homeostasis of γδ T cells during their lifespan, we will better capture their evolution and responses to age-related stressors. Finally, we will identify knowledge gaps within these topics that can advance our understanding of the relationship between γδ T cells and aging, as well as age-related diseases such as cancer.
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Affiliation(s)
- Weili Xu
- Biology of Aging Program and Immunomonitoring Platform, Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Immunos Building, Biopolis, Singapore 138648, Singapore; (W.X.); (Z.W.X.L.)
| | - Zandrea Wan Xuan Lau
- Biology of Aging Program and Immunomonitoring Platform, Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Immunos Building, Biopolis, Singapore 138648, Singapore; (W.X.); (Z.W.X.L.)
| | - Tamas Fulop
- Department of Geriatrics, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1K 2R1, Canada;
| | - Anis Larbi
- Biology of Aging Program and Immunomonitoring Platform, Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Immunos Building, Biopolis, Singapore 138648, Singapore; (W.X.); (Z.W.X.L.)
- Department of Geriatrics, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1K 2R1, Canada;
- Department of Microbiology, National University of Singapore, Singapore 117597, Singapore
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Ennezat PV, Le Jemtel T, Cosgrove S, Hallas J, Hansen MR. Outcome postponement as a potential patient centred measure of therapeutic benefit: examples in cardiovascular medicine. Acta Cardiol 2020; 75:10-19. [PMID: 30513258 DOI: 10.1080/00015385.2018.1534769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The impact of randomised controlled trials (RCTs) depends heavily on the presentation of the findings.Objective: Classically, RCT findings are presented in the form of absolute risk reduction (ARR), number needed to treat (NNT) to prevent one adverse outcome, and relative risk reduction (RRR) or hazard ratio (the most favourable means for drug marketing). However, the estimation of average survival gain (i.e. outcome postponement between a trial intervention and comparator) is an alternative and informative means of presenting the findings of RCTs.Study selection: Recent cardiovascular RCTs evaluating ezetimibe added to simvastatin, evolocumab, canakinumab, ticagrelor, rivaroxaban, ivabradine, LCZ 696 (sacubitril/valsartan), and transfemoral aortic valve replacement are analysed and discussed.Findings: The average survival gains ranged between 4.9 days on a composite end point with ticagrelor versus clopidogrel in randomised patients with acute coronary syndrome and 117 days of life expectancy obtained with TAVR versus standard therapy in patients with severe aortic stenosis deemed ineligible for surgery.Conclusions: Using outcome postponement as an additional measure of treatment effect is likely to be more easily understood than hazard ratio or RRR by both patients and physicians and could help when evaluating drugs.
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Affiliation(s)
- Pierre Vladimir Ennezat
- Centre Hospitalier Régional Universitaire Grenoble-Alpes, Service de Cardiologie, Grenoble, France
| | - Thierry Le Jemtel
- Tulane School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA, USA
| | - Shona Cosgrove
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jesper Hallas
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Morten Rix Hansen
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Erman A, Wong WWL, Feld JJ, Grootendorst P, Krahn MD. The health impact of delaying direct-acting antiviral treatment for chronic hepatitis C: A decision-analytic approach. Liver Int 2020; 40:51-59. [PMID: 31509639 DOI: 10.1111/liv.14247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 08/04/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) are highly effective, but expensive treatments for chronic hepatitis C (CHC). To manage costs, drug plans worldwide have rationed access to DAAs in a variety of ways. This study quantifies the health impact of formulary restrictions and presents a clinical decision tool for informing treatment timing decisions. METHODS A decision-analytic model was developed to quantify the health impact of delaying DAAs for subpopulations stratified by age, fibrosis level, viral genotype, and injection drug use over their lifetime. The health impact was quantified in terms of quality-adjusted life expectancy (quality-adjusted life years, or QALYs) and life expectancy (years). RESULTS Deferring DAAs for patients with no or mild fibrosis (F0/F1) for 1-5 years is unlikely to result in life expectancy losses and leads only to marginal losses of 0.02-0.06 QALYs per year of delay. However, for 30-50-year-olds with advanced fibrosis (≥F3) delays as short as a year results in a considerable health loss (0.25-1.04 QALYs and 0.19-1.53 years). Reimbursement limits for those with substance use are associated with large health losses. People who actively inject drugs with advanced fibrosis (≥F3) may lose 0.18-1.05 QALYs and 0.13-1.16 years per year of delay, despite the risk of reinfection and competing mortality. Results are robust to parameter uncertainty and key assumptions. CONCLUSIONS We present a clinical decision tool for informing treatment timing for various CHC subpopulations. In general, findings suggest that patients with at least moderate fibrosis should be treated promptly regardless of active drug use.
