Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial

BACKGROUND: Evidence comparing laparoscopic versus open hernia repair has varied with time and with changes in techniques used. Cost effectiveness is an important consideration when evidence for predominance of one surgical technique is lacking. Current cost estimates of hernia repair are not available. STUDY DESIGN: This study is a cost effectiveness analysis within a randomized controlled trial comparing open (OPEN) versus laparoscopic (LAP) hernia repair using mesh at 14 Department of Veterans Affairs medical centers, with 2-year followup for each patient. Between January 1999 and November 2001, 2,164 men with inguinal hernia were randomized and 1,983 had an operation; 1,395 patients (708 OPEN and 687 LAP) with outpatient hernia operations were included in the cost effectiveness analysis. Outcomes included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). RESULTS: Over 2 years, LAP cost an average of $638 more than OPEN. QALYs at 2 years were similar, resulting in $45,899 per QALY gained (95% CI: -$669,045, $722,457). The probability that LAP is cost effective at the $50,000 per QALY level (slightly more costly but more effective), was 51%. For unilateral primary and unilateral recurrent hernia repair, the probabilities that LAP is cost effective at the $50,000 per QALY level were 64% and 81%, respectively. For bilateral hernia repair, OPEN was less costly and more effective. CONCLUSIONS: Overall, laparoscopic hernia repair is not cost effective compared with open repair. For patients with unilateral (primary or recurrent) hernia, laparoscopic repair is a cost effective treatment option.     

IS LAPAROSCOPIC COLECTOMY FOR CANCER COST‐EFFECTIVE RELATIVE TO OPEN COLECTOMY?

BACKGROUND: Laparoscopic-assisted colectomy (LAC) for cancer has been shown to be safe, with equivalent long-term survival rates to conventional open colectomy (OC) and better short-term patient outcomes. However, LAC tends to require more operating theatre time and disposable equipment. This study investigated, in the context of the New Zealand public hospital system, the extent to which LAC for cancer is cost-effective relative to OC. METHODS: Estimates of the hospital resources used and patient recovery times for LAC and OC for colorectal cancer were obtained from a meta-analysis of published international randomized controlled trials. Using prices from a representative New Zealand public hospital, the additional resources for LAC (relative to OC) were summed to obtain an estimate of LAC's total incremental (additional) cost. The recovery time savings from LAC were also represented in quality-adjusted life years (QALY), enabling a cost-utility analysis of LAC, which was subjected to a one-way sensitivity analysis. RESULTS: On average, a LAC costs New Zealand public hospitals $1267 (range: $259-$3808; all dollars referred to are New Zealand dollars) more than an OC. Average recovery time savings of 12 and 33 days (from two randomized controlled trials) translate into QALY gains of 0.018 and 0.049. Thus, relative to an OC, an LAC costs $38 and $106 per recovery day saved, or $70 389 and $25 857 (combined range: $14 389-$211 556) per QALY gained. CONCLUSION: LAC for cancer appears to be cost-effective relative to OC (per recovery day saved and QALY gained, respectively) for the lower of the average cost estimates and is probably not cost-effective for the higher estimate. Expected future reductions in operating times, conversion rates and postoperative stays will further improve cost-effectiveness.     

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other. METHODS: We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data. RESULTS: For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB. CONCLUSION: The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.     

Cost-effectiveness Analysis of Active Surveillance Strategies for Men with Low-risk Prostate Cancer

