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Bernacki GM, McDermott CL, Matlock DD, O'Hare AM, Brumback L, Bansal N, Kirkpatrick JN, Engelberg RA, Curtis JR. Advance Care Planning Documentation and Intensity of Care at the End of Life for Adults With Congestive Heart Failure, Chronic Kidney Disease, and Both Illnesses. J Pain Symptom Manage 2022; 63:e168-e175. [PMID: 34363954 PMCID: PMC8814047 DOI: 10.1016/j.jpainsymman.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Heart failure (HF) and chronic kidney disease (CKD) are associated with high morbidity and mortality, especially in combination, yet little is known about the impact of these conditions together on end-of-life care. OBJECTIVES Compare end-of-life care and advance care planning (ACP) documentation among patients with both HF and CKD to those with either condition. METHODS We conducted a retrospective analysis of deceased patients (2010-2017) with HF and CKD (n = 1673), HF without CKD (n = 2671), and CKD without HF (n = 1706), excluding patients with cancer or dementia. We compared hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, hospital deaths, and ACP documentation >30 days before death. RESULTS 39% of patients with HF and CKD were hospitalized and 33% were admitted to the ICU in the last 30 days vs. 30% and 28%, respectively, for HF, and 26% and 23% for CKD. Compared to patients with both conditions, those with only 1 were less likely to be admitted to the hospital [HF: adjusted odds ratio (aOR) 0.72, 95%CI 0.63-0.83; CKD: aOR 0.63, 95%CI 0.53-0.75] and ICU (HF: aOR 0.83, 95%CI 0.71-0.94; CKD: aOR 0.68, 95%CI 0.56-0.80) and less likely to have ACP documentation (aOR 0.53, 95%CI 0.47-0.61 and aOR 0.70, 95%CI 0.60-0.81). CONCLUSIONS Decedents with both HF and CKD had more ACP documentation and received more intensive end-of-life care than those with only 1 condition. These findings suggest that patients with co-existing HF and CKD may benefit from interventions to ensure care received aligns with their goals.
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Affiliation(s)
- Gwen M Bernacki
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA.
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine (D.D.M.), Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center (D.D.M.), Denver, CO
| | - Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - Lyndia Brumback
- Department of Biostatistics, University of Washington (L.B.), Seattle
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Jared Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA
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Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis. AJR Am J Roentgenol 2019; 212:830-838. [PMID: 30779659 DOI: 10.2214/ajr.18.20415] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The objective of our study was to evaluate the cost-effectiveness of active surveillance (AS) versus nephron-sparing surgery (NSS) in patients with a Bosniak IIF or III renal cyst. MATERIALS AND METHODS Markov models were developed to estimate life expectancy and lifetime costs for 60-year-old patients with a Bosniak IIF or III renal cyst (the reference cases) managed by AS versus NSS. The models incorporated the malignancy rates, reclassification rates during follow-up, treatment effectiveness, complications and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify management preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold, using data from studies in the literature and the 2015 Medicare Physician Fee Schedule. The effects of key parameters were addressed in a multiway sensitivity analysis. RESULTS The prevalence of malignancy for Bosniak IIF and III renal cysts was 26% (25/96) and 52% (542/1046). Under base case assumptions for Bosniak IIF cysts, the incremental cost-effectiveness ratio of NSS relative to AS was $731,309 per QALY for women, exceeding the assumed societal willingness-to-pay threshold, and AS outperformed NSS for both life expectancy and cost for men. For Bosniak III cysts, AS yielded greater life expectancy (24.8 and 19.4 more days) and lower lifetime costs (cost difference of $12,128 and $11,901) than NSS for men and women, indicating dominance of AS over NSS. Superiority of AS held true in sensitivity analyses for men 46 years old or older and women 57 years old or older even when all parameters were set to favor NSS. CONCLUSION AS is more cost-effective than NSS for patients with a Bosniak IIF or III renal cyst.
