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Pongiglione B, Torbica A. How real can we get in generating real world evidence? Exploring the opportunities of routinely collected administrative data for evaluation of medical devices. Health Econ 2022; 31 Suppl 1:25-43. [PMID: 35762465 PMCID: PMC9796733 DOI: 10.1002/hec.4562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 06/02/2022] [Accepted: 06/09/2022] [Indexed: 06/14/2023]
Abstract
Real-world data are considered a potentially valuable source of evidence for assessing medical technologies in clinical practice, but their widespread use is hampered by numerous challenges. Using the case of coronary stents in Italy, we investigate the potential of administrative databases for estimating costs and health outcomes associated with the use of medical devices in real world conditions. An administrative dataset was created ad hoc by merging hospital records from patients admitted between 2013 and 2019 for stent implantations with ambulatory records, pharmaceutical use data and vital statistics. Health outcomes were multifold: all-cause and cardiac mortality and myocardial infarction, within 30 days, 1, 2, 5 years. Costs were estimated from the National Health System perspective. We used multivariable Cox models and propensity score (PS) methods (PS matching; stratification on PS; inverse probability of treatment weighting using PS; PS adjustment). 257,907 coronary stents were implanted in 113,912 patients. For all health outcomes and follow-up times, and across all methods, patients receiving drug-eluting stents (DES) presented lower risk. For all-cause mortality, the DES patient advantage over bare-metal stent (BMS) patients declined over time but remained significant even at 5 years. For myocardial infarction, results remained quite stable. The DES group presented lower cumulative total costs (ranging from 3264 to 2363 Euros less depending on methods). Our results confirm the consolidated evidence of the benefits of DES compared to BMS. The consistency of results across methods suggests internal validity of the study, while highlighting strengths and limitations of each depending on research context. Administrative data yield great potential to perform comparative effectiveness and cost-effectiveness analysis of medical devices provided certain conditions are met.
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Affiliation(s)
- Benedetta Pongiglione
- Centre for Research on Health and Social Care ManagementBocconi UniversityMilanoLombardiaItaly
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care ManagementBocconi UniversityMilanoLombardiaItaly
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Hughes T, Pietropaolo A, Jones P, Oderda M, Gontero P, Somani BK. Outcomes and Cost Evaluation Related to a Single-Use, Disposable Ureteric Stent Removal System: a Systematic Review of the Literature. Curr Urol Rep 2021; 22:41. [PMID: 34128107 DOI: 10.1007/s11934-021-01055-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To present the latest evidence related to the outcomes and cost of single-use, disposable ureteric stent removal system (Isiris). RECENT FINDINGS Our review suggests that compared to a reusable flexible cystoscope (re-FC), a disposable flexible cystoscope (d-FC) with built-in grasper (Isiris) significantly reduced procedural time and provided a cost benefit when the latter was used in a ward or outpatient clinic-based setting. The use of d-FC also allowed endoscopy slots to be used for other urgent diagnostic procedures. Disposable FCs are effective and safe for ureteric stent removal. They offer greater flexibility and, in most cases, have been demonstrated to be cost-effective compared to re-FCs. They are at their most useful in remote, low-volume centres, in less well-developed countries and in centres where large demand is placed on endoscopy resources.
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Affiliation(s)
- Thomas Hughes
- Urology Department, University Hospital Southampton NHS Trust, Tremona Road, Southampton, SO16 6YD, UK.
| | - Amelia Pietropaolo
- Urology Department, University Hospital Southampton NHS Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Patrick Jones
- Urology Department, University Hospital Southampton NHS Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Marco Oderda
- Division of Urology, Department of Surgical Sciences, Città della Salute e della Scienza di Torino - Molinette Hospital, University of Torino, Torino, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Città della Salute e della Scienza di Torino - Molinette Hospital, University of Torino, Torino, Italy
| | - Bhaskar K Somani
- Urology Department, University Hospital Southampton NHS Trust, Tremona Road, Southampton, SO16 6YD, UK
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Fang Z, Judelson D, Simons J, Steppacher R, Arous E, Sideman M, Schanzer A, Aiello FA. Vascular Surgeons Are Not Adequately Valued by Traditional Productivity Metrics. Ann Vasc Surg 2020; 73:446-453. [PMID: 33359694 DOI: 10.1016/j.avsg.2020.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period. METHODS Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement. RESULTS From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million). CONCLUSIONS Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons.
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Affiliation(s)
- Zachary Fang
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Dejah Judelson
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Jessica Simons
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Robert Steppacher
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Edward Arous
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Matthew Sideman
- Division of Vascular Surgery, University of Texas at San Antonio, San Antonio, TX
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Francesco A Aiello
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA.
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Rocha RV, De Mestral C, Tam DY, Lee DS, Al-Omran M, Austin PC, Forbes TL, Ouzounian M, Lindsay TF. Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2020; 73:1934-1941.e1. [PMID: 33098943 DOI: 10.1016/j.jvs.2020.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). METHODS Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. RESULTS Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). CONCLUSIONS TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles De Mestral
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Cardiovascular Program, ICES, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Program, ICES, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Ariyaratne TV, Ademi Z, Ofori-Asenso R, Huq MM, Duffy SJ, Yan BP, Ajani AE, Clark DJ, Billah B, Brennan AL, New G, Andrianopoulos N, Reid CM. The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience. Curr Med Res Opin 2020; 36:419-426. [PMID: 31870180 DOI: 10.1080/03007995.2019.1708288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.
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Affiliation(s)
- Thathya V Ariyaratne
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Ofori-Asenso
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Molla M Huq
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephen J Duffy
- Cardiovascular Medicine, Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Bryan P Yan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Andrew E Ajani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
- Royal Melbourne Hospital, Parkville, Australia
| | - David J Clark
- The Department of Cardiology, Austin Hospital, Heidelberg, Australia
| | - Baki Billah
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gishel New
- Department of Cardiology, Box Hill Hospital, Box Hill, Australia
| | - Nick Andrianopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Public Health, Curtin University, Perth, Australia
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Yuan XL, Wei B, Ye LS, Wu CC, Tan QH, Yao MH, Zhang YH, Zeng XH, Li Y, Zhang YY, Hu B. New antireflux plastic stent for patients with distal malignant biliary obstruction. World J Gastroenterol 2019; 25:2373-2382. [PMID: 31148908 PMCID: PMC6529883 DOI: 10.3748/wjg.v25.i19.2373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/28/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic biliary stenting is a well-established palliative treatment for patients with unresectable distal malignant biliary obstruction (MBO). However, the main problem with stent placement is the relatively short duration of stent patency. Although self-expanding metal stents (SEMSs) have a longer patency period than plastic stents (PSs), the higher costs limit the wide use of SEMSs. A PS with an antireflux valve is an attractive idea to prolong stent patency, but no ideal design for an antireflux PS (ARPS) has been proposed. We developed a new ARPS with a “duckbilled” valve attached to the duodenal end of the stent.
AIM To compare the patency of ARPSs with that of traditional PSs (TPSs) in patients with unresectable distal MBO.
METHODS We conducted a single-center, prospective, randomized, controlled, double-blind study. This study was conducted at the West China Hospital of Sichuan University. Consecutive patients with extrahepatic MBO were enrolled prospectively. Eligible patients were randomly assigned to receive either an ARPS or a TPS. Patients were followed by clinic visits or telephone interviews every 1-2 mo until stent exchange, death, or the final study follow-up in October 2018. The primary outcome was the duration of stent patency. Secondary outcomes included the rate of technical success, the rate of clinical success, adverse events, and patient survival.
RESULTS Between February 2016 and December 2017, 38 patients were randomly assigned to two groups, with 19 patients in each group, to receive ARPSs or TPSs. Stent insertion was technically successful in all patients. There were no significant differences between the two groups in the rates of clinical success or the rates of early or late adverse events (P = 0.660, 1.000, and 1.000, respectively). The median duration of stent patency in the ARPS group was 285 d [interquartile range (IQR), 170], which was significantly longer than that in the TPS group (median, 130 d; IQR, 90, P = 0.005). No significant difference in patient survival was noted between the two groups (P = 0.900).
CONCLUSION The new ARPS is safe and effective for the palliation of unresectable distal MBO, and has a significantly longer stent patency than a TPS.
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Affiliation(s)
- Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bin Wei
- Department of Gastroenterology, the First Hospital of Xi’an City, Xi’an 710002, Shaanxi Province, China
| | - Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing-Hua Tan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ming-Hong Yao
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu-Hang Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xian-Hui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu-Yan Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Goldstein BH, O’Byrne ML, Petit CJ, Qureshi AM, Dai D, Griffis HM, France A, Kelleman MS, McCracken CE, Mascio CE, Shashidharan S, Ligon RA, Whiteside W, Wallen WJ, Agrawal H, Aggarwal V, Glatz AC. Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow. Circ Cardiovasc Interv 2019; 12:e007232. [PMID: 30998390 PMCID: PMC6546294 DOI: 10.1161/circinterventions.118.007232] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.