BackgroundActive surveillance (AS) has become the recommended management strategy for men with low-risk prostate cancer. However, there is considerable uncertainty about the optimal follow-up schedule in terms of the tests to perform and their frequency.ObjectiveTo assess the costs and benefits of different AS follow-up strategies compared to watchful waiting (WW) or immediate treatment.Design, setting, and participantsA state-transition Markov model was developed to simulate the natural history (ie, no testing or intervention) of prostate cancer for a hypothetical cohort of 50-yr-old men newly diagnosed with low-risk prostate cancer. Following diagnosis, men were hypothetically managed with immediate treatment, watchful waiting, or one of several AS strategies. AS follow-up was performed either with transrectal ultrasound-guided biopsy or magnetic resonance imaging (MRI) which was scheduled annually, biennially, every 3 yrs, according to the PRIAS protocol (yrs 1, 4, 7, and 10, and then every 5 yr) or every 5 yr. Diagnosis of higher-grade or -stage disease while on AS resulted in curative treatment.Outcome measurements and statistical analysisWe measured discounted quality-adjusted life years (QALYs), discounted lifetime medical costs (2017 US$), and incremental cost-effectiveness ratios (ICERs).Results and limitationsCompared to WW, MRI-based surveillance performed every 5 yr improved quality-adjusted survival by 4.47 quality-adjusted months and represented high-value health care at the Medicare reimbursement rate using standard cost-effectiveness metrics. Biopsy-based strategies were less effective and less costly than the corresponding MRI-based strategies for each testing interval. MRI-based surveillance at more frequent intervals had ICERs greater than $800 000 per QALY and would not be considered cost-effective according to standard metrics. Our results were sensitive to the diagnostic accuracy and costs of both biopsy modes in detecting clinically significant cancer.ConclusionsIncorporation of MRI into surveillance protocols at Medicare reimbursement rates and decreasing the intensity of repeat testing may be cost-effective options for men opting for conservative management of low-risk prostate cancer.Patient summaryOur study modeled outcomes for men with low-risk prostate cancer undergoing watchful waiting, immediate treatment, or active surveillance with different follow-up schedules. We found that conservative management of low-risk disease optimizes health outcomes and costs. Furthermore, we showed that decreasing the intensity of active surveillance follow-up and incorporating magnetic resonance imaging (MRI) into surveillance protocols can be cost-effective, depending on the MRI costs.     

Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden

The aim of this study was to determine the threshold of fracture probability at which interventions became cost-effective in men and women, based on data from Sweden. We modeled the effects of a treatment costing $500 per year given for 5 years that decreased the risk of all osteoporotic fractures by 35% followed by a waning of effect for a further 5 years. Sensitivity analyses included a range of effectiveness (10-50%) and a range of intervention costs ($200–500/year). Data on costs and risks were from Sweden. Costs included direct costs, but excluded indirect costs due to morbidity. A threshold for cost-effectiveness of approximately $45,000/QALY gained was used. Cost of added years was included in a sensitivity analysis. With the base case ($500 per year; 35% efficacy) treatment in women was cost-effective with a 10-year hip fracture probability that ranged from 1.2% at the age of 50 years to 7.4% at the age of 80 years. Similar results were observed in men except that the threshold for cost-effectiveness was higher at younger ages than in women (2.0 vs 1.2%, respectively, at the age of 50 years). Intervention thresholds were sensitive to the assumed effectiveness and intervention cost. The exclusion of osteoporotic fractures other than hip fracture significantly increased the cost-effectiveness ratio because of the substantial morbidity from such other fractures, particularly at younger ages. We conclude that the inclusion of all osteoporotic fractures has a marked effect on intervention thresholds, that these vary with age, and that available treatments can be targeted cost-effectively to individuals at moderately increased fracture risk.     

Robotic-Assisted Versus Manual Unicompartmental Knee Arthroplasty: A Time-Driven Activity-Based Cost Analysis

BackgroundThe cost-effectiveness of robotic-assisted unicompartmental knee arthroplasty (RA-UKA) remains unclear. Time-driven activity-based costing (TDABC) has been shown to accurately reflect true resource utilization. This study aimed to compare true facility costs between RA-UKA and conventional UKA.MethodsWe identified 265 consecutive UKAs (133 RA, 132 conventional) performed at a specialty hospital in 2016-2020. Itemized facility costs were calculated using TDABC. Separate analyses including and excluding implant costs were performed. Multiple regression was performed to determine the independent effect of robotic assistance on facility costs.ResultsDue to longer operative time, RA-UKA patients had higher personnel costs and total facility costs ($2,270 vs $1,854, P < .001). Controlling for demographics and comorbidities, robotic assistance was associated with an increase in personnel costs of $399.25 (95% confidence interval [CI] $343.75-$454.74, P < .001), reduction in supply costs of $55.03 (95% CI $0.56-$109.50, P = .048), and increase in total facility costs of $344.27 (95% CI $265.24-$423.31, P < .001) per case. However, after factoring in implant costs, robotic assistance was associated with a reduction in total facility costs of $235.87 (95% CI $40.88-$430.85, P < .001) per case.ConclusionUsing TDABC, overall facility costs were lower in RA-UKA despite a longer operative time. To facilitate wider adoption of this technology, implant manufacturers may negotiate lower implant costs based on volume commitments when robotic assistance is used. These supply cost savings appear to offset a portion of the increased costs. Nonetheless, further research is needed to determine if RA-UKA can improve clinical outcomes and create value in arthroplasty.     