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Affiliation(s)
- Aysegul Erman
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada
| | - William W L Wong
- Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada.,School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, ON, Canada
| | - Paul Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Murray D Krahn
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Toronto Health Economics and Technology Assessment Collaborative (THETA), University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, Toronto, ON, Canada
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Cowen ME, Walsh MM, Posa PJ, Leeman LR, Van Hoek E, Czerwinski JL. Common Risk Stratification of Hospital and Ambulatory Patients. J Healthc Qual 2020; 42:37-45. [DOI: 10.1097/jhq.0000000000000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials. J Gen Intern Med 2019; 34:1607-1614. [PMID: 31073857 PMCID: PMC6667545 DOI: 10.1007/s11606-019-05024-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/12/2018] [Accepted: 03/21/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The average postponement of the outcome (gain in time to event) has been proposed as a measure to convey the effect of preventive medications. Among its advantages over number needed to treat and relative risk reduction is a better intuitive understanding among lay persons. OBJECTIVES To develop a novel approach for modeling outcome postponement achieved within a trial's duration, based on published trial data and to present a formalized meta-analysis of modeled outcome postponement for all-cause mortality in statin trials. METHODS The outcome postponement was modeled on the basis of the hazard ratio or relative risk, the mortality rate in the placebo group and the trial's duration. Outcome postponement was subjected to a meta-analysis. We also estimated the average outcome postponement as the area between Kaplan-Meier curves. Statin trials were identified through a systematic review. RESULTS The median modeled outcome postponement was 10.0 days (interquartile range, 2.9-19.5 days). Meta-analysis of 16 trials provided a summary estimate of outcome postponement for all-cause mortality of 12.6 days, with a 95% postponement interval (PI) of 7.1-18.0. For primary, secondary, and mixed prevention trials, respectively, outcome postponements were 10.2 days (PI, 4.0-16.3), 17.4 days (PI, 6.0-28.8), and 8.5 days (PI, 1.9-15.0). CONCLUSIONS The modeled outcome postponement is amenable to meta-analysis and may be a useful approach for presenting the benefits of preventive interventions. Statin treatment results in a small increase of average survival within the duration of a trial. SYSTEMATIC REVIEW REGISTRATION The systematic review was registered in PROSPERO [CRD42016037507] .
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Frank SC, Cohn J, Dunning L, Sacks E, Walensky RP, Mukherjee S, Dugdale CM, Turunga E, Freedberg KA, Ciaranello AL. Clinical effect and cost-effectiveness of incorporation of point-of-care assays into early infant HIV diagnosis programmes in Zimbabwe: a modelling study. Lancet HIV 2019; 6:e182-e190. [PMID: 30737187 PMCID: PMC6408227 DOI: 10.1016/s2352-3018(18)30328-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND New point-of-care (POC) assays for early infant HIV diagnosis are costlier than conventional total nucleic acid assays, but could increase access to testing, shorten time to results, and expedite initiation of antiretroviral therapy. We aimed to assess the clinical benefits and cost-effectiveness of incorporating these POC assays into early infant diagnosis programmes in Zimbabwe. METHODS We used the Cost Effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model to examine the clinical benefits, costs, and cost-effectiveness of replacing conventional assays for early infant HIV diagnosis with POC assays at age 6 weeks in Zimbabwe. We simulated two strategies for early infant HIV diagnosis: conventional and POC. Modelled assays differed in sensitivity; specificity; time to, and probability of, return of results; and cost. Model outcomes included survival, life expectancy, and mean lifetime per-person treatment cost, which were reported separately for all HIV-exposed infants and all infants with HIV. We calculated incremental cost-effectiveness ratios with discounted (3% per year) costs and life expectancy from a health-care system perspective for all HIV-exposed infants. We judged incremental cost-effectiveness ratios of $1010 (Zimbabwe's annual gross domestic product per person) or less per year of life saved to be cost-effective. FINDINGS When conventional assays were used for early infant diagnosis, projected undiscounted life expectancy was 22·7 years for infants with HIV and 62·5 years for all HIV-exposed infants, at a cost of $610 per HIV-exposed infant. Use of POC assays for early infant HIV diagnosis improved projected undiscounted life expectancy to 25·5 years among infants with HIV and 62·6 years among HIV-exposed infants at a cost of $690 per HIV-exposed infant. At age 12 weeks, survival among all infants with HIV was 76·1% with the conventional testing strategy and 83·5% with the POC testing strategy. The incremental cost-effectiveness ratio of POC assays versus conventional assays for early infant diagnosis was $680 per year of life saved. When conventional assay characteristics remained constant, this ratio remained under the cost-effectiveness threshold as long as the specificity and sensitivity of the POC assay were greater than 92% and 65%, respectively. Our results were robust to plausible variations in POC assay cost, the probability of ART initiation, and probability of return of the results of POC testing. INTERPRETATION Compared with conventional assays, POC assays for early infant HIV diagnosis in Zimbabwe will improve survival, extend life expectancy, and be cost-effective for HIV-exposed infants. FUNDING Elizabeth Glaser Pediatric AIDS Foundation, US National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Unitaid.
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Affiliation(s)
- Simone C. Frank
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
- Division of Infectious Disease, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sushant Mukherjee
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Caitlin M. Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Esther Turunga
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Kang SK, Huang WC, Elkin EB, Pandharipande PV, Braithwaite RS. Personalized Treatment for Small Renal Tumors: Decision Analysis of Competing Causes of Mortality. Radiology 2019; 290:732-743. [PMID: 30644815 PMCID: PMC6394736 DOI: 10.1148/radiol.2018181114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/21/2018] [Accepted: 11/23/2018] [Indexed: 12/29/2022]
Abstract
Purpose To compare the effectiveness of personalized treatment for small (≤4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. Materials and Methods A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. Results In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. Conclusion For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy. © RSNA, 2019 Online supplemental material is available for this article.