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Affiliation(s)
| | - Michael L. O’Byrne
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | | | - Athar M. Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Dingwei Dai
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Heather M. Griffis
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Ashton France
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | | | | | - Christopher E. Mascio
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Subi Shashidharan
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - R. Allen Ligon
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - Wendy Whiteside
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - W. Jack Wallen
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Varun Aggarwal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Andrew C. Glatz
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
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8
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Banerjee S, Jeon-Slaughter H, Armstrong EJ, Bajzer C, Abu-Fadel M, Khalili H, Prasad A, Bou Dargham B, Kamath P, Addo T, Luna M, Gigliotti O, Foteh M, Cawich I, Kinlay S, Ali M, Ramanan B, Niazi K, Tsai S, Shammas NW, Brilakis ES. Clinical Outcomes and Cost Comparisons of Stent and Non-Stent Interventions in Infrainguinal Peripheral Artery Disease: Insights From the Excellence in Peripheral Artery Disease (XLPAD) Registry. J Invasive Cardiol 2019; 31:1-9. [PMID: 30611122 PMCID: PMC6428413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The contemporary limb outcomes and costs of stent-based vs non-stent based strategies in endovascular revascularization of femoropopliteal (FP) peripheral artery disease (PAD) are not well understood. METHODS AND RESULTS We present data from the ongoing United States multicenter Excellence in Peripheral Artery Disease Registry between 2006-2016 to compare stent vs non-stent treatment outcomes and associated costs in FP interventions. A total of 2910 FP interventions were performed in 2162 patients (mean age, 66 years), comprising 1339 stent based (superficial femoral artery, 93%) in 1007 patients and 1571 non-stent interventions (superficial femoral artery, 85%) in 1155 patients. A growing trend for non-stent based interventions and a declining trend in repeat revascularization rate at 1 year were observed across years of registry enrollment. Stent implantation was the prevailing strategy in treating longer FP lesions (mean length, 152 mm vs 105 mm; P<.001) and chronic total occlusions (65% vs 40%; P<.001), while stent implantation was employed less frequently when treating in-stent restenotic lesions (14% vs 20%; P<.001). Stent and non-stent interventions had similar 1-year limb outcomes in all-cause death, target-limb revascularization, target-vessel revascularization, and major or minor amputation. The average procedure costs for the stent group were significantly higher than the non-stent group ($6215 vs $4790; P<.001). CONCLUSION There is a growing trend for non-stent FP artery interventions, with a significant decline in 1-year target-limb revascularization rates over time. One-year limb outcomes in stent-based compared to non-stent interventions are similar; however, at a significantly higher procedural cost.
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Affiliation(s)
- Subhash Banerjee
- Dallas VA Medical Center, 4500 S. Lancaster Road (111a), Dallas, TX 75216 USA.
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9
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Abstract
Pricing of stents is being questioned by healthcare stakeholders due to large differences in price of its product types and its variation across different markets. The stent pricing literature published during 1997-2017 were reviewed besides inputs from industry experts to identify initial key pricing drivers. Interpretive structural modeling was used to build priority for checking the price rise in emerging markets like India. Lack of regulation besides other drivers like R&D cost and price of substitute was found to be important drivers of high prices. The findings would help policy makers to take steps to make stent pricing affordable.
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Affiliation(s)
- Neeraj Pandey
- a National Institute of Industrial Engineering (NITIE) , Powai , Mumbai , India
| | - Ashutosh E Thombal
- a National Institute of Industrial Engineering (NITIE) , Powai , Mumbai , India
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10
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Ariyaratne TV, Ademi Z, Huq M, Rosenfeldt F, Duffy SJ, Parkinson B, Yap CH, Smith J, Billah B, Yan BP, Brennan AL, Tran L, Reid CM. The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience. Appl Health Econ Health Policy 2018; 16:661-674. [PMID: 29998450 DOI: 10.1007/s40258-018-0407-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice. OBJECTIVE The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources. METHODS Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results. RESULTS At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966). CONCLUSIONS At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.
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Affiliation(s)
- Thathya V Ariyaratne
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - Zanfina Ademi
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Molla Huq
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Franklin Rosenfeldt
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Bonny Parkinson
- Macquarie University Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Cheng-Hon Yap
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Cardiothoracic Unit, Geelong Hospital, Geelong, VIC, Australia
| | - Julian Smith
- Department of Surgery, School of Clinical Sciences, Monash Health, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Bryan P Yan
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Lavinia Tran
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- School of Public Health, Curtin University, Perth, WA, Australia
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11
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Kawashima Y, Kawaguchi Y, Kawanishi A, Ogawa M, Hirabayashi K, Nakagohri T, Mine T. Comparison between Endoscopic Treatment and Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis. Tokai J Exp Clin Med 2018; 43:117-121. [PMID: 30191547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Treatment of recurrent chronic obstructive pancreatitis is pancreatic duct decompression with endoscopic drainage (endoscopic pancreatic stenting [EPS] with extracorporeal shockwave lithotripsy [ESWL]) or surgical drainage. Despite the recent popularization of endoscopic drainage, treatment or stent removal is difficult in many patients. We compared the efficacy, safety, and medical cost of endoscopic and surgical treatments. PATIENTS AND METHODS We retrospectively compared the treatment course and medical cost of hospitalization between 41 patients who had undergone pancreatic stenting between 2006 and 2010 (EPS group) and 10 patients who had undergone surgery for poor control of pancreatitis between 2001 and 2005 (surgical drainage group). RESULTS No intergroup differences were observed in causes, symptoms, disease duration, smoking history, or endocrine and exocrine functions. The technical success rate was 100% in both groups, and pain had improved in all of the patients in both groups. The incidences of complications did not differ significantly, and the mortality rate was 0% in both groups. The rehospitalization rate was significantly higher in the EPS group (78%) than that in the surgical drainage group (20%; P<0.01). This was considered attributable to rehospitalization for stent replacement. The effects to improve endocrine and exocrine functions were not different between the two groups before and after treatment, and the current condition was maintained in 80% or more of the patients. For the entire EPS group, the mean hospitalization period was 18 days and the mean medical cost of hospitalization was 2,133,330 yen. For the entire surgical drainage group, the mean hospitalization period was 23 days and the mean medical cost of hospitalization was 2,246,548 yen, thus indicating no significant differences between the two groups. CONCLUSIONS Although both endoscopic and surgical treatments achieved high symptom control and safety rates, re-hospitalization is required for stent replacement, which leads to poor cost-effectiveness, particularly in patients in whom stent removal is difficult. Endoscopic treatment for severe pancreatic duct stenosis will need to be advanced and evaluated in the future.
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Affiliation(s)
- Yohei Kawashima
- Department of Gastroenterology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
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12
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Schur N, Brugaletta S, Cequier A, Iñiguez A, Serra A, Jiménez-Quevedo P, Mainar V, Campo G, Tespili M, den Heijer P, Bethencourt A, Vazquez N, Valgimigli M, Serruys PW, Ademi Z, Schwenkglenks M, Sabaté M. Cost-effectiveness of everolimus-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: An analysis from the EXAMINATION randomized controlled trial. PLoS One 2018; 13:e0201985. [PMID: 30114230 PMCID: PMC6095536 DOI: 10.1371/journal.pone.0201985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/21/2018] [Indexed: 12/02/2022] Open
Abstract
Background Use of everolimus-eluting stents (EES) has proven to be clinically effective and safe in patients with ST-segment elevation myocardial infarction but it remains unclear whether it is cost-effective compared to bare-metal stents (BMS) in the long-term. We sought to assess the cost-effectiveness of EES versus BMS based on the 5-year results of the EXAMINATION trial, from a Spanish health service perspective. Methods Decision analysis of the use of EES versus BMS was based on the patient-level clinical outcome data of the EXAMINATION trial. The analysis adopted a lifelong time horizon, assuming that long-term survival was independent of the initial treatment strategy after the end of follow-up. Life-expectancy, health-state utility scores and unit costs were extracted from published literature and publicly available sources. Non-parametric bootstrapping was combined with probabilistic sensitivity analysis to co-assess the impact of patient-level variation and parameter uncertainty. The main outcomes were total costs and quality-adjusted life-years. The incremental cost-effectiveness ratio was expressed as cost per quality-adjusted life-years gained. Costs and effects were discounted at 3%. Results The model predicted an average survival time in patients receiving EES and BMS of 10.52 and 10.38 undiscounted years, respectively. Over the life-long time horizon, the EES strategy was €430 more costly than BMS (€8,305 vs. €7,874), but went along with incremental gains of 0.10 quality-adjusted life-years. This resulted in an average incremental cost-effectiveness ratio over all simulations of €3,948 per quality-adjusted life-years gained and was below a willingness-to-pay threshold of €25,000 per quality-adjusted life-years gained in 86.9% of simulation runs. Conclusions Despite higher total costs relative to BMS, EES appeared to be a cost-effective therapy for ST-segment elevation myocardial infarction patients due to their incremental effectiveness. Predicted incremental cost-effectiveness ratios were below generally acceptable threshold values.