The Cost-Effectiveness of Total Hip Arthroplasty in Patients 80 Years of Age and Older

Background

This study investigates the cost-effectiveness of total hip arthroplasty (THA) in patients 80 years old.

Cost-effectiveness of open transforaminal lumbar interbody fusion (OTLIF) versus minimally invasive transforaminal lumbar interbody fusion (MITLIF): a systematic review and meta-analysis

Background ContextThe number of performed instrumented lumbar spine surgeries and associated health-care-related costs has increased over the last decades, and will increase further in the future. With the consistent growth of health-care-related costs, cost-effectiveness of surgical techniques is of major relevance. Common indications for instrumented lumbar spine surgery are spondylolisthesis and degenerative disease. A commonly used technique is the open transforaminal lumbar interbody fusion (OTLIF). Nowadays, there is an increasing interest in the minimally invasive variation of this technique (minimally invasive transforaminal lumbar interbody fusion [MITLIF]). Currently available literature describes that MITLIF has comparable or even better clinical results compared to OTLIF. Cost-effectiveness of MITLIF and OTLIF is important considering the growing health-care related costs, although no consensus has been reached regarding the most cost-effective technique. In this systematic review, previous literature concerning costs and cost-effectiveness of OTLIF was compared with MITLIF in patients with lumbar spondylolisthesis or degenerative disease. Furthermore, methodological quality of included studies was assessed.PurposeThis study aims to evaluate the current literature on cost-effectiveness of OTLIF compared MITLIF to in patients with lumbar spondylolisthesis or degenerative disease.Study DesignThis study is a systematic literature review and meta-analysis.Study SampleClinical studies reporting costs or cost-effectiveness for either OTLIF or MITLIF in patients with spondylolisthesis, lumbar instability, or degenerative disease were included.Outcome MeasuresThe following data items were evaluated: study design, study population, utility measurement tool, gained quality adjusted life years (QALYs), cost sources, health care and societal perspective costs, total costs, costs per QALY (cost-effectiveness) and incremental cost-effectiveness ratio (ICER).MethodsA systematic search was conducted using databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit and Web of Science on studies reporting OTLIF or MITLIF, spondylolisthesis or lumbar instability or degenerative disease, and costs. Relevant studies were selected and reviewed independently by two authors. For comparison, all costs were converted to American dollars with the reference year 2018.ResultsAfter duplicate removal, a total of 892 studies were identified. Eventually, 32 studies were included. Nine studies compared OTLIF and MITLIF directly. All studies mentioned health care perspective costs. Seven studies mentioned societal perspective costs. Cost-effectiveness of OTLIF was mentioned in five studies, ranging from $47,303/QALY to $218,766/QALY. Cost-effectiveness of MITLIF was mentioned in one study, $121,105/QALY. Meta-analysis of hospital perspective costs showed a significant overall effect in favor of MITLIF, with a mean difference of $2,650. There was great heterogeneity in health care and societal perspective costs due to different in-, and exclusion factors, baseline characteristics, and calculation methods. Overall quality of studies was low.ConclusionsOTLIF and MITLIF appear to be expensive interventions when using a threshold of $50,000/QALY. Results of this study and previous literature suggest that MITLIF is more cost-effective compared to OTLIF. Considering the increase in health care costs of instrumented spine surgery, cost-effectiveness could be one of the factors in surgical decision-making. Prospective randomized studies directly comparing cost-effectiveness of OTLIF and MITLIF from both hospital and societal perspectives are needed to obtain higher level of evidence.     