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Looi KL, Sidhu K, Cooper L, Dawson L, Slipper D, Gavin A, Lever N. Long-term outcomes of heart failure patients who received primary prevention implantable cardioverter-defibrillator: An observational study. J Arrhythm 2017; 34:46-54. [PMID: 29721113 PMCID: PMC5828273 DOI: 10.1002/joa3.12027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/20/2017] [Indexed: 11/07/2022] Open
Abstract
Background Implantable cardioverter-defibrillator (ICD) therapy is indicated for selected heart failure patients for the primary prevention of sudden cardiac death. Little is known about the outcomes in patients selected for primary prevention device therapy in the northern region of New Zealand. Method Heart failure patients with systolic dysfunction who underwent primary prevention ICD/cardiac resynchronization therapy-defibrillator (CRT-D) implantation between January 1, 2007, and June 1, 2015, were included. Complications, mortality, and hospitalization events were reviewed. Results Three hundred and eighty-five primary prevention devices were implanted (269 ICD, 116 CRT-D). Mean age at implant was 59.1 ± 11.4 years. Mean duration of follow-up was 3.64 ± 2.17 years. The commonest cause of death was heart failure (41.8%). Only 2 patients died from sudden arrhythmic death. The 5-year heart failure mortality rate was 6%, whereas the 5-year sudden arrhythmic death rate was 0.3%. Heart failure hospitalizations were commoner in those who received ICD than CRT-D (67.7% vs 25.8%, P < .001). Maori patients have low implant rates (14%) with relatively high rates of admissions with heart failure and ventricular arrhythmia admissions. Conclusions Even in appropriately selected heart failure patients who received primary prevention devices, only a small percentage died as a result of sudden arrhythmic death. CRT-D should be the device of choice where appropriate in heart failure patients. Significant challenges remain to improve access to device therapy and maximize benefit to those who do get implanted.
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Affiliation(s)
- Khang-Li Looi
- Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
| | - Karishma Sidhu
- Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
| | - Lisa Cooper
- Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
| | - Liane Dawson
- Cardiovascular Division North Shore Hospital Auckland New Zealand
| | - Debbie Slipper
- Cardiovascular Division North Shore Hospital Auckland New Zealand
| | - Andrew Gavin
- Cardiovascular Division North Shore Hospital Auckland New Zealand
| | - Nigel Lever
- Green Lane Cardiovascular Service Auckland City Hospital Auckland New Zealand
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MRI-guided focused ultrasound surgery for uterine fibroid treatment: a cost-effectiveness analysis. AJR Am J Roentgenol 2014; 203:361-71. [PMID: 25055272 DOI: 10.2214/ajr.13.11446] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this article is to evaluate the cost effectiveness of a treatment strategy for symptomatic uterine fibroids that uses MRI-guided focused ultrasound as a first-line therapy relative to uterine artery embolization (UAE) or hysterectomy. MATERIALS AND METHODS. We developed a decision-analytic model to compare the cost effectiveness of three first-line treatment strategies: MRI-guided focused ultrasound, UAE, and hysterectomy. Treatment-specific short- and long-term utilities, lifetime costs, and quality-adjusted life years (QALYs) were incorporated, allowing us to conduct an incremental cost-effectiveness analysis, using a societal willingness-to-pay (WTP) threshold of $50,000/QALY to designate a strategy as cost effective. Sensitivity analyses were subsequently performed on all key parameters. RESULTS. In the base-case analysis, UAE as a first-line treatment of symptomatic fibroids was the most effective and expensive strategy (22.75 QALYs; $22,968), followed by MRI-guided focused ultrasound (22.73 QALYs; $20,252) and hysterectomy (22.54 QALYs; $11,253). MRI-guided focused ultrasound was cost effective relative to hysterectomy, with an associated incremental cost-effectiveness ratio (ICER) of $47,891/QALY. The ICER of UAE relative to MRI-guided focused ultrasound was $234,565/QALY, exceeding the WTP threshold of $50,000/QALY, therefore rendering MRI-guided focused ultrasound also cost effective relative to UAE. In sensitivity analyses, results were robust to changes in most parameters but were sensitive to changes in probabilities of recurrence, symptom relief, and quality-of-life measures. CONCLUSION. First-line treatment of eligible women with MRI-guided focused ultra-sound is a cost-effective noninvasive strategy. For those not eligible for MRI-guided focused ultra-sound, UAE remains a cost-effective option. These recommendations integrate both the short- and long-term decrements in quality of life associated with the specific treatment modalities.