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Affiliation(s)
- Nadine Schur
- European Center for Pharmaceutical Medicine (ECPM), University of Basel, Basek, Switzerland
- * E-mail:
| | - Salvatore Brugaletta
- University Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Marco Valgimigli
- Erasmus MC, Rotterdam, Netherlands
- University Hospital of Bern, Inselhospital, Bern, Switzerland
| | - Patrick W. Serruys
- International Centre of Circulatory Health, Imperial College London, London, United Kingdom
| | - Zanfina Ademi
- European Center for Pharmaceutical Medicine (ECPM), University of Basel, Basek, Switzerland
| | - Matthias Schwenkglenks
- European Center for Pharmaceutical Medicine (ECPM), University of Basel, Basek, Switzerland
| | - Manel Sabaté
- University Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Locham SS, Paracha N, Dakour-Aridi H, Nejim B, Rizwan M, Malas MB. Comparison of the Cost of Drug-Eluting Stents versus Bare Metal Stents in the Treatment of Critical Limb Ischemia in the United States. Ann Vasc Surg 2018; 55:55-62.e2. [PMID: 30092444 DOI: 10.1016/j.avsg.2018.05.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite significant technical advancement in the last decade, the durability of endovascular management of critical limb ischemia (CLI) remains highly debatable. Drug-eluting stents (DESs) are being popularized for the management of CLI after its precedent success in coronary intervention. Initial reports on the durability of DES are promising. However, little is known on the additional cost of this relatively newer technology. The aim of this study is to compare the cost of the traditional bare metal stents (BMSs) to the newly introduced DES in a large cohort of CLI patients. METHODS Using the Premier database (2009-2015), we identified all patients with CLI undergoing DES and BMS. A multivariable generalized linear model was implemented to examine in-hospital cost adjusting for patients' characteristics, comorbidities, and regional characteristics. RESULTS A total of 20,702 patients with CLI underwent peripheral artery revascularization using BMS (18,924 [91.41%]) or DES (1,778 [8.6%]). Majority of patients were males (53%) and whites (71%). Patients undergoing BMS were slightly younger (median age [interquartile range]: 70 [62-79] versus 71 [63-80]) and were more likely to be smokers (46% vs. 39%) and have a history of cerebrovascular disease (10% vs. 8%) and chronic pulmonary disease (24.5% vs. 20.9%) as compared with those undergoing DES (all P < 0.05). On the other hand, DES patients had a high prevalence of diabetes (4% vs. 3%) and renal disease (25% vs. 22%) (both P < 0.05). There was also a significant increase in the proportion of patients undergoing DES and a corresponding decrease in BMS (P < 0.001) over the study period. Median total in-hospitalization cost (BMS: $13,342 [8,574 to 21,166], DES: $13,243 [8,560-20,232], P = 0.76) was similar for both approaches. After adjusting for potential confounders, DES was associated with $407 higher cost than BMS (adjusted mean difference [95% confidence interval]: 407 [17 to 798], P = 0.04). In addition, the cost was $672 higher in teaching hospitals, $1,153 higher in Rural areas, and increased in all regions compared with the Midwest (adjusted mean difference [95% confidence interval]-South: $293 [31 to 555], Northeast: $2,006 [1,517 to 2,495], West: $3,312 [2,930 to 3,695], all P < 0.05). CONCLUSIONS In this large cohort of CLI patients, after controlling for potential confounders, we demonstrated that the cost of endovascular revascularization is significantly higher in patients undergoing DES than those undergoing BMS. Regional disparities in cost were also observed. Further studies looking at the long-term durability and costs of DES versus BMS are needed.
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Affiliation(s)
- Satinderjit S Locham
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD
| | - Nawar Paracha
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD
| | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD
| | - Muhammad Rizwan
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD.
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Eaton Turner E, Jenks M, McCool R, Marshall C, Millar L, Wood H, Peel A, Craig J, Sims AJ. The Memokath-051 Stent for the Treatment of Ureteric Obstruction: A NICE Medical Technology Guidance. Appl Health Econ Health Policy 2018; 16:445-464. [PMID: 29616460 PMCID: PMC6028873 DOI: 10.1007/s40258-018-0389-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Memokath-051 is a thermo-expandable, nickel-titanium alloy spiral stent used to treat ureteric obstruction resulting from malignant or benign strictures. The National Institute for Health and Care Excellence (NICE) selected Memokath-051 for evaluation. The company, PNN Medical, claimed Memokath-051 has clinical superiority and cost savings compared with double-J stents. It identified five studies reporting clinical evidence on Memokath-051 and constructed a de novo cost model comparing Memokath-051 to double-J stents. Results indicated that Memokath-051 generated cost savings of £4156 per patient over 2.5 years. The External Assessment Centre (EAC) critiqued the company's submission and completed substantial additional work. Sixteen studies were identified assessing Memokath-051 and all listed comparators in the scope (double-J stents, reconstructive surgery and metallic and alloy stents) except nephrostomy. Similar success rates were reported for Memokath-051 compared with double-J and Resonance stents and worse outcomes compared with other options with evidence available. The EAC updated the company's cost model structure and modified several inputs. The EAC's model estimated that Memokath-051 generated savings of at least £1619 per patient over 5 years compared with double-J stents, was cost neutral compared with other metallic stents and was cost saving compared with surgery up to month 55. Overall, Memokath-051 is likely to be cost saving in patients not indicated for reconstructive surgery and those expected to require a ureteral stent for at least 30 months. The Medical Technologies Advisory Committee (MTAC) reviewed the evidence and supported the case for adoption, issuing partially supportive recommendations published after public consultation as Medical Technologies Guidance 35.
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Affiliation(s)
- Emily Eaton Turner
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK.
| | - Michelle Jenks
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Rachael McCool
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Chris Marshall
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Liesl Millar
- National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT, UK
| | - Hannah Wood
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Alison Peel
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Joyce Craig
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, Heslington, York, YO10 5NQ, UK
| | - Andrew J Sims
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
- Faculty of Medical Sciences, Institute of Cellular Medicine, University of Newcastle Upon Tyne, Newcastle upon Tyne, NE1 7RU, UK
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15
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Chen YI, Barkun AN, Adam V, Bai G, Singh VK, Bukhari M, Gutierrez OB, Elmunzer BJ, Moran R, Fayad L, El Zein M, Kumbhari V, Repici A, Khashab MA. Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis. Gastrointest Endosc 2018; 88:267-276.e1. [PMID: 29614262 DOI: 10.1016/j.gie.2018.03.021] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON. METHODS A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established. RESULTS LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results. CONCLUSION LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Alan N Barkun
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Viviane Adam
- Division of Gastroenterology and Hepatology, The McGill University Health Center, Montreal, Quebec, Canada
| | - Ge Bai
- Johns Hopkins Carey Business School, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozanno, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Berdahl JP, Khatana AK, Katz LJ, Herndon L, Layton AJ, Yu TM, Bauer MJ, Cantor LB. Cost-comparison of two trabecular micro-bypass stents versus selective laser trabeculoplasty or medications only for intraocular pressure control for patients with open-angle glaucoma. J Med Econ 2017; 20:760-766. [PMID: 28471282 DOI: 10.1080/13696998.2017.1327439] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM Patients with open-angle glaucoma (OAG) whose intraocular pressure is not adequately controlled by one medication have several treatment options in the US. This analysis evaluated direct costs of unilateral eye treatment with two trabecular micro-bypass stents (two iStents) compared to selective laser trabeculoplasty (SLT) or medications only. MATERIALS AND METHODS A population-based, annual state-transition, probabilistic, cost-of-care model was used to assess OAG-related costs over 5 years. Patients were modeled to initiate treatment in year zero with two iStents, SLT, or medications only. In years 1-5, patients could remain on initial treatment or move to another treatment option(s), or filtration surgery. Treatment strategy change probabilities were identified by a clinician panel. Direct costs were included for drugs, procedures, and complications. RESULTS The projected average cumulative cost at 5 years was lower in the two-stent treatment arm ($4,420) compared to the SLT arm ($4,730) or medications-only arm ($6,217). Initial year-zero costs were higher with two iStents ($2,810) than with SLT ($842) or medications only ($996). Average marginal annual costs in years 1-5 were $322 for two iStents, $777 for SLT, and $1,044 for medications only. The cumulative cost differences between two iStents vs SLT or medications only decreased over time, with breakeven by 5 or 3 years post-initiation, respectively. By year 5, cumulative savings with two iStents over SLT or medications only was $309 or $1,797, respectively. LIMITATIONS This analysis relies on clinical expert panel opinion and would benefit from real-world evidence on use of multiple procedures and treatment switching after two-stent treatment, SLT, or polypharmaceutical initial approaches. CONCLUSIONS Despite higher costs in year zero, annual costs thereafter were lowest in the two-stent treatment arm. Two-stent treatment may reduce OAG-related health resource use, leading to direct savings, especially over medications only or at longer time horizons.
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Affiliation(s)
| | | | - L Jay Katz
- c Wills Eye Hospital, Thomas Jefferson University , Philadelphia , PA , USA
- d Glaukos Corporation , Laguna Hills , CA , USA
| | | | | | - Tiffany M Yu
- f Quorum Consulting, Inc , San Francisco , CA , USA
| | | | - Louis B Cantor
- g Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine , Indianapolis , IN , USA
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17
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Lee VW, Cheng FW, Choi AY, Fong ST, Yu CM, Yan BP. Clinical, humanistic, and economic outcomes between drug-eluting stent (DES) and bare metal stent (BMS): 18-month follow-up study. J Med Econ 2017; 20:239-245. [PMID: 27737596 DOI: 10.1080/13696998.2016.1248971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is one of the most performed interventions for ischemic heart diseases. In Hong Kong, the total number of patient discharges and deaths for ischemic heart diseases in 2009 was 33,363, including 4,360 deaths. There are over 5,000 cases of PCI yearly. This study aimed to compare clinical, economic, and humanistic outcomes among patients receiving drug-eluting stent (DES) or bare metal stent (BMS) in Hong Kong. METHODS Patients who received stent implantation between September 15, 2009 and October 11, 2010 in Prince of Wales Hospital, Hong Kong, were recruited and followed for 18 months. Occurrence of major adverse cardiac events (cardiac death, non-fatal MI, TLR and TVR) was employed as the clinical outcome measurements. Improvement in quality-of-life by stent interventions was measured as quality-adjusted life-year (QALY). EQ-5D questionnaire was adopted to assess the QALY gained. Cost-utility analysis and cost-effectiveness analysis for BMS and DES were employed as the economic outcome measurement. RESULTS Six hundred and eighty-four patients (DES = 402; BMS = 282) were included. From 0-18 months, TLR rate (2.7% vs 3.5%, p = .549) and TVR rate (3.7% vs 6.4%, p = .111) were lower in the DES group, but without statistical significance. EQ VAS (71.06 ± 14.56 vs 71.07 ± 16.57, p = .998) and utility score (0.81 ± 0.17 vs 0.78 ± 0.16, p = .162) were comparable between DES and BMS group. Overall, the cost per QALY gained was HKD + 1,178,100 and ICER was HKD + 187,000 (1USD = 7.8 HKD). CONCLUSIONS No significant difference in TVR, TLR rates, EQ VAS, and utility score was found between the DES and BMS group. The higher cost of index procedure for the DES group was found to be partly offset by reduced cost of follow-up, offering cost-effectiveness in ACS patients, predominantly in STEMI patients. DES was recommended for STEMI patients.
