Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes.

BACKGROUND CONTEXT: Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system. PURPOSE: The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis. STUDY DESIGN/SETTING: We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD). PATIENT SAMPLE: This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied. OUTCOME MEASURES: The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies. METHODS: From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly. RESULTS: Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay. CONCLUSION: The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.     

A cost–utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients

Background: The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method. Materials and methods: The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios. Results: Compared to the expectant management, the incremental cost per QALY gained was $605 ($4086, 9.04 QALYs) for LR, $697 ($4290, 8.975 QALYs) for OM, and $1711 ($6200, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of $5526 the ICER of LR compared to OM surpasses the threshold of $50,000/QALY. Conclusions: On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.     

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.     

Vitamin K supplementation for the primary prevention of osteoporotic fractures: is it cost-effective and is future research warranted?

Summary

Lifetime supplementation with vitamin K, vitamin D₃, and calcium is likely to reduce fractures and increase survival in postmenopausal women. It would be a cost-effective intervention at commonly used thresholds, but high uncertainty around the cost-effectiveness estimates persists. Further research on the effect of vitamin K on fractures is warranted.

Introduction

Vitamin K might have a role in the primary prevention of fractures, but uncertainties about its effectiveness and cost-effectiveness persist.

Methods

We developed a state-transition probabilistic microsimulation model to quantify the cost-effectiveness of various interventions to prevent fractures in 50-year-old postmenopausal women without osteoporosis. We compared no supplementation, vitamin D₃ (800?IU/day) with calcium (1,200?mg/day), and vitamin K₂ (45?mg/day) with vitamin D₃ and calcium (at the same doses). An additional analysis explored replacing vitamin K₂ with vitamin K₁ (5?mg/day).

Results

Adding vitamin K₂ to vitamin D₃ with calcium reduced the lifetime probability of at least one fracture by 25%, increased discounted survival by 0.7 quality-adjusted life-years (QALYs) (95% credible interval (CrI) 0.2; 1.3) and discounted costs by $8,956, yielding an incremental cost-effectiveness ratio (ICER) of $12,268/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 95% and the population expected value of perfect information (EVPI) was $28.9 billion. Adding vitamin K₁ to vitamin D and calcium reduced the lifetime probability of at least one fracture by 20%, increased discounted survival by 0.4 QALYs (95% CrI ?1.9; 1.4) and discounted costs by $4,014, yielding an ICER of $9,557/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 80% while the EVPI was $414.9 billion. The efficacy of vitamin K was the most important parameter in sensitivity analyses.

Conclusions

Lifetime supplementation with vitamin K, vitamin D₃, and calcium is likely to reduce fractures and increase survival in postmenopausal women. Given high uncertainty around the cost-effectiveness estimates, further research on the efficacy of vitamin K on fractures is warranted.     

Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis

BACKGROUND: Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. STUDY DESIGN: We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. RESULTS: At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. CONCLUSION: At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.     

Next-Generation Sequencing vs Culture-Based Methods for Diagnosing Periprosthetic Joint Infection After Total Knee Arthroplasty: A Cost-Effectiveness Analysis

BackgroundPeriprosthetic joint infection (PJI) after total knee arthroplasty is challenging to diagnose. Compared with culture-based techniques, next-generation sequencing (NGS) is more sensitive for identifying organisms but is also less specific and more expensive. To date, there has been no study comparing the cost-effectiveness of these two methods to diagnose PJI after total knee arthroplasty.MethodsA Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine the cost-effectiveness from a societal perspective. The primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions.ResultsAt our base case values, culture was not determined to be cost-effective compared to NGS, with an incremental cost-effectiveness ratio of $422,784 per QALY. One-way sensitivity analyses found NGS to be the cost-effective choice above a pretest probability of 45.5% for PJI. In addition, NGS was cost-effective if its sensitivity was greater than 70.0% and its specificity greater than 94.1%. Two-way sensitivity analyses revealed that the pretest probability and test performance parameters (sensitivity and specificity) were the largest factors for identifying whether a particular strategy was cost-effective.ConclusionThe results of our model suggest that the cost-effectiveness of NGS to diagnose PJI depends primarily on the pretest probability of PJI and the performance characteristics of the NGS technology. Our results are consistent with the idea that NGS should be reserved for clinical contexts with a high pretest probability of PJI. Further study is required to determine the indications and subgroups for which NGS offers clinical benefit.     