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Federman DG, Kirsner RS, Viola KV. Skin cancer screening and primary prevention: facts and controversies. Clin Dermatol 2014; 31:666-70. [PMID: 24160270 DOI: 10.1016/j.clindermatol.2013.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.
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Affiliation(s)
- Daniel G Federman
- VA Connecticut Healthcare System, West Haven, CT and Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA.
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Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res 2014; 8:165-78. [DOI: 10.1586/14737167.8.2.165] [Citation(s) in RCA: 487] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Curiel-Lewandrowski C, Kim CC, Swetter SM, Chen SC, Halpern AC, Kirkwood JM, Leachman SA, Marghoob AA, Ming ME, Grichnik JM. Survival is not the only valuable end point in melanoma screening. J Invest Dermatol 2012; 132:1332-7. [PMID: 22336950 PMCID: PMC4575123 DOI: 10.1038/jid.2012.3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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8
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Bernard ML, Gold MR. Economic Implications and Cost-effectiveness of Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy. Heart Fail Clin 2011; 7:241-50, ix. [DOI: 10.1016/j.hfc.2010.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Langford P, Chrisp P. Fosaprepitant and aprepitant: an update of the evidence for their place in the prevention of chemotherapy-induced nausea and vomiting. CORE EVIDENCE 2010; 5:77-90. [PMID: 21042544 PMCID: PMC2963924 DOI: 10.2147/ce.s6012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The selective neurokinin-1 receptor antagonist aprepitant is effective in the treatment of acute and delayed chemotherapy-induced nausea and vomiting (CINV) associated with both moderately and highly emetogenic chemotherapy. Fosaprepitant has been developed as an intravenous prodrug of aprepitant. AIMS To update the evidence underlying the use of fosaprepitant to prevent CINV. EVIDENCE REVIEW Aprepitant in combination with a serotonin antagonist and a corticosteroid controls acute and delayed symptoms of CINV in patients receiving moderately to highly emetogenic chemotherapy. Bioequivalence of fosaprepitant with aprepitant has recently been demonstrated, which has led to its inclusion in clinical guidelines for treatment of acute CINV with highly, and some regimens of moderately, emetogenic chemotherapy. Early studies of the clinical efficacy of fosaprepitant have shown improvement over treatment with ondansetron. Both aprepitant and fosaprepitant are well tolerated with most adverse events observed of mild or moderate intensity. Conflicting economic evidence has shown that whilst aprepitant provides an increased quality of life in patients treated for CINV, there are differing views over its absolute cost in relation to standard therapy. The incremental cost-effectiveness ratio of aprepitant, however, appears to lie within acceptable bounds. PLACE IN THERAPY Fosaprepitant and aprepitant are recommended in guidelines for preventing CINV due to moderately and highly emetogenic chemotherapy. Fosaprepitant is bioequivalent to aprepitant, and could offer potential benefits for patients who may be unable to tolerate oral administration of antiemetics during an episode of nausea or vomiting.