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Affiliation(s)
- Vivian W Lee
- a School of Pharmacy, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
| | - Franco W Cheng
- a School of Pharmacy, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
| | - Adrian Y Choi
- a School of Pharmacy, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
| | - Sam T Fong
- a School of Pharmacy, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
| | - Cheuk Man Yu
- b Department of Medicine and Therapeutics, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
| | - Bryan P Yan
- b Department of Medicine and Therapeutics, Faculty of Medicine , The Chinese University of Hong Kong , Hong Kong , PR China
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Seklehner S, Sievert KD, Lee R, Engelhardt PF, Riedl C, Kunit T. A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal. Int Urol Nephrol 2017; 49:753-761. [PMID: 28197765 DOI: 10.1007/s11255-017-1538-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/04/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal. MATERIALS AND METHODS A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA). RESULTS Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure. CONCLUSION Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.
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Affiliation(s)
- Stephan Seklehner
- Department of Urology, Landesklinikum Baden-Mödling, Waltersdorfer Straße 75, 2500, Baden, Austria.
- Department of Urology, Paracelsus Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria.
| | - Karl-Dietrich Sievert
- Department of Urology, Paracelsus Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria
| | - Richard Lee
- Department of Urology, Weill Medical College of Cornell University, New York, NY, USA
| | - Paul F Engelhardt
- Department of Urology, Landesklinikum Baden-Mödling, Waltersdorfer Straße 75, 2500, Baden, Austria
- Department of Urology, Paracelsus Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria
| | - Claus Riedl
- Department of Urology, Landesklinikum Baden-Mödling, Waltersdorfer Straße 75, 2500, Baden, Austria
| | - Thomas Kunit
- Department of Urology, Paracelsus Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria
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Spanos K, Kouvelos G, Karathanos C, Xhepa S, Athanasios G, Matsagkas M. New devices to cross chronic total occlusion in critical limb ischemia. J Cardiovasc Surg (Torino) 2016; 57:817-829. [PMID: 27647338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chronic total occlusions (CTOs) represent a technically demanding subset of lesions, which in most cases require special endovascular methods, advanced operator skills, and utilization of sophisticated assisting devices for successful treatment. CTO crossing devices offer an additional option to interventionists in the treatment of challenging lower extremity peripheral arterial occlusions. These devices may improve crossing rates, allowing delivery of therapeutic devices to the target lesion. Initial technical results seem quite promising, although adequate data on patient and device selection are lacking. Until long-term clinical data verify the durability of those techniques, these devices must be used in a stepwise fashion in selected patients with CLI.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece - ,
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Budzyńska A, Nowakowska-Duława E, Marek T, Hartleb M. Comparison of patency and cost-effectiveness of self-expandable metal and plastic stents used for malignant biliary strictures: a Polish single-center study. Eur J Gastroenterol Hepatol 2016; 28:1223-8. [PMID: 27455079 DOI: 10.1097/meg.0000000000000699] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Most patients with malignant biliary obstruction are suited only for palliation by endoscopic drainage with plastic stents (PS) or self-expandable metal stents (SEMS). OBJECTIVE To compare the clinical outcome and costs of biliary stenting with SEMS and PS in patients with malignant biliary strictures. PATIENTS AND METHODS A total of 114 patients with malignant jaundice who underwent 376 endoscopic retrograde biliary drainage (ERBD) were studied. RESULTS ERBD with the placement of PS was performed in 80 patients, with one-step SEMS in 20 patients and two-step SEMS in 14 patients. Significantly fewer ERBD interventions were performed in patients with one-step SEMS than PS or the two-step SEMS technique (2.0±1.12 vs. 3.1±1.7 or 5.7±2.1, respectively, P<0.0001). The median hospitalization duration per procedure was similar for the three groups of patients. The patients' survival time was the longest in the two-step SEMS group in comparison with the one-step SEMS and PS groups (596±270 vs. 276±141 or 208±219 days, P<0.001). Overall median time to recurrent biliary obstruction was 89.3±159 days for PS and 120.6±101 days for SEMS (P=0.01). The total cost of hospitalization with ERBD was higher for two-step SEMS than for one-step SEMS or PS (1448±312, 1152±135 and 977±156&OV0556;, P<0.0001). However, the estimated annual cost of medical care for one-step SEMS was higher than that for the two-step SEMS or PS groups (4618, 4079, and 3995&OV0556;, respectively). CONCLUSION Biliary decompression by SEMS is associated with longer patency and reduced number of auxiliary procedures; however, repeated PS insertions still remain the most cost-effective strategy.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Cholangiopancreatography, Endoscopic Retrograde/adverse effects
- Cholangiopancreatography, Endoscopic Retrograde/economics
- Cholangiopancreatography, Endoscopic Retrograde/instrumentation
- Cholangiopancreatography, Endoscopic Retrograde/mortality
- Cholestasis/diagnostic imaging
- Cholestasis/economics
- Cholestasis/mortality
- Cholestasis/therapy
- Constriction, Pathologic
- Cost Savings
- Cost-Benefit Analysis
- Decompression, Surgical/adverse effects
- Decompression, Surgical/economics
- Decompression, Surgical/instrumentation
- Decompression, Surgical/mortality
- Drainage/adverse effects
- Drainage/economics
- Drainage/instrumentation
- Drainage/mortality
- Female
- Hospital Costs
- Humans
- Length of Stay/economics
- Male
- Metals/economics
- Middle Aged
- Plastics/economics
- Poland
- Prosthesis Design
- Recurrence
- Retrospective Studies
- Stents/economics
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Agnieszka Budzyńska
- Department of Gastroenterology and Hepatology, Medical University of Silesia, Katowice, Poland
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Kitrou P, Karnabatidis D, Katsanos K. Drug-coated balloons are replacing the need for nitinol stents in the superficial femoral artery. J Cardiovasc Surg (Torino) 2016; 57:569-577. [PMID: 27128105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Amassed evidence from several randomized controlled trials and high quality meta-analyses clearly support the primary use of paclitaxel-coated balloons (PCB) in the superficial femoral artery over traditional plain balloon angioplasty or primary bare nitinol stenting with significantly lower vascular restenosis, less need for repeat procedures, improved quality of life and potential cost savings for the healthcare system. Stents may be reserved for bail-out in case of a suboptimal dilatation result, and for selected more complex lesions, or in case of critical limb ischemia in order to eliminate vessel recoil and maximize immediate hemodynamic gain. Debulking atherectomy remains unproven, but holds a lot of promise in particular in combination with PCBs, in order to improve compliance of the vessel wall by plaque removal, allow for a better angioplasty result and optimize drug transfer and bioavailability. The present overview summarizes and discusses current evidence about femoropopliteal PCB angioplasty compared to the historical standard of plain old balloon angioplasty and bare nitinol stents. Available evidence is appraised in the context of clinically meaningful results, relevant unresolved issues are highlighted, and future trends are discussed.
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Affiliation(s)
- Panagiotis Kitrou
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Patras, Greece -
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Abstract
Use of endovascular interventions for arterial occlusive lesions continues to increase. With the evolution of the technology supporting these therapeutic measures, the results of these interventions continue to improve. In general, a comparison of techniques for revascularization of iliac occlusive diseases shows similar initial technical success rates for open versus percutaneous transluminal angioplasty. Angioplasty is often associated with lower periprocedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency, although late failure of percutaneous therapies may occur but still can be treated successfully with reintervention. The perpetual buildup of experience with angioplasty and stenting will eventually characterize its role in the management of occlusive disease. This review outlines the current consensus and applicability of endovascular management of iliac occlusive diseases.
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Affiliation(s)
- Albeir Y Mousa
- Division of Vascular Surgery, Brookdale University Hospital and Medical Center, One Brookdale Plaza, Brooklyn, NY 11212, USA.