Cost-Effectiveness of Recombinant Activated Factor VII as Adjunctive Therapy for Bleeding Control in Severely Injured Trauma Patients in Germany

Abstract Purpose: The purpose of this study was to assess the cost-effectiveness of recombinant activated factor VII (rFVIIa) as adjunctive therapy for the control of bleeding in patients with severe blunt trauma injuries in Germany. The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained. Materials and Methods: We developed a cost-effectiveness model based on patient-level data from a 30 day international, randomized, placebo-controlled phase II trial. The data were supplemented with secondary data from the German Trauma Register and German life tables to estimate lifetime costs and benefits. We assumed that the non-significant difference in mortality observed in the phase II trial of 5% in favor of rFVIIa could be verified in the ongoing, much larger follow-up trauma study. We adopted the perspective of third-party payers in Germany, and included all trauma-related healthcare costs. Results: The incremental cost per QALY gained with rFVIIa relative to placebo was e29,451. The probability that this was below e30,000 and e40,000 was 51 and 58%, respectively. The estimates were sensitive to the differences observed in mortality and the applied discount rate. Conclusions: Based on preliminary evidence from a phase II trial, we conclude that, relative to placebo, rFVIIa may be a cost-effective therapy from the thirdparty payer perspective in Germany.     

A cost-utility analysis of apalutamide for metastatic castrationsensitive prostate cancer

IntroductionEarlier application of oral androgen receptor-axis-targeted therapies in patients with metastatic castration-sensitive prostate cancer (mCSPC) has established improvements in overall survival, as compared to androgen deprivation therapy (ADT) alone. Recently, the use of apalutamide plus ADT has demonstrated improvement in mCSPC-related mortality vs. ADT alone, with an acceptable toxicity profile. However, the cost-effectiveness of this therapeutic option remains unknown.MethodsWe used a state-transition model with probabilistic analysis to compare apalutamide plus ADT, as compared to ADT alone, for mCSPC patients over a time horizon of 20 years. Primary outcomes included expected life-years (LY), quality-adjusted life-years (QALY), lifetime cost (2020 Canadian dollars), and incremental cost-effectiveness ratio (ICER). Parameter and model uncertainties were assessed through scenario analyses. Health outcomes and cost were discounted at 1.5%, as per Canadian guidelines.ResultsFor the base-case analysis, expected LY for ADT and apalutamide plus ADT were 4.11 and 5.56, respectively (incremental LY 1.45). Expected QALYs were 3.51 for ADT and 4.84 for apalutamide plus ADT (incremental QALYs 1.33); expected lifetime cost was $36 582 and $255 633, respectively (incremental cost $219 051). ICER for apalutamide plus ADT, as compared to ADT alone, was $164 700/QALY. Through scenario analysis, price reductions ≥50% were required for apalutamide in combination with ADT to be considered cost-effective, at a cost-effectiveness threshold of $100 000/QALY.ConclusionsApalutamide plus ADT is unlikely to be cost-effective from the Canadian healthcare perspective unless there are substantial reductions in the price of apalutamide treatment.     

Survival after emergency department thoracotomy: review of published data from the past 25 years

BACKGROUND: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. STUDY DESIGN: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. RESULTS: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. CONCLUSIONS: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.     

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.     

Cost Effectiveness of Routine Laparoscopic Ultrasound for Assessment of Resectability of Gallbladder Cancer

Background

In addition to a diagnostic laparoscopy (DL), a routine laparoscopic ultrasound (LUS) has been proposed to identify undetected hepatic metastases and/or anatomically advanced disease in patients with T2 or higher gall bladder cancer (GBC) patients planned for surgical resection. It was hypothesized that a routine LUS is not a cost-effective strategy for these patients.