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Affiliation(s)
| | - Paul Chrisp
- Core Medical Publishing, Knutsford, UK; These affiliations were correct at the time the manuscript was prepared
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Pandharipande PV, Gervais DA, Hartman RI, Harisinghani MG, Feldman AS, Mueller PR, Gazelle GS. Renal mass biopsy to guide treatment decisions for small incidental renal tumors: a cost-effectiveness analysis. Radiology 2010; 256:836-46. [PMID: 20720070 PMCID: PMC2923731 DOI: 10.1148/radiol.10092013] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate the effectiveness, cost, and cost-effectiveness of using renal mass biopsy to guide treatment decisions for small incidentally detected renal tumors. MATERIALS AND METHODS A decision-analytic Markov model was developed to estimate life expectancy and lifetime costs for patients with small (< or = 4-cm) renal tumors. Two strategies were compared: renal mass biopsy to triage patients to surgery or imaging surveillance and empiric nephron-sparing surgery. The model incorporated biopsy performance, the probability of track seeding with malignant cells, the prevalence and growth of benign and malignant tumors, treatment effectiveness and costs, and patient outcomes. An incremental cost-effectiveness analysis was performed to identify strategy preference under a willingness-to-pay threshold of $75,000 per quality-adjusted life-year (QALY). Effects of changes in key parameters on strategy preference were evaluated in sensitivity analysis. RESULTS Under base-case assumptions, the biopsy strategy yielded a minimally greater quality-adjusted life expectancy (4 days) than did empiric surgery at a lower lifetime cost ($3466), dominating surgery from a cost-effectiveness perspective. Over the majority of parameter ranges tested in one-way sensitivity analysis, the biopsy strategy dominated surgery or was cost-effective relative to surgery based on a $75,000-per-QALY willingness-to-pay threshold. In two-way sensitivity analysis, surgery yielded greater life expectancy when the prevalence of malignancy and propensity for biopsy-negative cancers to metastasize were both higher than expected or when the sensitivity and specificity of biopsy were both lower than expected. CONCLUSION The use of biopsy to guide treatment decisions for small incidentally detected renal tumors is cost-effective and can prevent unnecessary surgery in many cases.
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Affiliation(s)
- Pari V Pandharipande
- Department of Abdominal Imaging and Interventional Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA 02114, USA.
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Otero HJ, Rybicki FJ, Greenberg D, Neumann PJ. Twenty years of cost-effectiveness analysis in medical imaging: are we improving? Radiology 2008; 249:917-25. [PMID: 19011188 DOI: 10.1148/radiol.2493080237] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE To determine the growth rate, methodologic clarity, and quality changes in cost-effectiveness analyses (CEAs) and to assess whether the U.S. Panel on Cost-effectiveness in Health and Medicine recommendations affected CEA studies in which imaging technologies were evaluated. MATERIALS AND METHODS Six databases were systematically searched for CEA reports published between 1985 and 2005. All imaging-related studies were selected and grouped according to year, country, and journal of publication, as well as imaging modality and disease being studied. Two readers with formal training in decision analysis and CEA used a seven-point (1, low; 7, high) Likert scale based on reasonableness of assumptions, quality of presentation, and adherence to guidelines to independently evaluate study quality. Quality scores according to year, country, and journal of publication were compared with the unpaired Student t test. RESULTS The first radiology-related CEA was published in 1985; 111 radiology-related CEAs were published between 1985 and 2005. The average number of studies increased from 1.6 per year between 1985 and 1995 to 9.4 per year between 1996 and 2005. Eighty-six studies were performed to evaluate diagnostic imaging technologies, and 25 were performed to evaluate interventional imaging technologies. Ultrasonography (35.0%), angiography (31.5%), magnetic resonance imaging (22.5%), and computed tomography (19.8%) were evaluated most frequently. Forty-nine studies received government funds; 42 did not disclose the source of funding. The mean quality score was 4.23 +/- 1.12 (standard deviation), without significant improvement over time. Scores in studies performed in the United States were significantly higher than scores in studies that were not performed in the United States (4.45 +/- 1.02 vs 3.61 +/- 1.17, respectively; P < .01). Scores were also higher in journals with three or more CEA articles published during the study period than in journals with two or fewer CEA articles published during this period (4.54 +/- 1.09 vs 3.91 +/- 1.06, respectively; P < .01). CONCLUSION CEAs are an important tool with which to analyze the value of diagnostic imaging. However, improvement in the quality of analyses is needed. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/249/3/917/DC1.