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Kassimis G, Banning AP. Is it time to take bare metal stents off the catheter laboratory shelf? Eur Heart J 2016; 37:3372-3375. [PMID: 27282614 DOI: 10.1093/eurheartj/ehw215] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/03/2016] [Accepted: 05/08/2016] [Indexed: 01/14/2023] Open
Affiliation(s)
- George Kassimis
- Cardiology Department, NHS Gloucestershire Hospitals, Cheltenham General Hospital, Cheltenham GL53 7AN, UK
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Morris S, Patel NV, Dobson J, Featherstone RL, Richards T, Luengo-Fernandez R, Rothwell PM, Brown MM. Cost-utility analysis of stenting versus endarterectomy in the International Carotid Stenting Study. Int J Stroke 2016; 11:446-53. [PMID: 26880056 PMCID: PMC5341766 DOI: 10.1177/1747493016632237] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/09/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The International Carotid Stenting Study was a multicenter randomized trial in which patients with symptomatic carotid artery stenosis were randomly allocated to treatment by carotid stenting or endarterectomy. Economic evidence comparing these treatments is limited and inconsistent. AIMS We compared the cost-effectiveness of stenting versus endarterectomy using International Carotid Stenting Study data. METHODS We performed a cost-utility analysis estimating mean costs and quality-adjusted life years per patient for both treatments over a five-year time horizon based on resource use data and utility values collected in the trial. Costs of managing stroke events were estimated using individual patient data from a UK population-based study (Oxford Vascular Study). RESULTS Mean costs per patient (95% CI) were US$10,477 ($9669 to $11,285) in the stenting group (N = 853) and $9669 ($8835 to $10,504) in the endarterectomy group (N = 857). There were no differences in mean quality-adjusted life years per patient (3.247 (3.160 to 3.333) and 3.228 (3.150 to 3.306), respectively). There were no differences in adjusted costs between groups (mean incremental costs for stenting versus endarterectomy $736 (95% CI -$353 to $1826)) or adjusted outcomes (mean quality-adjusted life years gained -0.010 (95% CI -0.117 to 0.097)). The incremental net monetary benefit for stenting versus endarterectomy was not significantly different from zero at the maximum willingness to pay for a quality-adjusted life year commonly used in the UK. Sensitivity analyses showed little uncertainty in these findings. CONCLUSIONS Economic considerations should not affect whether patients with symptomatic carotid stenosis undergo stenting or endarterectomy.
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Affiliation(s)
- Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Nishma V Patel
- Department of Applied Health Research, University College London, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Roland L Featherstone
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK
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Okafor PN, Stobaugh DJ, Wong Kee Song LM, Limburg PJ, Talwalkar JA. Socioeconomic Inequalities in the Utilization of Colorectal Stents for the Treatment of Malignant Bowel Obstruction. Dig Dis Sci 2016; 61:1669-76. [PMID: 26738737 DOI: 10.1007/s10620-015-4019-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 12/20/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Colorectal stents are increasingly employed as a bridge to surgery or for palliative relief of malignant large bowel obstruction. AIM To explore determinants of inpatient colorectal stent utilization (CRSU). METHODS An analysis of the 2012 National Inpatient Sample was performed. International Classification of Diseases, 9th revision, codes were used to identify discharges associated with CRSU and patient/hospital factors for inclusion in a logistic regression model. RESULTS We identified 217,055 inpatient colonoscopies, approximating 1.1 million inpatient colonoscopies nationwide. Colorectal stents were placed in 1.4 % of all procedures. Across all racial groups, Medicare was the most common payer. Patients with commercial insurance had lower CRSU compared with Medicare patients [adjusted odds ratio (OR) 0.83, 95 % confidence interval (CI) 0.75-0.92]. No gender disparities were identified (OR 0.96, 95 % CI 0.89-1.03). In addition, no racial differences in CRSU existed between Caucasians versus African-Americans (OR 0.94, 95 % CI 0.83-1.06) and Caucasians versus Hispanics (OR 0.96, 95 % CI 0.83-1.1). Compared with patients living in less affluent neighborhoods, those residing in more affluent areas had higher CRSU (OR 1.65, 95 % CI 1.46-1.86). This displayed a linear relationship with the odds of CRSU increasing as household income increased. Less affluent patients also had the highest total charges and longest wait time to CRSU. CRSU was highest among patients treated in larger medical centers (OR 1.7, 95 % CI 1.51-1.93) and teaching hospitals (OR 3.9, 95 % CI 3.2-4.8). CONCLUSION Individuals from less affluent neighborhoods have lower colorectal stent utilization. This disparity is independent of race and likely related to poorer access to healthcare resources.
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Affiliation(s)
- Philip N Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derrick J Stobaugh
- North Shore University Health System, 4901 Searle Pkwy, Skokie, IL, 60077, USA
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Paul J Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jayant A Talwalkar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Zorrón Pu L, de Moura EGH, Bernardo WM, Baracat FI, Mendonça EQ, Kondo A, Luz GO, Furuya Júnior CK, Artifon ELDA. Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis. World J Gastroenterol 2015; 21:13374-13385. [PMID: 26715823 PMCID: PMC4679772 DOI: 10.3748/wjg.v21.i47.13374] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/22/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.
METHODS: A systematic review of randomized clinical trials (RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL (EBSCO), MEDLINE, LILACS/CENTRAL (BVS), SCOPUS, CAPES (Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and re-intervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables and mean differences (MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ2 and the Higgins method (I2). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student’s t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.
RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents (SEMS) and plastic stents (PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct (proximal) and pancreatic tumors (distal). The preferred SEMS diameter used was the 10 mm (30 Fr) and the preferred PS diameter used was 10 Fr. In the meta-analysis, SEMS had lower overall stent dysfunction compared to PS (21.6% vs 46.8%, P < 0.00001) and fewer re-interventions (21.6% vs 56.6%, P < 0.00001), with no difference in complications (13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group (182 d vs 150 d, P < 0.0001), with a higher patency period (250 d vs 124 d, P < 0.0001) and a lower cost per patient (4193.98 vs 4728.65 Euros, P < 0.0985).
CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.
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Kern MJ. Conversations in cardiology--Is BVS ready for prime time? More about the absorb study. Catheter Cardiovasc Interv 2015; 87:902-8. [PMID: 26649485 DOI: 10.1002/ccd.26343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/06/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Morton J Kern
- Department of Medicine, Division of Cardiology, Veterans Administration Long Beach Health Care System, University of California, Irvine, California
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Abstract
OBJECTIVE The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis. STUDY DESIGN We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model. RESULTS Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables. CONCLUSION Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.
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Affiliation(s)
- Kevin Wymer
- Division of Biological Sciences, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Beth A Plunkett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Evanston, IL
| | - Sangtae Park
- Division of Urology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL.
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Barkun AN, Adam V, Martel M, AlNaamani K, Moses PL. Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis. Can J Gastroenterol Hepatol 2015; 29:377-83. [PMID: 26125107 PMCID: PMC4610649 DOI: 10.1155/2015/743417] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 03/17/2015] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED BACKGROUND⁄ OBJECTIVE Partially covered self-expandable metal stents (SEMS) and polyethylene stents (PES) are both commonly used in the palliation of malignant biliary obstruction. Although SEMS are significantly more expensive, they are more efficacious than PES. Accordingly, a cost-effectiveness analysis was performed. METHODS A cost-effectiveness analysis compared the approach of initial placement of PES versus SEMS for the study population. Patients with malignant biliary obstruction underwent an endoscopic retrograde cholangiopancreatography to insert the initial stent. If the insertion failed, a percutaneous transhepatic cholangiogram was performed. If stent occlusion occurred, a PES was inserted at repeat endoscopic retrograde cholangiopancreatography, either in an outpatient setting or after admission to hospital if cholangitis was present. A third-party payer perspective was adopted. Effectiveness was expressed as the likelihood of no occlusion over the one-year adopted time horizon. Probabilities were based on a contemporary randomized clinical trial, and costs were issued from national references. Deterministic and probabilistic sensitivity analyses were performed. RESULTS A PES-first strategy was both more expensive and less efficacious than an SEMS-first approach. The mean per-patient costs were US$6,701 for initial SEMS and US$20,671 for initial PES, which were associated with effectiveness probabilities of 65.6% and 13.9%, respectively. Sensitivity analyses confirmed the robustness of these results. CONCLUSION At the time of initial endoscopic drainage for patients with malignant biliary obstruction undergoing palliative stenting, an initial SEMS insertion approach was both more effective and less costly than a PES-first strategy.
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Affiliation(s)
- Alan N Barkun
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
- Division of Epidemiology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Viviane Adam
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Myriam Martel
- Division of Gastroenterology, Biostatistics and Occupational Health, McGill University Health Centre, McGill University, Montreal, Quebec
| | - Khalid AlNaamani
- Division of Gastroenterology, Hepatology and Liver Transplantation, The Armed Forces Hospital, Muscat, Oman
| | - Peter L Moses
- Division of Gastroenterology and Hepatology, University of Vermont, Burlington, Vermont, USA
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González-Díaz B, Garduño-Espinosa J, Salinas-Escudero G, Reyes-López A, Granados-García V. Economic Evaluation of the Use of Drug-Eluting Stents versus Bare-Metal Stents in Adults with Ischemic Cardiomyopathy Requiring Angioplasty. Rev Invest Clin 2015; 67:219-226. [PMID: 26426587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The value of drug-eluting stents in preventing cardiovascular events has not been investigated in Mexico. OBJECTIVE To conduct a cost-effectiveness analysis of early and new-generation drug-eluting stents from the perspective of a healthcare provider. METHODS We conducted a cost-effectiveness analysis of early and new-generation drug-eluting stents in patients with ischemic cardiomyopathy attending a Cardiology Hospital of the Mexican Social Security Institute. The health endpoint used was major acute cardiovascular events prevented. The effectiveness by stent type was obtained from the literature. A retrospective chart review study was conducted to collect cost data on cardiovascular events including seven cost categories. Average and incremental cost-effectiveness ratios were estimated. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of estimates. RESULTS Incremental cost-effectiveness ratios in base-case were 28,910 and US$ 35,590 for early and new-generation stents, respectively. In an optimal scenario, incremental-cost effectiveness ratio was 24,776 and US$ 25,262 for early and new stents, respectively. Probabilistic sensitivity analysis suggested that 90% of cases were cost-effective when willingness-to-pay was 58,000 and US$ 66,000 for early and new-generation stents, respectively. CONCLUSIONS The cost-effectiveness ratios of early and new-generation stents were significantly higher than corresponding bare-metal stents.
