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PURPOSE - To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.
METHODS - Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1-3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.
RESULTS - PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.
CONCLUSIONS - Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.
BACKGROUND - The economic burden of treating end-stage renal disease (ESRD) continues to grow. As one response, effective January 1, 2011, Medicare implemented a bundled prospective payment system (PPS, including injectable drugs) for dialysis patients. This study investigated the 5-year budget impact on Medicare under the new PPS of changes in the distribution of patients undergoing peritoneal dialysis (PD), in-center hemodialysis (ICHD), and home hemodialysis (HHD).
METHODS - An Excel-based budget impact model was created to assess dialysis-associated Medicare costs. The model accounted for dialysis access establishment, the current monthly capitation physician payment for ESRD, Medicare dialysis payments (including start-up costs), training, oral drug costs, and the costs and probabilities of adverse events including access failure, hospitalization for access infection, pneumonia, septicemia, and cardiovascular events. United States Renal Data System (USRDS) data were used to project the US Medicare dialysis patient population across time. The baseline scenario assumed a stable distribution of PD (7.7%), HHD (1.3%) and ICHD (91.0%) over 5 years. Three comparison scenarios raised the proportions of PD and HHD by (1) 1% and 0.5%, (2) 2% and 0.75%, and (3) 3% and 1% each year; a fourth scenario held HHD constant and lowered PD by 1% per year.
RESULTS - Under the bundled PPS, scenarios that increased PD and HHD from 7.7% and 1.3% over 5 years resulted in cumulative savings to Medicare of $114.8M (Scenario 1, 11.7% PD and 3.3% HHD at year 5), $232.9M (Scenario 2, 15.7% PD and 4.3% HHD at year 5), and $350.9M (Scenario 3, 19.7% PD and 5.3% HHD at year 5). When the PD population was decreased from 7.7% in 2013 to 3.7% by 2017 with a constant HHD population, the total Medicare payment for dialysis patients increased by over $121.2M.
CONCLUSIONS - Under Medicare bundled PPS, increasing the proportion of patients on PD and HHD vs ICHD could generate substantial savings in dialysis-associated costs to Medicare.
Copyright © 2014 International Society for Peritoneal Dialysis.
SETTING - A large randomized controlled trial recently showed that for treating latent tuberculous infection (LTBI) in persons at high risk of progression to tuberculosis (TB) disease, a 12-dose regimen of weekly rifapentine plus isoniazid (3HP) administered as directly observed treatment (DOT) can be as effective as 9 months of daily self-administered isoniazid (9H).
OBJECTIVES - To assess the cost-effectiveness of 3HP compared to 9H.
DESIGN - A computational model was designed to simulate individuals with LTBI treated with 9H or 3HP. Costs and health outcomes were estimated to determine the incremental costs per active TB case prevented and per quality-adjusted life year (QALY) gained by 3HP compared to 9H.
RESULTS - Over a 20-year period, treatment of LTBI with 3HP rather than 9H resulted in 5.2 fewer cases of TB and 25 fewer lost QALYs per 1000 individuals treated. From the health system and societal perspectives, 3HP would cost respectively US$21,525 and $4294 more per TB case prevented, and respectively $4565 and $911 more per QALY gained.
CONCLUSIONS - 3HP may be a cost-effective alternative to 9H, particularly if the cost of rifapentine decreases, the effectiveness of 3HP can be maintained without DOT, and 3HP treatment is limited to those with a high risk of progression to TB disease.
BACKGROUND - Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.
OBJECTIVE - This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.
DATA SOURCES - MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.
REVIEW METHODS - Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.
RESULTS - The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.
LIMITATIONS - The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.
CONCLUSIONS - This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.
FUNDING - The National Institute for Health Research Health Technology Assessment programme.
BACKGROUND - Streptococcus pneumoniae continues to cause a variety of common clinical syndromes, despite vaccination programs for both adults and children. The total U.S. burden of pneumococcal disease is unknown.
METHODS - We constructed a decision tree-based model to estimate U.S. healthcare utilization and costs of pneumococcal disease in 2004. Data were obtained from the 2004-2005 National (Hospital) Ambulatory Medical Care Surveys (outpatient visits, antibiotics) and the National Hospital Discharge Survey (hospitalization rates), and CDC surveillance data. Other assumptions regarding the incidence of each syndrome due to pneumococcus, expected health outcomes, and healthcare utilization were derived from literature and expert opinion. Healthcare and time costs used 2007 dollars.