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Affiliation(s)
- Hansel J Otero
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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Staging MR Lymphangiography of the Axilla for Early Breast Cancer: Cost-Effectiveness Analysis. AJR Am J Roentgenol 2008; 191:1308-19. [DOI: 10.2214/ajr.07.3861] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Gelblum DY, Amols H. Implanted cardiac defibrillator care in radiation oncology patient population. Int J Radiat Oncol Biol Phys 2008; 73:1525-31. [PMID: 18977096 DOI: 10.1016/j.ijrobp.2008.06.1903] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 06/19/2008] [Accepted: 06/20/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To review the experience of a large cancer center with radiotherapy (RT) patients bearing implantable cardiac defibrillators (ICDs) to propose some preliminary care guidelines as we learn more about the devices and their interaction with the therapeutic radiation environment. METHODS AND MATERIALS We collected data on patients with implanted ICDs treated with RT during a 2.5-year period at any of the five Memorial Sloan-Kettering clinical campuses. Information regarding the model, location, and dose detected from the device, as well as the treatment fields, fraction size, and treatment energy was collected. During this time, a new management policy for these patients had been implemented requiring treatment with low-energy beams (6 MV) and close surveillance of the patients in partnership with their electrophysiologist, as they received RT. RESULTS During the study period, 33 patients were treated with an ICD in place. One patient experienced a default of the device to its initial factory setting that was detected by the patient hearing an auditory signal from the device. This patient had initially been treated with a 15-MV beam. After this episode, his treatment was replanned to be completed with 6-MV photons, and he experienced no further events. CONCLUSION Patients with ICDs and other implanted computer-controlled devices will be encountered more frequently in the RT department, and proper management is important. We present a policy for the safe treatment of these patients in the radiation oncology environment.
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Affiliation(s)
- Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 11725, USA.
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Eliminating out-of-pocket drug costs may improve outcomes after myocardial infarction—but at what cost to Medicare? ACTA ACUST UNITED AC 2008; 5:606-7. [DOI: 10.1038/ncpcardio1309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 06/18/2008] [Indexed: 11/08/2022]
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Ibrahim T. Academic internal medicine in the United States: current trends, future implications for academic nephrology. Clin J Am Soc Nephrol 2008; 3:1887-94. [PMID: 18667740 DOI: 10.2215/cjn.02110508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Pandharipande PV, Gervais DA, Mueller PR, Hur C, Gazelle GS. Radiofrequency ablation versus nephron-sparing surgery for small unilateral renal cell carcinoma: cost-effectiveness analysis. Radiology 2008; 248:169-78. [PMID: 18458248 DOI: 10.1148/radiol.2481071448] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the relative cost-effectiveness of percutaneous radiofrequency (RF) ablation versus nephron-sparing surgery (NSS) in patients with small (<or=4-cm) renal cell carcinoma (RCC), given a commonly accepted level of societal willingness to pay. MATERIALS AND METHODS A decision-analytic Markov model was developed to estimate life expectancy and lifetime costs for 65-year-old patients with a small RCC treated with RF ablation or NSS. The model incorporated RCC presence, treatment effectiveness and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify treatment preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold level, within proposed ranges for guiding implementation of new health care interventions. The effect of changes in key parameters on strategy preference was addressed in sensitivity analysis. RESULTS By using base-case assumptions, NSS yielded a minimally greater average quality-adjusted life expectancy than did RF ablation (2.5 days) but was more expensive. NSS had an incremental cost-effectiveness ratio of $1,152,529 per QALY relative to RF ablation, greatly exceeding $75,000 per QALY. Therefore, RF ablation was considered preferred and remained so if the annual probability of post-RF ablation local recurrence was up to 48% higher relative to that post-NSS. NSS preference required an estimated NSS cost reduction of $7500 or RF ablation cost increase of $6229. Results were robust to changes in most model parameters, but treatment preference was dependent on the relative probabilities of local recurrence after RF ablation and NSS, the short-term costs of both, and quality of life after NSS. CONCLUSION RF ablation was preferred over NSS for small RCC treatment at a societal willingness-to-pay threshold level of $75,000 per QALY. This result was robust to changes in most model parameters, but somewhat dependent on the relative probabilities of post-RF ablation and post-NSS local recurrence, NSS and RF ablation short-term costs, and post-NSS quality of life, factors which merit further primary investigation.