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Affiliation(s)
- Belinda González-Díaz
- Department of Hemodynamics, Hospital de Cardiología, Unidad Médica de Alta Especialidad, CMN-SXXI, Instituto Mexicano del Seguro Social (IMSS), México, D.F., México
| | - Juan Garduño-Espinosa
- Department of Investigation, Hospital Infantil de México Federico Gómez, México, D.F., México
| | - Guillermo Salinas-Escudero
- Center for Economic and Social Studies in Health, Hospital Infantil de México Federico Gómez, México, D.F., México
| | - Alfonso Reyes-López
- Center for Economic and Social Studies in Health, Hospital Infantil de México Federico Gómez, México, D.F., México
| | - Víctor Granados-García
- Department for Epidemiological Investigation and Health Services, Aging Area, CMN-SXXI, IMSS, México, D.F., México
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Michel M, Becquemin JP, Clément MC, Marzelle J, Quelen C, Durand-Zaleski I. Editor's choice - thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms. Eur J Vasc Endovasc Surg 2015; 50:189-96. [PMID: 26100447 DOI: 10.1016/j.ejvs.2015.04.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 04/08/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare 30 day outcomes and costs of fenestrated and branched stent grafts (f/b EVAR) and open surgery (OSR) for the treatment of complex abdominal aortic aneurysms (AAA) and thoraco-abdominal aortic aneurysms (TAAA). METHODS The multicenter prospective registry WINDOW was set up to evaluate f/b EVAR in high risk patients with para/juxtarenal AAA, and infradiaphragmatic and supradiaphragmatic TAAA. A control group of patients treated by OSR was extracted from the national hospital discharge database. The primary endpoint was 30 day mortality. Secondary endpoints included severe complications, length of stay, and costs. Mortality was assessed by survival analysis and uni/multivariate Cox regression analyses using pre- and post-operative characteristics. Bootstrap methods were used to estimate the cost-effectiveness of f/b EVAR versus OSR. RESULTS Two hundred and sixty eight cases and 1,678 controls were included. There was no difference in 30 day mortality (6.7% vs. 5.4%, p = 0.40), but costs were higher with f/b EVAR (€38,212 vs. €16,497, p < .001). After group stratification, mortality was similar with both treatments for para/juxtarenal AAA (4.3% vs. 5.8%, p = .26) and supradiaphragmatic TAAA (11.9% vs. 19.7%, p = .70), and higher with f/b EVAR for infradiaphragmatic TAAA (11.9% vs. 4.0%, p = .010). Costs were higher with f/b EVAR for para/juxtarenal AAA (€34,425 vs. €14,907, p < .0001) and infradiaphragmatic TAAA (€37,927 vs. €17,530, p < .0001), but not different for supradiaphragmatic TAAA (€54,710 vs. €44,163, p = .18). CONCLUSION f/b EVAR does not appear justified for patients with para/juxtarenal AAA and infradiaphragmatic TAAA fit for OSR but may be an attractive option for patients with para/juxtarenal AAA not eligible for surgery and patients with supradiaphragmatic TAAA. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov/ct2/show/NCT01168037; identifier: NCT01168037 (WINDOW registry).
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MESH Headings
- Aged
- Aged, 80 and over
- Aortic Aneurysm, Abdominal/diagnosis
- Aortic Aneurysm, Abdominal/economics
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/diagnosis
- Aortic Aneurysm, Thoracic/economics
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/surgery
- Blood Vessel Prosthesis/economics
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/economics
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/mortality
- Case-Control Studies
- Chi-Square Distribution
- Cost-Benefit Analysis
- Endovascular Procedures/adverse effects
- Endovascular Procedures/economics
- Endovascular Procedures/instrumentation
- Endovascular Procedures/mortality
- Female
- France
- Hospital Costs
- Humans
- Kaplan-Meier Estimate
- Length of Stay/economics
- Male
- Middle Aged
- Models, Economic
- Multivariate Analysis
- Proportional Hazards Models
- Prospective Studies
- Prosthesis Design
- Registries
- Stents/economics
- Time Factors
- Treatment Outcome
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Affiliation(s)
- M Michel
- URC Eco Ile de France, DRCD, AP-HP, Hôtel Dieu, Paris, France.
| | - J-P Becquemin
- Department of Vascular Surgery, CHU Henri Mondor, Créteil, France
| | - M-C Clément
- URC Eco Ile de France, DRCD, AP-HP, Hôtel Dieu, Paris, France
| | - J Marzelle
- Department of Vascular Surgery, CHU Henri Mondor, Créteil, France
| | - C Quelen
- URC Eco Ile de France, DRCD, AP-HP, Hôtel Dieu, Paris, France
| | - I Durand-Zaleski
- URC Eco Ile de France, DRCD, AP-HP, Hôtel Dieu, Paris, France; UPEC, CHU Henri Mondor, Créteil, France
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Reynolds MR, Apruzzese P, Galper BZ, Murphy TP, Hirsch AT, Cutlip DE, Mohler ER, Regensteiner JG, Cohen DJ. Cost-effectiveness of supervised exercise, stenting, and optimal medical care for claudication: results from the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) trial. J Am Heart Assoc 2014; 3:e001233. [PMID: 25389284 PMCID: PMC4338709 DOI: 10.1161/jaha.114.001233] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 10/08/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Both supervised exercise (SE) and stenting (ST) improve functional status, symptoms, and quality of life compared with optimal medical care (OMC) in patients with claudication. The relative cost-effectiveness of these strategies is not well defined. METHODS AND RESULTS The Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) study randomized patients with claudication due to aortoiliac stenosis to a 6-month SE program, to ST, or to OMC. Participants who completed 6-month follow-up (n=98) were included in a health economic analysis through 18 months. Costs were assessed using resource-based methods and hospital billing data. Quality-adjusted life-years were estimated using the EQ-5D. Markov modeling based on the in-trial results was used to explore the impact of assumptions about the longer term durability of observed differences in quality of life. Through 18 months, mean healthcare costs were $5178, $9804, and $14 590 per patient for OMC, SE, and ST, respectively. Measured quality-adjusted life-years through 18 months were 1.04, 1.16, and 1.20. In our base case analysis, which assumed that observed differences in quality of life would dissipate after 5 years, the incremental cost-effectiveness ratios were $24 070 per quality-adjusted life-year gained for SE versus OMC, $41 376 for ST versus OMC, and $122 600 for ST versus SE. If the treatment effect of ST was assumed to be more durable than that of SE, the incremental cost-effectiveness ratio for ST versus SE became more favorable. CONCLUSIONS Both SE and ST are economically attractive by US standards relative to OMC for the treatment of claudication in patients with aortoiliac disease. ST is more expensive than SE, with uncertain incremental benefit. CLINICAL TRIAL REGISTRATION URL www.clinicaltrials.gov, Unique identifier: NCT00132743.
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Affiliation(s)
| | | | | | | | | | | | - Emile R. Mohler
- Division of Cardiovascular Disease, Section of Vascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (E.R.M.)
| | | | - David J. Cohen
- Saint‐Luke's Mid America Heart Institute, University of Missouri‐Kansas City School of Medicine, Kansas City, MO (D.J.C.)
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Salamone G, Falco N, Atzeni J, Tutino R, Licari L, Gulotta G. Colonic stenting in acutely obstructed left-sided colon cancer Clinical evaluation and cost analysis. Ann Ital Chir 2014; 85:556-562. [PMID: 25711367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
AIM This retrospective study aims to evaluate clinical and cost effectiveness of colonic stenting as a bridge to surgery and as a palliative treatment in acutely obstructed left-sided colon cancer. MATERIAL AND METHODS Onehundred fortyfour patients were collected between 2006 and 2012, with acute left-sided malignant colonic obstruction with no evidence of peritonitis: 96 patients underwent surgical treatment, 48 underwent decompressive stenting. For the stenting we used self-expandable metallic stent in nitinol. RESULTS Patients who had successful colonic stenting were 40, 8 underwent elective surgery within 10 days, 32 decompression stenting had only palliative intent. in 8/48 patients subjected to stenting decompression there was a technical failure (16%) and underwent emergency surgery. 40 patients had follow-up. at the time of observation 36 patients had a functioning stent, within 10 days 8 underwent elective definitive colonic resection with primary anastomosis trought videolaparoscopic thecnical, 4 (10%) had major complications and underwent emergency surgery. no patient of 40 in the stenting group required defunctioning stomas compared to 38 of 96 in emergency surgery group. we also compared the cost of decompressive stenting and emergency surgery treatment in acutely obstructed left-sided colon cancer referring to average cost of drg (1 and 2 code t-student test). the comparison of the average costs between decompressive stenting and emergency surgery was performed in the group of patients underwent palliative treatment separately from ones underwent radical treatment. CONCLUSION Colonic stenting followed by elective surgery may be safer and cost-effective, comparing to emergency surgery for left-sided malignant colonic obstruction. KEY WORDS Bowel obstruction, Colonic cancer, Colonic stenting.