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Affiliation(s)
- Stella K. Kang
- From the Departments of Radiology (S.K.K.), Population Health (S.K.K., R.S.B.), Urology (W.C.H.), and Medicine (R.S.B.), NYU School of Medicine, 550 First Ave, New York, NY 10016; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (E.B.E.); and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Boston, Mass (P.V.P.)
| | - William C. Huang
- From the Departments of Radiology (S.K.K.), Population Health (S.K.K., R.S.B.), Urology (W.C.H.), and Medicine (R.S.B.), NYU School of Medicine, 550 First Ave, New York, NY 10016; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (E.B.E.); and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Boston, Mass (P.V.P.)
| | - Elena B. Elkin
- From the Departments of Radiology (S.K.K.), Population Health (S.K.K., R.S.B.), Urology (W.C.H.), and Medicine (R.S.B.), NYU School of Medicine, 550 First Ave, New York, NY 10016; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (E.B.E.); and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Boston, Mass (P.V.P.)
| | - Pari V. Pandharipande
- From the Departments of Radiology (S.K.K.), Population Health (S.K.K., R.S.B.), Urology (W.C.H.), and Medicine (R.S.B.), NYU School of Medicine, 550 First Ave, New York, NY 10016; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (E.B.E.); and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Boston, Mass (P.V.P.)
| | - R. Scott Braithwaite
- From the Departments of Radiology (S.K.K.), Population Health (S.K.K., R.S.B.), Urology (W.C.H.), and Medicine (R.S.B.), NYU School of Medicine, 550 First Ave, New York, NY 10016; Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (E.B.E.); and Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Boston, Mass (P.V.P.)
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Ayvaci MUS, Alagoz O, Ahsen ME, Burnside ES. Preference-Sensitive Management of Post-Mammography Decisions in Breast Cancer Diagnosis. PRODUCTION AND OPERATIONS MANAGEMENT 2018; 27:2313-2338. [PMID: 31031555 PMCID: PMC6481963 DOI: 10.1111/poms.12897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Decision models representing the clinical situations where treatment options entail a significant risk of morbidity or mortality should consider the variations in risk preferences of individuals. In this study, we develop a stochastic modeling framework that optimizes risk-sensitive diagnostic decisions after a mammography exam. For a given patient, our objective is to find the utility maximizing diagnostic decisions where we define the utility over quality-adjusted survival duration. We use real data from a private mammography database to numerically solve our model for various utility functions. Our choice of utility functions for the numerical analysis is driven by actual patient behavior encountered in clinical practice. We find that invasive diagnostic procedures such as biopsies are more aggressively used than what the optimal risk-neutral policy would suggest, implying a far-sighted (or equivalently risk-seeking) behavior. When risk preferences are incorporated into the clinical practice, policy makers should bear in mind that a welfare loss in terms of survival duration is inevitable as evidenced by our structural and empirical results.
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Affiliation(s)
- Mehmet Ulvi Saygi Ayvaci
- Information Systems, Naveen Jindal School of Management, University of Texas at Dallas, 800 W Campbell Rd SM33, Richardson, Texas 75080, USA,
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin 53705, USA,
| | - Mehmet Eren Ahsen
- Icahn School of Medicine at Mount Sinai, San Francisco, California 94108, USA,
| | - Elizabeth S Burnside
- Department of Radiology, University of Wisconsin, Madison, Wisconsin 53792, USA,
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Carpal Tunnel Syndrome Management in Breast Cancer Survivors at Risk for Lymphedema: A Markov Model. Plast Reconstr Surg 2018; 141:689e-696e. [PMID: 29697616 DOI: 10.1097/prs.0000000000004318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast cancer survivors that have undergone axillary lymph node dissection have an increased risk of developing same-side upper extremity lymphedema. Patients with carpal tunnel syndrome in the ipsilateral limb may not receive appropriate surgical therapy (carpal tunnel release) because of concerns that it may trigger or worsen lymphedema. METHODS A state transition cohort model was used to evaluate the treatment options for breast cancer survivors at risk of upper extremity lymphedema presenting with carpal tunnel syndrome. The model reflected three treatment strategies: (1) early surgical intervention, (2) delayed surgical intervention, or (3) nonsurgical management. Both life-years and quality-adjusted life-years were modeled over a 30-year time horizon. RESULTS Over a 30-year time horizon, the preferred strategy was delayed surgery, which resulted in 21.41 quality-adjusted life-years. Early surgery and nonsurgical management yielded 20.42 and 21.06 quality-adjusted life-years, respectively. The model was robust and was not sensitive to variation in any of the parameters within the clinically plausible ranges. CONCLUSIONS Based on this decision analytic model, the optimal choice for breast cancer survivors with mild carpal tunnel syndrome who are at risk for lymphedema would be delaying surgery until severe symptoms develop. This strategy balances the potential increased risk of lymphedema following carpal tunnel release with the decreased long-term risk of severe carpal tunnel syndrome. The model comprehensively assesses a controversial area in the breast cancer and hand surgery literature to inform decision-making for patients and clinicians.