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Affiliation(s)
- Pari V Pandharipande
- Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, 101 Merrimac St, Boston, MA 02114, USA.
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Hillner BE, Smith TJ. Do the Large Benefits Justify the Large Costs of Adjuvant Breast Cancer Trastuzumab? J Clin Oncol 2007; 25:611-3. [PMID: 17308264 DOI: 10.1200/jco.2006.09.3542] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Moore S, Tumeh J, Wojtanowski S, Flowers C. Cost-effectiveness of aprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with highly emetogenic chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2007; 10:23-31. [PMID: 17261113 DOI: 10.1111/j.1524-4733.2006.00141.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Chemotherapy-induced nausea and vomiting (CINV) is a significant problem for cancer patients. Aprepitant, a novel NK-1 receptor antagonist, is approved for use with 5-HT3 antagonists and corticosteroids to prevent CINV associated with highly emetogenic chemotherapy. Nevertheless, the cost-effectiveness of standard aprepitant use has not been established. METHODS We developed a Markov model to compare three strategies for CINV: conventional treatment with a 5-HT3 antagonist and a corticosteroid, conventional treatment plus aprepitant, and conventional treatment with aprepitant added after the onset of CINV. Data from published clinical trials provided probabilities and utilities for the model. Data from the Centers for Medicare and Medicaid Services and the Federal Supply Scale provided costs for medical resources and medications utilized. Resource use data were based on a randomized clinical trial and routine clinical practice. The incremental cost-effectiveness ratio (ICER) for each aprepitant strategy was calculated in US$ per healthy day equivalent (HDE) and converted to dollars per quality-adjusted life-year (QALY). Univariate and probabilistic sensitivity analyses addressed uncertainty in model parameters. RESULTS Adding aprepitant after CINV occurred cost $264 per HDE ($96,333/QALY). The three-drug strategy cost $267/HDE with a 95% confidence range of $248-$305/HDE ($97,429/QALY; $90,396-$111,239/QALY). In univariate analyses, the most influential factors on the ICER were: the cost of aprepitant, the likelihood of delayed CINV without aprepitant, the likelihood of acute CINV with/without aprepitant, and the increase in HDE from avoiding CINV. CONCLUSIONS Aprepitant provides modest incremental benefits compared with conventional management of CINV. Routine aprepitant use appears most cost-effective when the likelihood of delayed CINV or the cost of rescue medications is high.
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Affiliation(s)
- Susan Moore
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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Losina E, Walensky RP, Geller A, Beddingfield FC, Wolf LL, Gilchrest BA, Freedberg KA. Visual screening for malignant melanoma: a cost-effectiveness analysis. ARCHIVES OF DERMATOLOGY 2007; 143:21-8. [PMID: 17224538 PMCID: PMC2365732 DOI: 10.1001/archderm.143.1.21] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of various melanoma screening strategies proposed in the United States. DESIGN We developed a computer simulation Markov model to evaluate alternative melanoma screening strategies. PARTICIPANTS Hypothetical cohort of the general population and siblings of patients with melanoma. Intervention We considered the following 4 strategies: background screening only, and screening 1 time, every 2 years, and annually, all beginning at age 50 years. Prevalence, incidence, and mortality data were taken from the Surveillance, Epidemiology, and End Results Program. Sibling risk, recurrence rates, and treatment costs were taken from the literature. MAIN OUTCOME MEASURES Outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. Cost-effectiveness ratios were in dollars per quality-adjusted life year (US dollars/QALY) gained. RESULTS In the general population, screening 1 time, every 2 years, and annually saved 1.6, 4.4, and 5.2 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 10,100/QALY, US dollars 80,700/QALY, and US dollars 586,800/QALY, respectively. In siblings of patients with melanoma (relative risk, 2.24 compared with the general population), 1-time, every-2-years, and annual screenings saved 3.6, 9.8, and 11.4 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 4000/QALY, US dollars 35,500/QALY, and US dollars 257,800/QALY, respectively. In higher risk siblings of patients with melanoma (relative risk, 5.56), screening was more cost-effective. Results were most sensitive to screening cost, melanoma progression rate, and specificity of visual screening. CONCLUSIONS One-time melanoma screening of the general population older than 50 years is very cost-effective compared with other cancer screening programs in the United States. Screening every 2 years in siblings of patients with melanoma is also cost-effective.