Cost−utility analysis of shockwave lithotripsy vs ureteroscopic stone treatment in adults

Objectives

To assess the cost-effectiveness, resource use implications, quality-adjusted life-years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones.

Patients and Methods

Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost-effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality-of-life data were calculated using a generic instrument, the EuroQol EQ-5D-3L. Results are expressed as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves.

Results

The mean QALY difference (SWL vs URS) was −0.021 (95% confidence interval [CI] −0.033 to −0.010) and the mean cost difference was −£809 (95% CI −£1061 to −£551). The QALY difference translated into approximately 10 more healthy days over the 6-month period for the patients on the URS care pathway. The probabaility that SWL is cost-effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000.

Conclusion

The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost-effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision-makers need to determine if costs saved justify the loss in QALYs.     

The cost-effectiveness of early surgery versus watchful waiting in the management of small abdominal aortic aneurysms

Purpose: The purpose of this study was to compare the relative cost-effectiveness of two clinical strategies for managing 4 to 5 cm diameter abdominal aortic aneurysms (AAAs): early surgery (repair 4 cm AAA when diagnosed) versus watchful waiting (monitor AAA with ultrasound size measurements every 6 months and repair if the diameter reaches 5 cm).Methods: We used a Markov decision tree to compute the expected survival in quality-adjusted life years (QALYs) for each strategy, based on literature-derived estimates for the probabilities of different outcomes in this model. We determined hospital costs for patients undergoing elective and emergency AAA repair at our center. With standard methods of cost accounting, we then calculated the additional cost per year of life saved by early surgery compared with watchful waiting (cost-effectiveness ratio, dollars/QALY).Results: Mean hospital costs for elective and emergency AAA repair were $24,020 and $43,208, respectively (1992 dollars). For our base-case analysis (60-year-old men with 4 cm diameter AAAs, with 5% elective operative mortality rate and 3.3% annual rupture rate), early surgery improved survival by 0.34 QALYs compared with watchful waiting, at an incremental cost of $17,404/QALY. Increased elective surgical mortality rate, decreased AAA rupture risk, and increased patient age all reduced the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery.Conclusions: The cost effectiveness of early surgery for 4 cm diameter AAAs in carefully selected patients compares favorably with that of other commonly accepted preventive interventions such as hypertension screening and treatment. With an upper limit of $40,000/QALY as an "acceptable" cost-effectiveness ratio, early surgery appears to be justified for patients 70 years old or younger, if the AAA rupture risk is 3%/year or more and the elective operative mortality rate is 5% or less. Although not a substitute for clinical judgment, this cost-effectiveness analysis delineates the essential tradeoffs and uncertainties in treating patients with small AAAs. (J VASC SURG 1994;19:980–91.)     

Cost-utility analysis of emergency department thoracotomy for trauma victims

BACKGROUND: Our objective was to assess the cost-effectiveness of emergency department thoracotomy (EDT) performed on both penetrating and blunt trauma victims, using both published survival and outcome data and previously unaccounted for data on the cost of occupational exposure. METHODS: Cost-utility analysis was performed using decision-analytic models constructed for both penetrating and blunt trauma scenarios. Survival and impairment data, the rates and costs of occupational exposure, and the utilities of neurologic impairment and provider seroconversion were all based on published literature. Costs of EDT were estimated using the National Inpatient Sample (NIS) from the Health Care Utilization Project database. One-way sensitivity analyses on input parameters and probabilistic sensitivity analyses using Monte Carlo simulations were performed. RESULTS: The incremental cost-effectiveness ratio of EDT for penetrating trauma was $16,125 per quality-adjusted life year (QALY), and less than $50,000 per QALY with a 93.4% probability. The incremental cost-effectiveness ratio for blunt trauma was $163,136 per QALY, and less than $50,000 per QALY with a 37% probability. Neither model was sensitive to provider exposure. The penetrating model was insensitive to the probability of neurologically intact survival, the utility adjustment, procedure costs, and long-term care. The blunt model was sensitive to the probabilities of survival and of neurologic impairment. CONCLUSIONS: EDT is cost-effective for penetrating trauma, and not cost-effective for blunt trauma given current rates of survival and impairment. Occupational exposure does not significantly impact the cost-effectiveness of the procedure.     