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The Optimal Age for Screening Adolescents and Young Adults Without Identified Risk Factors for HIV. J Adolesc Health 2018; 62:22-28. [PMID: 29273141 PMCID: PMC5745059 DOI: 10.1016/j.jadohealth.2017.08.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 08/31/2017] [Accepted: 08/31/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE To assess the optimal age at which a one-time HIV screen should begin for adolescents and young adults (AYA) in the U.S. without identified HIV risk factors, incorporating clinical impact, costs, and cost-effectiveness. METHODS We simulated HIV-uninfected 12-year-olds in the U.S. without identified risk factors who faced age-specific risks of HIV infection (.6-71.3/100,000PY). We modeled a one-time screen ($36) at age 15, 18, 21, 25, or 30, each in addition to current U.S. screening practices (30% screened by age 24). Outcomes included retention in care, virologic suppression, life expectancy, lifetime costs, and incremental cost-effectiveness ratios in $/year-of-life saved (YLS) from the health-care system perspective. In sensitivity analyses, we varied HIV incidence, screening and linkage rates, and costs. RESULTS All one-time screens detected a small proportion of lifetime infections (.1%-10.3%). Compared with current U.S. screening practices, a screen at age 25 led to the most favorable care continuum outcomes at age 25: proportion diagnosed (77% vs. 51%), linked to care (71% vs. 51%), retained in care (68% vs. 44%), and virologically suppressed (49% vs. 32%). Compared with the next most effective screen, a screen at age 25 provided the greatest clinical benefit, and was cost-effective ($96,000/YLS) by U.S. standards (<$100,000/YLS). CONCLUSIONS For U.S. AYA without identified risk factors, a one-time routine HIV screen at age 25, after the peak of incidence, would optimize clinical outcomes and be cost-effective compared with current U.S. screening practices. Focusing screening on AYA ages 18 or younger is a less efficient use of a one-time screen among AYA than screening at a later age.
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Zhang Y, Wu H, Denton BT, Wilson JR, Lobo JM. Probabilistic sensitivity analysis on Markov models with uncertain transition probabilities: an application in evaluating treatment decisions for type 2 diabetes. Health Care Manag Sci 2017; 22:34-52. [DOI: 10.1007/s10729-017-9420-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/22/2017] [Indexed: 10/18/2022]
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29
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Messori A, Caccese E, D'Avella MC. Estimating the 95% confidence interval for survival gain between an experimental anti-cancer treatment and a control. Ther Adv Med Oncol 2017; 9:721-723. [PMID: 29344108 PMCID: PMC5764153 DOI: 10.1177/1758834017731084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR Toscana, Regional Health System, via San Salvi 12, 50100 Florence, Italy
| | - Erminia Caccese
- HTA Unit, ESTAR Toscana, Regional Health System, Florence, Italy
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Xu W, Larbi A. Markers of T Cell Senescence in Humans. Int J Mol Sci 2017; 18:E1742. [PMID: 28796199 PMCID: PMC5578132 DOI: 10.3390/ijms18081742] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/22/2017] [Accepted: 07/26/2017] [Indexed: 12/25/2022] Open
Abstract
Many countries are facing the aging of their population, and many more will face a similar obstacle in the near future, which could be a burden to many healthcare systems. Increased susceptibility to infections, cardiovascular and neurodegenerative disease, cancer as well as reduced efficacy of vaccination are important matters for researchers in the field of aging. As older adults show higher prevalence for a variety of diseases, this also implies higher risk of complications, including nosocomial infections, slower recovery and sequels that may reduce the autonomy and overall quality of life of older adults. The age-related effects on the immune system termed as "immunosenescence" can be exemplified by the reported hypo-responsiveness to influenza vaccination of the elderly. T cells, which belong to the adaptive arm of the immune system, have been extensively studied and the knowledge gathered enables a better understanding of how the immune system may be affected after acute/chronic infections and how this matters in the long run. In this review, we will focus on T cells and discuss the surface and molecular markers that are associated with T cell senescence. We will also look at the implications that senescent T cells could have on human health and diseases. Finally, we will discuss the benefits of having these markers for investigators and the future work that is needed to advance the field of T cell senescence markers.
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Affiliation(s)
- Weili Xu
- Biology of Aging Program and Immunomonitoring Platform, Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Immunos Building, Biopolis, Singapore 138648, Singapore.
- School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore.
| | - Anis Larbi
- Biology of Aging Program and Immunomonitoring Platform, Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Immunos Building, Biopolis, Singapore 138648, Singapore.
- School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore.
- Department of Microbiology, National University of Singapore, Singapore 117597, Singapore.
- Department of Geriatrics, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1K 2R1, Canada.
- Faculty of Sciences, University ElManar, Tunis 1068, Tunisia.
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Decision-Making in Critical Limb Ischemia: A Markov Simulation. Ann Vasc Surg 2017; 45:1-9. [PMID: 28739455 DOI: 10.1016/j.avsg.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/08/2017] [Accepted: 07/17/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. METHODS We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses. RESULTS In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. CONCLUSIONS For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.