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Abstract
PURPOSE The aim of this study was to evaluate the cost-effectiveness of the use of drug-eluting stents (DESs), as compared with bare-metal stents (BMSs) in Korea. MATERIALS AND METHODS A retrospective cohort study was conducted between January 2000 and December 2007. Subjects were stent-treated for the first time between 2004 and 2005, with four years of follow-up (2004-2007) (n=43674). The incremental cost-effectiveness ratio (ICER) was used to calculate the costs of DESs compared with BMSs among patients with coronary artery disease (CAD). Cost-effectiveness was assessed with effectiveness defined as a reduction in major adverse cardiac events after six months and after one, two, three, and four years. RESULTS The total costs of a DESs were 674108 Korean won (KRW) higher than that of a BMSs at the end of the follow-up; 13635 thousand KRW per patient treated with DESs and 12960 thousand KRW per patient treated with BMSs. The ICER was 256315 per KRW/death avoided and 293090 per KRW/re-stenting avoided among the CAD patients at the end of the follow-up. CONCLUSION The ICER for the high-risk patients was lower than that for the low-risk patients. The use of DESs is clinically more useful than the use of BMSs for CAD and myocardial infarction patients, especially for those considered to be high-risk patients in Korea.
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Affiliation(s)
- SooJin Lee
- Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon, Korea
| | - KyungWon Baek
- Division of Social Welfare, Baekseok University, Cheonan, Korea
| | - Kihong Chun
- Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon, Korea.; Graduate School of Public Health, Ajou University, Suwon, Korea.
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Adamson D, Blazeby J, Nelson A, Hurt C, Nixon L, Fitzgibbon J, Crosby T, Staffurth J, Evans M, Kelly NH, Cohen D, Griffiths G, Byrne A. Palliative radiotherapy in addition to self-expanding metal stent for improving dysphagia and survival in advanced oesophageal cancer (ROCS: Radiotherapy after Oesophageal Cancer Stenting): study protocol for a randomized controlled trial. Trials 2014; 15:402. [PMID: 25336193 PMCID: PMC4223756 DOI: 10.1186/1745-6215-15-402] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/01/2014] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The single most distressing symptom for patients with advanced esophageal cancer is dysphagia. Amongst the more effective treatments for relief of dysphagia is insertion of a self-expanding metal stent (SEMS). It is possible that the addition of a palliative dose of external beam radiotherapy may prolong the relief of dysphagia and provide additional survival benefit. The ROCS trial will assess the effect of adding palliative radiotherapy after esophageal stent insertion. METHODS/DESIGN The study is a randomized multicenter phase III trial, with an internal pilot phase, comparing stent alone versus stent plus palliative radiotherapy in patients with incurable esophageal cancer. Eligible participants are those with advanced esophageal cancer who are in need of stent insertion for primary management of dysphagia. Radiotherapy will be administered as 20 Gray (Gy) in five fractions over one week or 30 Gy in 10 fractions over two weeks, within four weeks of stent insertion. The internal pilot will assess rates and methods of recruitment; pre-agreed criteria will determine progression to the main trial. In total, 496 patients will be randomized in a 1:1 ratio with follow up until death. The primary outcome is time to progression of patient-reported dysphagia. Secondary outcomes include survival, toxicity, health resource utilization, and quality of life. An embedded qualitative study will explore the feasibility of patient recruitment by examining patients' motivations for involvement and their experiences of consent and recruitment, including reasons for not consenting. It will also explore patients' experiences of each trial arm. DISCUSSION The ROCS study will be a challenging trial studying palliation in patients with a poor prognosis. The internal pilot design will optimize methods for recruitment and data collection to ensure that the main trial is completed on time. As a pragmatic trial, study strengths include collection of all follow-up data in the usual place of care, and a focus on patient-reported, rather than disease-orientated, outcomes. Exploration of patient experience and health economic analyses will be integral to the assessment of benefit for patients and the NHS. TRIAL REGISTRATION The trial was registered with Current Controlled Trials (registration number: ISRCTN12376468) on 10 July 2012.
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Affiliation(s)
- Douglas Adamson
- />Tayside Cancer Centre, Ward 32, Ninewells Hospital, Dundee, DD1 9SY UK
| | - Jane Blazeby
- />School of Social & Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Annmarie Nelson
- />Marie Curie Palliative Care Research Centre, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 1st Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Chris Hurt
- />Wales Cancer Trials Unit, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Lisette Nixon
- />Wales Cancer Trials Unit, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Jim Fitzgibbon
- />Wales Cancer Trials Unit, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Tom Crosby
- />Velindre Cancer Centre, Velindre Hospital, Whitchurch, Cardiff, CF14 2TL UK
| | - John Staffurth
- />Institute of Cancer and Genetics, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XW UK
| | - Mim Evans
- />National Institute for Social Care and Health Research (NISCHR), Clinical Research Centre, 3rd Floor 12 Cathedral Road, Cardiff, CF11 9LJ UK
| | - Noreen Hopewell Kelly
- />Marie Curie Palliative Care Research Centre, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 1st Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - David Cohen
- />NISCHR Welsh Health Economics Support Service, University of South Wales, Pontypridd, CF37 1DL UK
| | - Gareth Griffiths
- />University of Southampton Clinical Trials Unit, MP 131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Anthony Byrne
- />Marie Curie Palliative Care Research Centre, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 1st Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
- />Wales Cancer Trials Unit, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, 6th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
- />Velindre Cancer Centre, Velindre Hospital, Whitchurch, Cardiff, CF14 2TL UK
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Radhakrishnan M, Peacock J, Rua T, Clough RE, Ofuya M, Wang Y, Morris E, Lewis C, Keevil S. E-vita open plus for treating complex aneurysms and dissections of the thoracic aorta: a NICE medical technology guidance. Appl Health Econ Health Policy 2014; 12:485-95. [PMID: 25056415 PMCID: PMC4175038 DOI: 10.1007/s40258-014-0114-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The E-vita open plus is a one-stage endoluminal stent graft system used for treating complex aneurysms and dissections of the thoracic aorta. The National Institute for Health and Care Excellence (NICE), as a part of its Medical Technologies Evaluation Programme (MTEP), selected this device for evaluation and invited the manufacturer, JOTEC GmbH, to submit clinical and economic evidence. King's Technology Evaluation Centre (KiTEC), an External Assessment Centre (EAC) commissioned by the NICE, independently critiqued the manufacturer's submissions. The EAC considered that the manufacturer had included most of the relevant evidence for the E-vita open plus, based on international E-vita open registry data for 274 patients, but had provided only limited evidence for the comparators. The EAC therefore conducted a systematic review and meta-analysis of all comparators to supplement the information, and found ten additional studies providing outcome data for the three two-stage comparators. The EAC noted that the cost model submitted by the manufacturer did not include key complications during the procedures. The EAC developed a new economic model incorporating data on complications along with their long-term costs. The revised model indicated that the E-vita open plus might not provide cost savings when compared with some of the comparators in the short-term (1 year), but would have high cost savings in the long-term, from the second year onwards. The NICE Medical Technologies Guidance MTG 16, issued in December 2013, recommended the adoption of the E-vita open plus in selected patients within the National Health Service in England.
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Sangchan A, Chaiyakunapruk N, Supakankunti S, Pugkhem A, Mairiang P. Cost utility analysis of endoscopic biliary stent in unresectable hilar cholangiocarcinoma: decision analytic modeling approach. Hepatogastroenterology 2014; 61:1175-1181. [PMID: 25436278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Endoscopic biliary drainage using metal and plastic stent in unresectable hilar cholangiocarcinoma (HCA) is widely used but little is known about their cost-effectiveness. This study evaluated the cost-utility of endoscopic metal and plastic stent drainage in unresectable complex, Bismuth type II-IV, HCA patients. METHODOLOGY Decision analytic model, Markov model, was used to evaluate cost and quality-adjusted life year (QALY) of endoscopic biliary drainage in unresectable HCA. Costs of treatment and utilities of each Markov state were retrieved from hospital charges and unresectable HCA patients from tertiary care hospital in Thailand, respectively. Transition probabilities were derived from international literature. Base case analyses and sensitivity analyses were performed. RESULTS Under the base-case analysis, metal stent is more effective but more expensive than plastic stent. An incremental cost per additional QALY gained is 192,650 baht (US$ 6,318). From probabilistic sensitivity analysis, at the willingness to pay threshold of one and three times GDP per capita or 158,000 baht (US$ 5,182) and 474,000 baht (US$ 15,546), the probability of metal stent being cost-effective is 26.4% and 99.8%, respectively. CONCLUSIONS Based on the WHO recommendation regarding the cost-effectiveness threshold criteria, endoscopic metal stent drainage is cost-effective compared to plastic stent in unresectable complex HCA.
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Sun XR, Tang CW, Lu WM, Xu YQ, Feng WM, Bao Y, Zheng YY. Endoscopic Biliary Stenting Versus Percutaneous Transhepatic Biliary Stenting in Advanced Malignant Biliary Obstruction: Cost-effectiveness Analysis. Hepatogastroenterology 2014; 61:563-566. [PMID: 26176036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS This study aims to compare the clinical outcomes and costs between endoscopic biliary stenting (EBS) and percutaneous transhepatic biliary stenting (PTBS). METHODOLOGY We randomly assigned 112 patients with unresectable malignant biliary obstruction 2006 and 2011 to receive EBS or PTBS with self-expandable metal stent (SEMS) as palliative treatment. PTBS was successfully performed in 55 patients who formed the PTBS group (failed in 2 patients). EBS was successfully performed in 52 patients who formed the EBS group (failed in 3 patients). The effectiveness of biliary drainage, hospital stay, complications, cost, survival time and mortality were compared. RESULTS Patients in PTBS group had shorter hospital stay and lower initial and overall expense than the BBS group (P < 0.05). There was no significant difference in effectiveness of biliary drainage (P = 0.9357) or survival time between two groups (P = 0.6733). Early complications occurred in PTBS group was significantly lower than in EBS group (3/55 vs 11/52, P = 0.0343). Late complications in the EBS group did not differ significantly from PTBS group (7/55 vs 9/52, P = 0.6922). The survival curves in the two groups showed no significant difference (P = 0.5294). Conclusions: 3.