CAGS AND ACS EVIDENCE BASED REVIEWS IN SURGERY. 45: Cost-effectiveness of bariatric surgery for severely obese adults with diabetes

Objective: To analyze the cost-effectiveness of bariatric surgery in severely obese adults who have diabetes. Base case: Patients with body mass index (BMI) ≥ 35 who have diabetes. Methods: The Centre for Disease Control (CDC)-RTI Diabetes Cost-Effectiveness Model, which is a Markov simulation model of disease progression and cost-effectiveness for type 2 diabetes, was expanded to consider the effects of bariatric surgery. Interventions considered: Gastric bypass and gastric banding compared with usual diabetes care. Outcomes considered: Diabetes-related and surgical complications, diabetes remission and relapse rates, deaths, costs and quality of life. Results: Bariatric surgery increased quality-adjusted life years (QALYs) and increased costs. Bypass surgery had cost-effectiveness ratios of $7 000 per QALY and $12 000 per QALY for severely obese patients with newly diagnosed and established diabetes, respectively. Gastric banding had cost-effectiveness ratios of $11 000 per QALY and $13 000 per QALY, respectively. In sensitivity analyses, the cost-effectiveness ratios were most affected by assumptions about the direct gain in quality of life and by BMI reduction following surgery. Conclusion: The analysis indicates that gastric bypass and gastric banding are cost-effective methods of reducing mortality and diabetes-related complications in severely obese adults with diabetes.     

Cost-Effectiveness of Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer

Background

A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer.

Methods

A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty.

Results

MIE was estimated to cost $1641 (95 % confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95 % confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Conclusions

MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.     

Cost-effectiveness of conventional and endovascular repair of abdominal aortic aneurysms: results of a randomized trial

BACKGROUND: Two randomized trials have shown similar mid-term outcomes for survival and quality of life after endovascular and conventional open repair of abdominal aortic aneurysms (AAA). With reduced hospital and intensive care stay, endovascular repair has been hypothesized to be more efficient than open repair. The Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was undertaken to assess the balance of costs and effects of endovascular vs open aneurysm repair. METHODS: We conducted a multicenter, randomized trial comparing endovascular repair with open repair in 351 patients with an AAA and studied costs, cost-effectiveness, and clinical outcome 1 year after surgery. In addition to clinical outcome, costs and quality of life were recorded up to 1 year in 170 patients in the endovascular repair group and in 170 in the open repair group. Incremental cost-effectiveness ratios were estimated for cost per life-year, event-free life-year, and quality adjusted life-year (QALY) gained. Uncertainty regarding these outcomes was assessed using bootstrapping. RESULTS: Patients in the endovascular repair group experienced 0.72 QALY vs 0.73 in the open repair group (absolute difference, 0.01; 95% confidence interval [CI], -0.038 to 0.058). Endovascular repair was associated with additional euro 4293 direct costs (euro 18,179 vs euro 13.886; 95% CI, euro 2,770 to euro 5,830). Most of the bootstrap estimates indicated that endovascular repair resulted in slightly longer overall and event-free survival associated with respective incremental cost-effectiveness ratios of euro76,100 and euro 171,500 per year gained. Open repair appeared the dominant strategy in costs per QALY. CONCLUSION: Presently, routine use of endovascular repair in patients also eligible for open repair does not result in a QALY gain at 1 year postoperatively, provides only a marginal overall survival benefit, and is associated with a substantial, if not prohibitive, increase in costs.     

Does delay of hernia repair in minimally symptomatic men burden the patient's family?