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Ennezat PV, Cosgrove S, Bouvaist H, Maréchaux S, Guerbaai RA, Le Jemtel T, Andréjak M, Vital-Durand D. From evidence-based medicine to personalized medicine, with particular emphasis on drug-safety monitoring. Arch Cardiovasc Dis 2017; 110:413-419. [PMID: 28552224 DOI: 10.1016/j.acvd.2017.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 01/09/2023]
Abstract
Nowadays, guidelines are derived from the findings of randomized controlled therapeutic trials. However, an overall significant P value does not exclude that some patients may be harmed by or will not respond to the therapeutic agent being studied. Trials in patients with a low risk of events and/or a limited chance of providing significant differences in therapeutic effects require a large patient population to demonstrate a beneficial effect. Composite efficacy endpoints are often employed to obviate the need for a large patient population when low rates of events or limited therapeutic efficacy are anticipated. Results of randomized controlled therapeutic trials are commonly expressed in terms of relative risk reduction, whereas absolute risk reduction allows the calculation of the "number needed to treat" to prevent an adverse outcome. The number needed to treat is a far more clinically relevant variable than relative risk reduction. The clinician's mission is to match treatment to patient with the goal of achieving optimal therapeutic response. Drug-safety monitoring is also of major importance to avoid exposing patients to irreversible adverse effects. Unfortunately, drug-safety monitoring is often overlooked in routine clinical practice. Finally, the lack of long-term therapeutic data (>5-10 years) is an unsolved dilemma, as most trials are limited to a duration of a few months or years.
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Affiliation(s)
| | - Shona Cosgrove
- Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Hélène Bouvaist
- Service de Cardiologie, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
| | - Sylvestre Maréchaux
- Department of Cardiology, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté Libre de Médecine, Université Catholique de Lille, 59000 Lille, France; INSERM U1088, Université de Picardie, Amiens, France
| | | | - Thierry Le Jemtel
- Tulane University Heart and Vascular Institute, Tulane School of Medicine, New Orleans, LA, USA
| | - Michel Andréjak
- Department of Clinical Pharmacology, CHU d'Amiens, 80054 Amiens cedex 1, France
| | - Denis Vital-Durand
- Department of Internal Medicine, CHU Lyon Sud, 69310 Pierre-Bénite, France
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Wallis CJD, Morton G, Jerath A, Satkunasviam R, Szumacher E, Herschorn S, Kodama RT, Kulkarni GS, Naimark D, Nam RK. Adjuvant Versus Salvage Radiotherapy for Patients With Adverse Pathological Findings Following Radical Prostatectomy: A Decision Analysis. MDM Policy Pract 2017; 2:2381468317709476. [PMID: 30288422 PMCID: PMC6124936 DOI: 10.1177/2381468317709476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 04/05/2017] [Indexed: 01/28/2023] Open
Abstract
Background: Patients undergoing surgery for prostate cancer who have
adverse pathological findings experience high rates of recurrence. While there
are data supporting adjuvant radiotherapy compared to a wait-and-watch strategy
to reduce recurrence rates, there are no randomized controlled trials comparing
adjuvant radiotherapy with the other standard of care, salvage radiotherapy
(radiotherapy administered at the time of recurrence). Methods: We
constructed a health state transition (Markov) model employing two-dimensional
Monte Carlo simulation using a lifetime horizon to compare the quality-adjusted
survival associated with postoperative strategies using adjuvant or salvage
radiotherapy. Prior to analysis, we calibrated and validated our model using the
results of previous randomized controlled trials. We considered clinically
important oncological health states from immediately postoperative to prostate
cancer–specific death, commonly described complications from prostate cancer
treatment, and other causes of mortality. Transition probabilities and utilities
for disease states were derived from a literature search of MEDLINE and expert
consensus. Results: Salvage radiotherapy was associated with an
increased quality-adjusted life expectancy (QALE) (58.3 months) as compared with
adjuvant radiotherapy (53.7 months), a difference of 4.6 months (standard
deviation 8.8). Salvage radiotherapy had higher QALE in 53% of hypothetical
cohorts. There was a minimal difference in overall life expectancy (-0.1
months). Examining recurrence rates, our model showed validity when compared
with available randomized controlled data. Conclusions: A salvage
radiotherapy strategy appears to provide improved QALE for patients with adverse
pathological findings following radical prostatectomy, compared with adjuvant
radiotherapy. As these findings reflect, population averages, specific patient
and tumor factors, and patient preferences remain central for individualized
management.