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Affiliation(s)
- Elena Losina
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118, USA.
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Sweesy MW, Wilkoff BL, Smith KW, Holland JL. Group Purchasing Organizations: Optimizing Cardiac Device Selection, Therapy Delivery, and Fiscal Responsibility. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1404-9. [PMID: 17201849 DOI: 10.1111/j.1540-8159.2006.00554.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Group purchasing organizations (GPOs) have played a major role in supporting health care delivery in recent years as the healthcare industry has faced stronger economic pressures. Consequently, a position statement was drafted to act as a guideline for a GPO in creating a fiscally responsible, yet unrestricted environment for physicians to select the most appropriate cardiac device for their patients. This cardiac device selection guideline is to be implemented in hundreds of member hospitals but may be of use in non-member hospitals as well. The guideline will only be effective when the physicians or cardiac device caregivers have the knowledge and skills to optimally program and match device therapies and algorithms to individual patient needs.
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Affiliation(s)
- Mark W Sweesy
- Arrhythmia Technologies Institute, Greenville, South Carolina, USA.
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Cram P, Katz D, Vijan S, Kent DM, Langa KM, Fendrick AM. Implantable or external defibrillators for individuals at increased risk of cardiac arrest: where cost-effectiveness hits fiscal reality. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2006; 9:292-302. [PMID: 16961547 DOI: 10.1111/j.1524-4733.2006.00118.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Implantable cardioverter defibrillators (ICDs) are highly effective at preventing cardiac arrest, but their availability is limited by high cost. Automated external defibrillators (AEDs) are likely to be less effective, but also less expensive. We used decision analysis to evaluate the clinical and economic trade-offs of AEDs, ICDs, and emergency medical services equipped with defibrillators (EMS-D) for reducing cardiac arrest mortality. METHODS A Markov model was developed to compare the cost-effectiveness of three strategies in adults meeting entry criteria for the MADIT II Trial: strategy 1, individuals experiencing cardiac arrest are treated by EMS-D; strategy 2, individuals experiencing cardiac arrest are treated with an in-home AED; and strategy 3, individuals receive a prophylactic ICD. The model was then used to quantify the aggregate societal benefit of these three strategies under the conditions of a constrained federal budget. RESULTS Compared with EMS-D, in-home AEDs produced a gain of 0.05 quality-adjusted life-years (QALYs) at an incremental cost of $5225 ($104,500 per QALY), while ICDs produced a gain of 0.90 QALYs at a cost of $114,660 ($127,400 per QALY). For every $1 million spent on defibrillators, 1.7 additional QALYs are produced by purchasing AEDs (9.6 QALYs/$million) instead of ICDs (7.9 QALYs/$million). Results were most sensitive to defibrillator complication rates and effectiveness, defibrillator cost, and adults' risk of cardiac arrest. CONCLUSIONS Both AEDs and ICDs reduce cardiac arrest mortality, but AEDs are significantly less expensive and less effective. If financial constraints were to lead to rationing of defibrillators, it might be preferable to provide more people with a less effective and less expensive intervention (in-home AEDs) instead of providing fewer people with a more effective and more costly intervention (ICDs).
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Affiliation(s)
- Peter Cram
- University of Iowa College of Medicine, Iowa City, IA, USA.
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Buxton MJ. Substantial returns to health-care spending: but do we spend too little or too much? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2006; 9:144-5. [PMID: 16689707 DOI: 10.1111/j.1524-4733.2006.00094.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
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Affiliation(s)
- Peter J Neumann
- Department of Health Policy and Management and the Center for Risk Analysis, Harvard School of Public Health, Boston, USA
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