BACKGROUND: Although inguinal hernia repair is a common and safe procedure, a significant portion of patients who undergo surgical repair experience postoperative chronic pain. We conducted a clinical trial to determine if delay of repair is a safe and acceptable alternative for men with minimally symptomatic inguinal hernias. Here we report on the effects of delay on the patient's family. STUDY DESIGN: Data are from a randomized trial in which men with asymptomatic or minimally symptomatic inguinal hernia were randomly assigned to either open tension-free repair (TFR) or watchful waiting (WW). Patients indicated a person who could assist them if necessary because of their hernia or hernia operation, and these persons (mostly spouses) answered a questionnaire at baseline and followup addressing concern about the patient's ability to perform home, social, and recreational activities and time spent assisting the patient with chores because of his hernia condition. RESULTS: In both intention-to-treat and as-treated analyses, at 2 years after enrollment, family members of patients assigned to WW were more likely to report concern about the patient's ability to perform the four types of activities. But a majority of respondents in both the WW and TFR groups indicated no concern about performance of any of the activities. In the as-treated analysis, family members of patients assigned to TFR who did not receive repair reported more time assisting the patient than those of TFR patients who received the assigned treatment. CONCLUSIONS: The results favor repair, but the low level of concern about the patient's functioning reported for both TFR and WW patients suggests that this is not a major issue in delaying repair of inguinal hernias in minimally symptomatic men.     

Cost-Effectiveness of Preventing Hip Fracture in the General Female Population

The aims of this study were to determine whether treatments that reduce the incidence of hip fracture might be used in the general female population rather than screening or case-finding strategies. Cost-effectiveness, measured as cost per quality-adjusted life-year (QALY) gained using threshold values for cost-effectiveness of $20.000 or $30.000/QALY gained, was assessed during and after treatment using a computer simulation model applied to the female population of Sweden. The base case assumed a 5-year intervention that reduced the risk of hip fracture by 35% during the treatment period, and an effect that reversed to the pretreatment risk during the next 5 years. Sensitivity analyses included the effects of age, different treatment costs and effectiveness. Cost-effectiveness was critically dependent upon the age and costs of intervention. Reasonable cost-effectiveness was shown even with relatively high intervention costs for women at average risk at the age of 84 years or more. For the cheapest interventions ($63/year) cost-effectiveness could be found from the age of 53 years. Variations in effectiveness (15–50% risk reduction) had marked effects on the age that treatment was worthwhile. We conclude that segments of the apparently healthy population could be advantaged by treatment if efficacy were supported by randomized controlled studies. Received: May 2000 / Accepted: November 2000     

Cost-effectiveness of ablation surgery in patients with atrial fibrillation undergoing cardiac surgery

This study was performed to assess the cost-effectiveness of concomitant ablation surgery (AS) compared to regular cardiac surgery in atrial fibrillation (AF) patients over a one-year follow-up. Cost analysis was performed from a societal perspective alongside a prospective, randomised, double-blinded, multicentre trial. One hundred and fifty patients with documented AF were randomly assigned to undergo cardiac surgery with or without AS. One hundred and thirty-two patients were included in the cost-effectiveness study. All costs (medical and non-medical) were measured during follow-up. Costs data were combined with quality adjusted life years (QALYs) to obtain the incremental costs per QALY. Total costs of the AS group were significantly higher compared to the regular cardiac surgery group [cost difference bootstrap: €4,724; 95% uncertainty interval (UI), €2,770-€6,678]. The bootstrapped difference in QALYs was not statistically significant (0.06; 95% UI: -0.024 to 0.14). The incremental cost-effectiveness ratio is €73,359 per QALY. The acceptability curve showed that, even in the case of a maximum threshold value of €80,000 per QALY gained, the probability of AS being more cost-effective than regular cardiac surgery did not reach beyond 50%. Concluding that concomitant AS in AF is not cost-effective after a one-year follow-up compared to regular cardiac surgery.     

Direct health-care costs attributed to hip fractures among seniors: a matched cohort study

Summary

Using a matched cohort design, we estimated the mean direct attributable cost in the first year after hip fracture in Ontario to be $36,929 among women and $39,479 among men. These estimates translate into an annual $282 million in direct attributable health-care costs in Ontario and $1.1 billion in Canada.

Introduction

Osteoporosis is a major public health concern that results in substantial fracture-related morbidity and mortality. It is well established that hip fractures are the most devastating consequence of osteoporosis, yet the health-care costs attributed to hip fractures in Canada have not been thoroughly evaluated.

Methods

We determined the 1- and 2-year direct attributable costs and cost drivers associated with hip fractures among seniors in comparison to a matched non-hip fracture cohort using health-care administrative data from Ontario (2004–2008). Entry into long-term care and deaths attributable to hip fracture were also determined.