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Affiliation(s)
- Christopher J D Wallis
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Gerard Morton
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Angela Jerath
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Raj Satkunasviam
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Ewa Szumacher
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre (CJDW, RS, SH, RTK, RKN), University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (CJDW, AJ, DN, RKN), University of Toronto, Toronto, Ontario, Canada.,Department of Radiation Oncology (GM, ES), University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia (AJ), University of Toronto, Toronto, Ontario, Canada.,Division of Urology, University Health Network (GSK), University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre (DN), University of Toronto, Toronto, Ontario, Canada
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Messori A, Trippoli S, Marinai C. Appraisal of Innovative Anticancer Agents: Do the Scores of European Society for Medical Oncology–Magnitude of Clinical Benefit Scale and American Society of Clinical Oncology Task Force Correlate With Survival Gains? J Clin Oncol 2017; 35:1132-1133. [DOI: 10.1200/jco.2016.69.2731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrea Messori
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
| | - Claudio Marinai
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
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35
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Guy GP, Zhang Y, Ekwueme DU, Rim SH, Watson M. The potential impact of reducing indoor tanning on melanoma prevention and treatment costs in the United States: An economic analysis. J Am Acad Dermatol 2016; 76:226-233. [PMID: 27939556 DOI: 10.1016/j.jaad.2016.09.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/06/2016] [Accepted: 09/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Indoor tanning is associated with an increased risk of melanoma. The US Food and Drug Administration proposed prohibiting indoor tanning among minors younger than 18 years. OBJECTIVE We sought to estimate the health and economic benefits of reducing indoor tanning in the United States. METHODS We used a Markov model to estimate the expected number of melanoma cases and deaths averted, life-years saved, and melanoma treatment costs saved by reducing indoor tanning. We examined 5 scenarios: restricting indoor tanning among minors younger than 18 years, and reducing the prevalence by 20%, 50%, 80%, and 100%. RESULTS Restricting indoor tanning among minors younger than 18 years was estimated to prevent 61,839 melanoma cases, prevent 6735 melanoma deaths, and save $342.9 million in treatment costs over the lifetime of the 61.2 million youth age 14 years or younger in the United States. The estimated health and economic benefits increased as indoor tanning was further reduced. LIMITATIONS Limitations include the reliance on available data and not examining compliance to indoor tanning laws. CONCLUSIONS Reducing indoor tanning has the potential to reduce melanoma incidence, mortality, and treatment costs. These findings help quantify and underscore the importance of continued efforts to reduce indoor tanning and prevent melanoma.
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Affiliation(s)
- Gery P Guy
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Yuanhui Zhang
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Donatus U Ekwueme
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sun Hee Rim
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Meg Watson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Chambers JD, Thorat T, Pyo J, Chenoweth M, Neumann PJ. Despite high costs, specialty drugs may offer value for money comparable to that of traditional drugs. Health Aff (Millwood) 2016; 33:1751-60. [PMID: 25288419 DOI: 10.1377/hlthaff.2014.0574] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Specialty drugs are often many times more expensive than traditional drugs, which raises questions of affordability and value. We compared the value of specialty and traditional drugs approved by the Food and Drug Administration (FDA) in the period 1999-2011. To do this, we identified published estimates of additional health gains (measured in quality-adjusted life-years, or QALYs) and increased costs of drug and health care resource use that were associated with fifty-eight specialty drugs and forty-four traditional drugs, compared to preexisting care. We found that specialty drugs offered greater QALY gains (0.183 versus 0.002 QALYs) but were associated with greater additional costs ($12,238 versus $784), compared to traditional drugs. The two types of drugs had comparable cost-effectiveness. However, the distributions across the two types differed, with 26 percent of specialty drugs--but only 9 percent of traditional drugs--associated with incremental cost-effectiveness ratios of greater than $150,000 per QALY. Our study suggests that although specialty drugs often have higher costs than traditional drugs, they also tend to confer greater benefits and hence may still offer reasonable value for money.
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Affiliation(s)
- James D Chambers
- James D. Chambers is an investigator at the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and an assistant professor of medicine in the School of Medicine, Tufts University, in Boston, Massachusetts
| | - Teja Thorat
- Teja Thorat is a research associate at the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center
| | - Junhee Pyo
- Junhee Pyo was a research associate at the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, when she worked on this article. She is currently preparing to enroll in a Ph.D. program to earn a doctorate in health economics
| | - Matthew Chenoweth
- Matthew Chenoweth is a research associate at the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center
| | - Peter J Neumann
- Peter J. Neumann is director of the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, and a professor of medicine in the School of Medicine at Tufts University
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37
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Life Expectancy and Years of Potential Life Lost: Useful Outcome Measures in Cardiovascular Medicine? J Am Coll Cardiol 2016; 66:656-8. [PMID: 26248992 DOI: 10.1016/j.jacc.2015.05.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/12/2015] [Indexed: 11/22/2022]
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38
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Tumor Anatomy Scoring and Renal Function for Nephron-Sparing Treatment Selection in Patients With Small Renal Masses: A Microsimulation-Based Decision Analysis. AJR Am J Roentgenol 2016; 207:344-53. [DOI: 10.2214/ajr.15.15823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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39
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Canudas-Romo V, DuGoff E, Wu AW, Ahmed S, Anderson G. Life Expectancy in 2040: What Do Clinical Experts Expect? ACTA ACUST UNITED AC 2016. [DOI: 10.1080/10920277.2016.1179123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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40