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Polcari AJ, Hugen CM, López-Huertas HL, Turk TMT. Cost analysis and clinical applicability of the Resonance®metallic ureteral stent. Expert Rev Pharmacoecon Outcomes Res 2014; 10:11-5. [PMID: 20121560 DOI: 10.1586/erp.09.74] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Anthony J Polcari
- Loyola University Medical Center, Department of Urology, Building 54, Room 200, Maywood, IL 60153, USA
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Zhang NN, Li P, Zhang ST. Efficiency analysis of stenting for acute colorectal obstruction. Chin Med J (Engl) 2013; 126:4189-4191. [PMID: 24229696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Affiliation(s)
- Na-Na Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Wisløff T, Atar D, Sønbø Kristiansen I. Cost effectiveness of drug-eluting stents as compared with bare metal stents in patients with coronary artery disease. Am J Ther 2013; 20:596-601. [PMID: 21822114 DOI: 10.1097/mjt.0b013e3182211a01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this study was to estimate the incremental cost effectiveness of replacing bare metal stents (BMS) by drug-eluting stents (DES) when using trial data and registry data. We developed a Markov model (model of cost effectiveness of coronary artery disease) in which 60-year-old patients started by undergoing percutaneous coronary intervention for acute or subacute coronary artery disease. The patients are followed until death or 100 years of age. Data on the occurrence of events (revascularization, acute myocardial infarction, and death) were based on Scandinavian registry data. Separate analyses were conducted with data on effectiveness based on randomized controlled trials and patient registries. On using trial data, it was found that sirolimus-eluting stents (SES) yield 0.003 greater life expectancy and $3300 lower costs than do BMS (dominant strategy). Paclitaxel-eluting stents (PES) yield 0.148 more life years than do SES at additional lifetime costs of $2800 ($21,400 per life year gained). On using registry data, the cost per life year gained was found to be $4900 when replacing BMS with DES. Probabilistic sensitivity analyses, on the other hand, indicate that PES only has a 50%-75% probability of being cost effective, regardless of the type of effectiveness data. DESs are cost effective with current willingness to pay for life year gains. Whether PES or SES is the most effective DES remains uncertain.
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Affiliation(s)
- Torbjørn Wisløff
- 1Health Economics and Drug Unit, Norwegian Knowledge Centre for the Health Services; 2Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Norway; 3Department of Cardiology B, Oslo University Hospital Ullevål; and 4Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
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Shankar JJS, Vandorpe R, Pickett G, Maloney W. SILK flow diverter for treatment of intracranial aneurysms: initial experience and cost analysis. J Neurointerv Surg 2013; 5 Suppl 3:iii11-5. [PMID: 23424227 DOI: 10.1136/neurintsurg-2012-010590] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jai Jai Shiva Shankar
- Department of Diagnostic Imaging, Division of Neuroradiology, QE II Hospital, Halifax, Nova Scotia, Canada
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Withers K, Carolan-Rees G, Dale M. Pipeline™ embolization device for the treatment of complex intracranial aneurysms: a NICE Medical Technology Guidance. Appl Health Econ Health Policy 2013; 11:5-13. [PMID: 23341264 PMCID: PMC3563954 DOI: 10.1007/s40258-012-0005-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
As part of its Medical Technologies Evaluation Programme, the National Institute of Health and Clinical Excellence (NICE) invited the manufacturer, Covidien, to provide clinical and economic evidence for the evaluation of the Pipeline™ embolization device (PED) for the treatment of complex intracranial aneurysms. Cedar; a consortium between Cardiff and Vale University Health Board and Cardiff University, was commissioned to act as an External Assessment Centre (EAC) for NICE to independently critique the manufacturers' submissions. This article gives an overview of the evidence provided, the findings of the EAC and the final guidance published by NICE. The scope issued by NICE considered PED as the intervention in a patient population with complex unruptured intracranial aneurysms (IAs), specifically large/giant, wide-necked and fusiform aneurysms. The comparator treatments identified were stent-assisted coiling, parent vessel occlusion, neurosurgical techniques and conservative management. The manufacturer claimed that PED fulfils a currently unmet clinical need in the treatment of large or giant, wide-necked or fusiform IAs. Thirteen studies were identified by the manufacturer as being relevant to the decision problem, with two of these included for data extraction. The EAC identified 16 studies as relevant, three of which had been published after the manufacturer's search. Data extraction was carried out on these studies as, although many were low level research comprising of case reports and case series, they provided useful, pertinent safety and outcome data. No relevant economic studies of the device were identified; therefore, a new economic model was designed by the manufacturer. The base-case scenario provided recognized the costs of PED to be higher than the costs for endovascular parent vessel occlusion, neurosurgical parent vessel occlusion, neurosurgical clipping and conservative management. However, PED was found to be cost saving compared with stent-assisted coiling, with a saving of £13,110 per patient. Analysis of the clinical data suggested that treatment with PED has high rates of clinical success with high rates of aneurysm occlusion and acceptable adverse events for the patient population. Economic evidence suggested that the costs in the base-case for PED may have been underestimated, meaning that PED would only become cost saving in patients who would otherwise require treatment with 32 coils or more. NICE Medical Technologies Guidance MTG10, issued in May 2012, recommends the adoption of PED in selected patients within the UK National Health Service (NHS).
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Affiliation(s)
- Kathleen Withers
- Cedar, Cardiff and Vale University Health Board, Cardiff Medicentre, Heath Park, Wales, UK.
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Carlson J. Unclear terms. 'Unnecessary' use of stents can be hard to prove. Mod Healthc 2013; 43:14. [PMID: 23390698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Sadamasa N, Koyanagi M, Iwamuro Y, Chin M, Handa A, Yamagata S. [Cost Comparison of Carotid Endarterectomy versus Carotid Stenting in Japan]. No Shinkei Geka 2013; 41:31-35. [PMID: 23269253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Carotid artery stenting (CAS) has been covered by the health insurance system in Japan since 2008. There have been few studies concerning medical costs and charges for patients who received CEA or CAS in Japan. The aim of this study was to elucidate the difference in the costs between the patients who received CEA and those who received CAS in Japan. Between 2010 and 2011, 19 patients who received CEA and 20 patients who received CAS were retrospectively reviewed. Age, sex, symptomatic/asymptomatic, emergent/scheduled, length of stay, outcome, cost for the procedure (professional fee), supply for the operation, the total medical service fee, and copayment of the patients was compared between the two treatment groups. No significant difference was detected between the two groups except for the supply of the operation and the total medical service fee (CEA:mean 1,565,580 yen vs CAS 2,758,360 yen, p=0.0001). On the other hand, no significant difference was obtained in the copayment of the patients (CEA 71,895 yen, CAS 72,458 yen). Even when limited to the scheduled cases, similar results were obtained. There is a monthly copayment limit in the health insurance system in Japan, which results in a reasonable charge for patients who received CAS, despite the fact that the rest of the fee including high costs for the supplies was paid by the company and the nation. To reduce the medical costs, Japanese have to be aware of the high costs in CAS, most of which is due to the supplies.
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Affiliation(s)
- Nobutake Sadamasa
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki-city, Okayama, Japan
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Blankenship JC, Marshall JJ. Reimbursement changes with new PCI codes in 2013. Catheter Cardiovasc Interv 2012. [PMID: 23184396 DOI: 10.1002/ccd.24685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Birim Ö, Bogers AJJC, Kappetein AP. Comparing cost aspects of coronary artery bypass graft surgery with coronary artery stenting. J Cardiovasc Surg (Torino) 2012; 53:641-650. [PMID: 22252542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Randomized trials have compared revascularization of coronary artery disease by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). CABG is an expensive treatment. However, it manages to improve quality of life, restore general well being, and alleviate symptoms of patients. Coronary stents have improved the safety and durability of PCI. Nonetheless, stenting remains limited by a relatively high in-stent restenosis and thrombosis rate. The costs and cost-effectiveness for these different treatment modalities are relevant issues because cardiovascular disease and its management are prime targets for cost reduction initiatives. There is a debate as to which is the optimal treatment strategy as well as to the cost-effectiveness comparing CABG and PCI. This review provides an overview of cost-effectiveness of CABG compared with PCI. PCI has high costs due to the need for subsequent revascularization procedures, with absence of mortality and survival benefit compared with CABG. Despite the relative lower initial costs of PCI in the first year, PCI is not a cost-effective intervention in comparison with CABG. However, the studies undertaken to date have predominantly been short term and provide a very limited evidence base by which to assess the cost-effectiveness of modern clinical practice. It seems that in longer term, the benefits of CABG may exceed those of stenting and the difference in net cost may be in favour of CABG as the risk of repeat revascularization still increases with PCI regardless of the use of DES. However, to date no long-term data are available in cost-effectiveness between CABG and PCI. The 5-year outcome of the ongoing SYNTAX trial is essential and might therefore provide new insights into the comparison of cost-effectiveness between CABG and DES PCI.
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Affiliation(s)
- Ö Birim
- Department of Cardio-Thoracic Surgery, Erasmus MC Rotterdam, Rotterdam, The Netherlands.
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Cloft H. Regarding "Cost implications of more widespread carotid artery stenting consistent with the American College of Cardiology/American Heart Association guideline". J Vasc Surg 2012; 56:899. [PMID: 22917055 DOI: 10.1016/j.jvs.2012.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 04/04/2012] [Accepted: 04/05/2012] [Indexed: 11/28/2022]
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