Methods

Decision tree modeling was undertaken to compare DL-LUS vs. DL at the time of definitive resection of GBC (with no prior cholecystectomy). Costs in US dollars (payer’s perspective), quality-adjusted life weeks (QALWs), and incremental cost-effectiveness ratios (ICER) were calculated (horizon: 6 weeks, willingness-to-pay: $1,000/QALW or $50,000/QALY).

Results

DL-LUS was cost effective at the base case scenario (costs: $30,838 for DL vs. $30,791 for DL-LUS and effectiveness 3.81 QALWs DL vs. 3.82 QALW DL-LUS), resulting in a cost reduction of $9,220 per quality-adjusted life week gained (or $479,469 per QALY). DL-LUS became less cost effective as the cost of ultrasound increased or the probability of exclusion from resection decreased.

Conclusions

Routine LUS with DL for the assessment of resectability and exclusion of metastases is cost effective for patients with GBC. Until improvements in preoperative imaging occur to decrease the probability of exclusion, this appears to be a feasible strategy.     

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis

Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.     

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.

The value and cost-effectiveness of adult degenerative lumbar surgery

Patients often seek surgical treatment for relief of their chronic lower back pain, generally caused by spinal stenosis, disc herniation, or spondylolisthesis. Many studies have reported the effectiveness of these surgical procedures in terms of health-related quality-of-life (HRQOL) measures; however, little has been published regarding the value and cost-effectiveness of surgical intervention. In this systematic review of the literature: (1) we identified studies that reported economic interventional outcomes, specifically cost per quality-adjusted life years (QALY) or incremental cost-effectiveness ratios (ICER) and (2) we determined whether this literature demonstrates the cost-effectiveness of surgical intervention in treating degenerative lumbar conditions. A systematic search of databases such as PubMed and Cochrane Library, as well as hand searching the references of selected works, was focused on surgical and non-operative treatments for degenerative lumbar conditions, specifically spinal stenosis, lumbar disc herniation, and degenerative spondylilolysthesis. Outcomes were collected as cost-effectiveness values reported, as cost per quality-adjusted life years (QALY) gained in cohort studies, and as incremental cost-effectiveness ratios (ICER) in comparative studies. Five studies directly compared the cost-effectiveness of surgery to non-operative treatment. Twelve others simply reported cost-effectiveness in a single cohort manner. From the comparative studies, the mean ICER value was $45,962. From the single cohort studies, the mean cost/QALY was $75,017. Interventions with a value between $50,000 and $100,000, or less, are generally considered cost effective. The results of our literature review suggest that surgical intervention for degenerative lumbar conditions is indeed cost-effective. In fact, the value of surgery appears to increase with additional follow-up time. That is, surgery is more cost effective in the later years of follow-up. Our review also revealed a paucity of quality studies evaluating cost-effectiveness. With the economic burden of degenerative lumbar conditions being so great to the patient and society, we encourage clinicians to continue to report outcomes from an economic standpoint, using cost/QALY and ICER values.     

Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head

Management of symptomatic pre-collapse osteonecrosis of the femoral head continues to be controversial. Patients are often young and active, therefore hip-preserving procedures such as free vascularized fibular grafting (FVFG) have been developed to relieve pain and restore function, thereby delaying or preventing the need for joint arthroplasty. This study compared the cost-effectiveness of FVFG to total hip arthroplasty (THA) in the young adult. A Markov decision model was created for a cost-utility analysis of FVFG compared to THA. Outcome probabilities and effectiveness, expressed in QALYs gained, were derived from existing literature. Principal outcome measures included average incremental costs, effectiveness, and net health benefits. Multivariate sensitivity analysis was used to validate the model. THA resulted in a greater average incremental cost (+$5,933) while at a lower average incremental effectiveness (-0.15 QALY) compared to FVFG. On average, THA gained 22.08 QALYs at a cost-effectiveness (C/E) ratio of $1026/QALY, whereas FVFG gained 22.23 QALYs at a C/E ratio of $752/QALY. Threshold sensitivity analysis determined that the yearly all-cause probability of revision for FVFG would have to be more than three times greater than THA before THA became more cost-effective. Free vascularized fibular grafting is a more cost-effective procedure to treat osteonecrosis in certain populations. Markov decision analysis accounts for the impact of treatment strategies over the lifetime of a patient cohort. These findings can inform clinical decision making in the absence of universally accepted management strategies.     