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Authors' Reply: Is Genotype Testing Really Cost-Effective for Primary Resistance in Brazil? J Acquir Immune Defic Syndr 2016; 71:e56. [PMID: 26579987 DOI: 10.1097/qai.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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41
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Mannan H, Curtis AJ, Forbes A, Magliano DJ, Lowthian JA, Gambhir M, McNeil JJ. Improvements in life expectancy among Australians due to reductions in smoking: Results from a risk percentiles approach. BMC Public Health 2016; 16:77. [PMID: 26813029 PMCID: PMC4729127 DOI: 10.1186/s12889-016-2750-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 01/19/2016] [Indexed: 11/11/2022] Open
Abstract
Background Tobacco smoking is a major burden on the Australian population in terms of health, social and economic costs. Because of this, in 2008, all Australian Governments agreed to set targets to reduce prevalence of smoking to 10 % by 2018 and subsequently introduced several very strong anti-smoking measures. On this backdrop, we estimated in 2012-13 the impact of several scenarios related to reduction of smoking prevalence to 10 % across the entire Australian population and for below specific ages, on improving life expectancy. Methods Using the risk percentiles method the Australian Diabetes, Obesity and Lifestyle (AUSDIAB) baseline survey and the Australian Bureau of Statistics (ABS) age-sex specific death counts were analyzed. Results Amongst men the gains in life expectancy associated with 10 % smoking prevalence are generally greater than those of women with average life expectancy for men increasing by 0.11 to 0.41 years, and for women by 0.12 to 0.29 years. These are at best 54 % and 49 % for men and women of the gains achieved by complete smoking cessation. The gains plateau for interventions targeting those <70 and <80 years. Amongst smokers the potential gains are much greater, with an increase in average life expectancy amongst men smokers of 0.43 to 2.08 years, and 0.73 to 2.05 years amongst women smokers. These are at best 46 % and 38 % for men and women smokers of the gains achieved by complete smoking cessation. Conclusion The estimated optimum gain in life expectancy is consistent with potentially moderate gains which occur when both men and women below 60 years are targeted to reduce smoking prevalence to 10 %. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2750-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haider Mannan
- Centre for Health Research, School of Medicine, Western Sydney University, Building 3, level G, Campbelltown campus, NSW, 2560, Australia.
| | - Andrea J Curtis
- Department of Epidemiology & Preventive Medicine, Monash University, level 3, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Andrew Forbes
- Department of Epidemiology & Preventive Medicine, Monash University, level 3, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Dianna J Magliano
- Baker International Diabetes Institute, Melbourne, Victoria, 3805, Australia
| | - Judy A Lowthian
- Department of Epidemiology & Preventive Medicine, Monash University, level 3, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Manoj Gambhir
- Department of Epidemiology & Preventive Medicine, Monash University, level 3, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - John J McNeil
- Department of Epidemiology & Preventive Medicine, Monash University, level 3, Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia
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Fanari Z, Weiss S, Weintraub WS. Cost Effectiveness of Antiplatelet and Antithrombotic Therapy in the Setting of Acute Coronary Syndrome: Current Perspective and Literature Review. Am J Cardiovasc Drugs 2015; 15:415-27. [PMID: 26068886 PMCID: PMC4661116 DOI: 10.1007/s40256-015-0131-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Acute coronary syndromes (ACS) are associated with high rates of morbidity and mortality. The advances of antiplatelet and anticoagulation therapy over several years time have resulted in improved in cardiac outcomes, but with increased health care costs. Multiple cost-effectiveness studies have been performed to evaluate the use of available antiplatelet agents and anticoagulation in the setting of both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Early on, the use of glycoprotein IIb/IIIa receptor inhibitors (GPIs) proved to be economically attractive in the management of ACS; however, the introduction of P2Y12 receptor antagonists limited their use to a bail out agents in complex interventions. Generic clopidogrel is probably still an economically attractive P2Y12 receptor antagonist choice, especially in low-risk ACS, while both ticagrelor and prasugrel present an economically attractive alternative option, especially in high-risk ACS and patients at risk for stent thrombosis. While enoxaparin presents an economically dominant alternative to heparin in NSTE-ACS, its role in STEMI in the contemporary era is unclear. During percutaneous coronary intervention (PCI), bivalirudin monotherapy was shown to be an economically dominant alternative to the combination of heparin and GPI in ACS. However, new studies may suggest that using heparin monotherapy may offer an attractive alternative. The comparative and cost effectiveness of different combinations of antiplatelet and antithrombotic therapy will be the focus of future expected clinical and economic assessments.
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Affiliation(s)
- Zaher Fanari
- Section of Cardiology, Christiana Care Health System, 4755 Ogletown-Stanton Rd., Newark, DE, 19718, USA.
| | - Sandra Weiss
- Section of Cardiology, Christiana Care Health System, 4755 Ogletown-Stanton Rd., Newark, DE, 19718, USA
| | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, 4755 Ogletown-Stanton Rd., Newark, DE, 19718, USA
- Value Institute, Christiana Care Health System, Newark, DE, USA
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Kristensen ML, Christensen PM, Hallas J. The effect of statins on average survival in randomised trials, an analysis of end point postponement. BMJ Open 2015; 5:e007118. [PMID: 26408281 PMCID: PMC4593138 DOI: 10.1136/bmjopen-2014-007118] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To estimate the average postponement of death in statin trials. SETTING A systematic literature review of all statin trials that presented all-cause survival curves for treated and untreated. INTERVENTION Statin treatment compared to placebo. PRIMARY OUTCOME MEASURES The average postponement of death as represented by the area between the survival curves. RESULTS 6 studies for primary prevention and 5 for secondary prevention with a follow-up between 2.0 and 6.1 years were identified. Death was postponed between -5 and 19 days in primary prevention trials and between -10 and 27 days in secondary prevention trials. The median postponement of death for primary and secondary prevention trials were 3.2 and 4.1 days, respectively. CONCLUSIONS Statin treatment results in a surprisingly small average gain in overall survival within the trials' running time. For patients whose life expectancy is limited or who have adverse effects of treatment, withholding statin therapy should be considered.