Results

We successfully matched 22,418 female (mean age?=?83.3 years) and 7,611 male (mean age?=?81.3 years) hip fracture patients. The mean attributable cost in the first year after fracture was $36,929 (95 % CI $36,380–37,466) among women and $39,479 (95 % CI $38,311–$40,677) among men. These estimates translate into an annual $282 million in direct attributable health-care costs in Ontario and $1.1 billion in Canada. Primary cost drivers were acute and post-acute institutional care. Approximately 24 % of women and 19 % of men living in the community at the time of fracture entered a long-term care facility, and 22 % of women and 33 % of men died within the first year following hip fracture. Attributable costs remained elevated into the second year ($9,017 among women, $10,347 among men) for patients who survived the first year.

Conclusions

We identified significant health-care costs, entry into long-term care, and mortality attributed to hip fractures. Results may inform health economic analyses and policy decision-making in Canada.     

Transurethral prostate resection,noncontact laser therapy or conservative management in men with symptoms of benign prostatic enlargement? An economic evaluation

PURPOSE: We evaluated the cost-effectiveness of noncontact laser therapy compared with transurethral prostate resection and conservative treatment in men with symptoms associated with benign prostatic enlargement. MATERIALS AND METHODS: A total of 340 men with uncomplicated lower urinary tract symptoms participated in a large multicenter pragmatic randomized trial called the CLasP (Conservative management, Laser therapy, transurethral resection of the Prostate) study. Costs to the United Kingdom National Health Service and patients were determined from the time of randomization to the 7.5-month followup. Incremental cost-effectiveness ratios using conservative management as the base case were calculated for certain trial outcomes, including International Prostate Symptom Score (I-PSS), I-PSS quality of life score, maximum urinary flow, post-void residual urine volume, quality adjusted life-years and a composite measure of success based on I-PSS and maximum urinary flow. One-way sensitivity analysis of the basic costs and incremental cost-effectiveness ratios were done from the NHS viewpoint. RESULTS: Mean costs per patient were greatest for noncontact laser therapy and least for conservative management. The incremental cost-effectiveness ratios showed that transurethral prostate resection was more cost-effective than noncontact laser treatment for all primary trial outcomes. The incremental cost-effectiveness ratios of transurethral prostate resection compared with conservative management were pound 81 per unit decrease in the I-PSS score and pound 1,338 per additional successful case per 100 patients. Sensitivity analysis showed that the initial results were robust. CONCLUSIONS: Noncontact laser was the mostly costly treatment option. Transurethral prostate resection was more cost-effective than noncontact laser therapy in terms of symptomatic improvement. In men wishing to delay treatment conservative treatment appears to provide a cost-effective alternative in the short term.     

OPCAB surgery is cost-effective for elderly patients

Abstract

Objective. To determine the cost-effective operative strategy for coronary artery bypass surgery in patients above 70 years. Design. Randomized, controlled trial of 900 patients above 70 years of age subjected to coronary artery bypass surgery. Patients were randomized to either on-pump or off-pump coronary artery bypass surgery. Data on direct and indirect costs were prospectively collected. Preoperatively and six months postoperatively, quality of life was assessed using EuroQol-5D questionnaires. Perioperative in-hospital costs and costs of re-intervention were included. Results. The Summary Score of EuroQol-5D increased in both groups between preoperatively and postoperatively. In the on-pump group, it increased from 0.75 (0.16) (mean (SD)) to 0.84 (0.17), while the increase in the off-pump group was from 0.75 (0.15) to 0.84 (0.18). The difference between the groups was 0.0016 QALY and not significantly different. The mean costs were 148.940 D.Kr (CI, 130.623 D.Kr–167.252 D.Kr) for an on-pump patient and 138.693 D.Kr (CI, 123.167 D.Kr–154.220 D.Kr) for an off-pump patient. The ICER base-case point estimate was 6,829,999 D.Kr/QALY. The cost-effectiveness acceptability curve showed 89% probability of off-pump being cost-effective at a threshold value of 269,400 D.Kr/QALY. Conclusions. Off-pump surgery tends to be more cost-effective than on-pump surgery. Long-term comparisons are warranted.