Potential cost-effective use of spine radiographs to detect vertebral deformity and select osteopenic post-menopausal women for amino-bisphosphonate therapy

Prevalent vertebral deformities are predictive of future clinical fractures independent of bone density. We used a Markov model with eight health states to estimate from the societal perspective the cost-effectiveness of using spine radiographs to identify postmenopausal women age 60 or older with one or more vertebral deformities and then treat them with anti-resorptive drug therapy to prevent fractures. We compared three strategies: 5 years of amino-bisphosphonate (alendronate) therapy for all, 5 years of alendronate therapy for only those with prevalent a radiographic vertebral deformity or no initial alendronate treatment. Lifetime direct medical and indirect costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were tracked. For women with one or more prevalent vertebral deformities, the costs per QALY gained ranged from $5,084 (for an 80 year old with a T-score of –2.4) to $61,192 (for a 60 year old with a T-score of –1.0). For women without prevalent vertebral deformity, the costs per QALY gained ranged from $41,897 (for a 60 year old with a T-score of –2.4) to $166,219 (for an 80 year old with a T-score of –1.0). These results were modestly sensitive to reasonable changes in fracture rates, disutility, discount rates and assumptions about the accuracy of spinal radiographs for detecting vertebral deformity. Assuming a societal willingness to pay per QALY gained of $50,000, the strategy of performing spine radiographs in post-menopausal osteopenic women with T-scores at or below –1.5 and treating those with 1 or more prevalent vertebral deformities is likely to be cost-effective. However, further research on the accuracy of vertebral deformity ascertainment from routine clinical radiographs and on the efficacy of amino-bisphosphonate drugs for reducing the risk of non-vertebral fractures in osteopenic women is needed to define more precisely the subset of osteopenic post-menopausal women in whom use of spinal radiographs is most cost-effective.     

Robotic-assisted gastrectomy compared with open resection: a comparative study of clinical outcomes and cost-effectiveness analysis

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

     

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 of surgery for small abdominal aortic aneurysms on the basis of data from the United Kingdom small aneurysm trial

PURPOSE: Although the United Kingdom small aneurysm trial reported no survival benefit for early operation in patients with small (4. 0-5.5 cm) abdominal aortic aneurysms (AAAs), the trial lacked statistical power to detect small but potentially meaningful gains in life expectancy, particularly for specific subgroups. We used decision analysis to better characterize the potential benefits and cost-effectiveness of early surgery. METHODS: We used a Markov model to assess the marginal cost-effectiveness (incremental cost per quality-adjusted life year [QALY] saved) of early surgery relative to surveillance for small AAAs, using data from the UK Trial. Subgroup analyses were performed by patient age and AAA diameter. Sensitivity analysis was used to evaluate the effect of elective operative mortality on cost-effectiveness. RESULTS: In our baseline analysis, early operations provided a small survival advantage (0.14 QALYs) at a small incremental cost of $1510. Thus, despite a small survival benefit, early surgery appeared cost-effective ($10, 800/QALY). The small cost differential resulted from the large proportion of patients who underwent surveillance, who eventually underwent AAA repair, and therefore incurred the cost of the surgical procedures. The survival advantage and cost-effectiveness of early operation increased with lower operative mortality, younger age, and larger AAA diameter. CONCLUSION: Despite the negative conclusions of the UK trial, early surgery may be cost-effective for patients with small AAAs, particularly younger patients (<72 years of age) with larger AAAs (> or = 4.5 cm). Because the gains in life expectancy are relatively small, however, clinical decision making should be strongly guided by patient preferences.