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Affiliation(s)
| | | | - Jesper Hallas
- Department of Clinical Pharmacology, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice. Br J Gen Pract 2015; 64:e199-207. [PMID: 24686884 DOI: 10.3399/bjgp14x677824] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients. AIM To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication. DESIGN AND SETTING Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations. METHOD GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication. RESULTS Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats. CONCLUSION Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.
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Fanari Z, Weintraub WS. Cost-effectiveness of transcatheter versus surgical management of structural heart disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 17:44-7. [PMID: 26440768 DOI: 10.1016/j.carrev.2015.08.011] [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: 05/02/2015] [Revised: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
Transcatheter management of valvular and structural heart disease is the most growing aspect of interventional cardiology. While the early experience was limited to patients who were not candidate for surgery, the continuous improvement in the efficacy and safety expanded its use to different degree depending on the procedure and the disease involved. The cost of these procedures is a major concern for health care in developed world. Cost-effectiveness of these transcatheter structural procedures varies depending on the procedure itself, the burden of the underlying disease, the feasibility and cost of both the Transcatheter and surgical procedures. In this review, we turn now to a specific discussion of the medical economics of percutaneous valvular and structural interventions.
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Affiliation(s)
- Zaher Fanari
- Division of Cardiology, University of Kansas School of Medicine, Kansas City, KS.
| | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, Newark, DE; Value institute, Christiana Care Health System, Newark, DE
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Il Beneficio dei Farmaci Oncologici: Commento All'Articolo di Ballatori e Colleghi. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2015. [DOI: 10.5301/grhta.5000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Fanari Z, Weintraub WS. Cost-effectiveness of medical, endovascular and surgical management of peripheral vascular disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:421-5. [PMID: 26238266 DOI: 10.1016/j.carrev.2015.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/14/2015] [Accepted: 06/22/2015] [Indexed: 11/16/2022]
Abstract
Peripheral arterial disease (PAD) is responsible for 20% of all US hospital admissions. Management of PAD has evolved over time to include many medical and transcatheter interventions in addition to the traditional surgical approach. Non-invasive interventions including supervised exercise programs and antiplatelets use are economically attractive therapies that should be considered in all patients at risk. While surgery offers so far a clinically and economically appropriate option, the improvement of percutaneous transluminal angioplasty (PTA) technique with the addition of drug-coated balloons offers a reasonably clinically and economically attractive alternative that will continue to evolve in the future.
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Affiliation(s)
- Zaher Fanari
- Section of Cardiology, Christiana Care Health System, Newark, DE.
| | - William S Weintraub
- Section of Cardiology, Christiana Care Health System, Newark, DE; Value institute, Christiana Care Health System, Newark, DE
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Schaer B, Kühne M, Reichlin T, Osswald S, Sticherling C. Incidence of and predictors for appropriate implantable cardioverter-defibrillator therapy in patients with a secondary preventive implantable cardioverter-defibrillator indication. Europace 2015; 18:227-31. [DOI: 10.1093/europace/euv188] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/01/2015] [Indexed: 12/31/2022] Open
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Müller D, Borsi L, Stracke C, Stock S, Stollenwerk B. Cost-effectiveness of a multifactorial fracture prevention program for elderly people admitted to nursing homes. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:517-527. [PMID: 24818587 DOI: 10.1007/s10198-014-0605-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 04/14/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Fractures are one of the most costly consequences of falls in elderly patients in nursing homes. OBJECTIVES To compare the cost-effectiveness of a 'multifactorial fracture prevention program' provided by a multidisciplinary team with 'no prevention' in newly admitted nursing home residents. METHODS We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses. RESULTS Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of 21,353 euro per quality-adjusted life-year. The total costs for SHI/LCI would result in 1.7 euro million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses. CONCLUSION Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.
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Affiliation(s)
- Dirk Müller
- Cologne Institute for Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Cologne, Germany,
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Abstract
We investigate how beliefs about the efficacy of medical interventions are influenced by searchers' exposure to information on retrieved Web pages. We present a methodology for measuring participants' beliefs and confidence about the efficacy of treatment before, during, and after search episodes. We consider interventions studied in the Cochrane collection of meta-analyses. We extract related queries from search engine logs and consider the Cochrane assessments as ground truth. We analyze the dynamics of belief over time and show the influence of prior beliefs and confidence at the end of sessions. We present evidence for confirmation bias and for anchoring-and-adjustment during search and retrieval. Then, we build predictive models to estimate postsearch beliefs using sets of features about behavior and content. The findings provide insights about the influence of Web content on the beliefs of people and have implications for the design of search systems.
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