RESULTS - We estimate that, in 2004, pneumococcal disease caused 4.0 million illness episodes, 22,000 deaths, 445,000 hospitalizations, 774,000 emergency department visits, 5.0 million outpatient visits, and 4.1 million outpatient antibiotic prescriptions. Direct medical costs totaled $3.5 billion. Pneumonia (866,000 cases) accounted for 22% of all cases and 72% of pneumococcal costs. In contrast, acute otitis media and sinusitis (1.5 million cases each) comprised 75% of cases but only 16% of direct medical costs. Patients ≥ 65 years old, accounted for most serious cases and the majority of direct medical costs ($1.8 billion in healthcare costs annually). In this age group, pneumonia caused 242,000 hospitalizations, 1.4 million hospital days, 194,000 emergency department visits, 374,000 outpatient visits, and 16,000 deaths. However, if work loss and productivity are considered, the cost of pneumococcal disease among younger working adults (18-<50) nearly equaled those ≥ 65.
CONCLUSIONS - Pneumococcal disease remains a substantial cause of morbidity and mortality even in the era of routine pediatric and adult vaccination. Continued efforts are warranted to reduce serious pneumococcal disease, especially adult pneumonia.
Copyright © 2011 Elsevier Ltd. All rights reserved.
BACKGROUND - Although annual per-person health care costs for patients with end-stage renal disease (ESRD) on in-center hemodialysis greatly exceed those for patients on peritoneal dialysis (PD), which is a home dialysis therapy, current use of PD remains low. In April 2008, the Centers for Medicare & Medicaid Services issued a new Dialysis Conditions of Coverage final rule underscoring its intent to promote use of home dialysis whenever appropriate.
OBJECTIVES - The objectives of this paper were to provide context for the use of in-home versus in-center dialysis, to describe factors that influence patterns of dialysis utilization in the United States, and to explore the magnitude of the potential savings that might result from broader use of home dialysis therapies.
METHODS - A 5-year budget-impact analysis was performed using data from the 2007 Annual Data Report of the United States Renal Data System. Scenarios were developed in which the PD share of total dialysis was varied to estimate the impact on total Medicare dialysis costs. This study took the perspective of Medicare, the main payer for dialysis in the United States.
RESULTS - If the PD share of total dialysis were to decrease from the current 8% to 5%, Medicare spending for dialysis would increase by an additional $401 million over a 5-year period. Alternatively, if the PD share of total dialysis were to increase to 15%, Medicare could realize potential savings of >$1.1 billion over 5 years.
CONCLUSIONS - Similar to the conclusion articulated in the Dialysis Conditions of Coverage final rule, increasing clinically appropriate use of PD would be associated with considerable savings to Medicare and to the taxpayers who fund Medicare. These savings could be used to offset part of the financial burden of ESRD care on Medicare and to help legislators meet ever-tightening budgetary constraints.
BACKGROUND/PURPOSE - Two strategies are commonly used for the initial diagnosis of hypertrophic pyloric stenosis (HPS): (1) physical examination and (2) radiologic evaluation using upper gastrointestinal series (UGI) or sonography. The authors wished to determine the sensitivity and relative cost of each strategy.
METHODS - The charts of 234 patients presenting over 3 years with a history suggestive of HPS were reviewed retrospectively. Cost, expressed as mean diagnostic charges (MDC) and mean total charges (MTC), was calculated according to two theoretical models. In model A, all patients first are examined by a surgeon. If an olive is palpable, they proceed to surgery. If not, they are sent to radiology. In model B, all patients have radiologic investigation first, and then surgical evaluation if the study result is positive.
RESULTS - Of the 234 patients, 150 had HPS (64%). Olives were appreciated in 111 of these (palpation sensitivity of 74%). There was one false-positive olive (0.7%) and no false-negatives. Sonography and UGI were equally accurate (sensitivity of 100%, 0.5% false-positive). Equations were generated to estimate MDC and MTC for our patient population under each model. In model A, MDC = $507 - ($221 x palpation sensitivity) and MTC = $2,543 ($240 x palpation sensitivity). In model B, MDC = $449 and MTC = $2,454, and costs were independent of ability to feel an olive. When cost was plotted against palpation sensitivity, model A yielded a lower MDC than model B if palpation sensitivity was at least 26%, and a lower MTC if palpation sensitivity was at least 37%. Because our palpation sensitivity was 74%, approximately $100 per patient would be saved by sending all infants suspected of having HPS to a surgeon for examination as an initial step.
CONCLUSIONS - Although highly sensitive, imaging is superfluous if an olive is palpable. Children suspected of having HPS should have a surgical consultation before a radiology study as long as the surgeon's palpation sensitivity for an olive is at least 37%. Improved palpation skills will result in maximum financial savings.