Cost-Effectiveness of Everolimus- Versus Paclitaxel-Eluting Stents for Patients Undergoing Percutaneous Coronary Revascularization (from the SPIRIT-IV Trial)

Although several drug-eluting stents (DESs) have been shown to be economically attractive compared to bare-metal stents in patients at moderate to high risk of restenosis, little is known about the cost-effectiveness of alternative DES designs, especially second-generation DESs. We therefore performed an economic substudy alongside the SPIRIT-IV trial, in which 3,687 patients undergoing single or multivessel percutaneous coronary intervention were randomized to receive second-generation everolimus-eluting stents (EESs; n = 2,458) or first-generation paclitaxel-eluting stents (PESs; n = 1,229). Costs through 2 years of follow-up were assessed from the perspective of the United States health care system. The primary cost-effectiveness end point was the incremental cost-effectiveness ratio assessed as cost per quality-adjusted life year gained. Over a 2-year period, use of EESs versus PESs led to a trend toward decreased overall repeat revascularization procedures (14.2 vs 16.2 per 100 subjects, p = 0.20) driven by a significant decrease in the number of target vessel revascularization procedures (8.2 vs 11.0 per 100 subjects, p = 0.02) but also a slight increase in the number of nontarget vessel revascularization procedures (6.0 vs 5.1 per 100 subjects, p = 0.37). Follow-up cardiovascular costs were decreased by $273/patient in the EES group (95% confidence interval for difference 1,048 less to 502 more, p = 0.49). Formal cost-effectiveness analysis based on these results demonstrated that the probability that EES was an economically attractive strategy (incremental cost-effectiveness ratio <$50,000/quality-adjusted life year gained) was 85.7%. These findings demonstrate that in patients undergoing percutaneous coronary intervention with DESs, use of EESs is economically attractive compared to PESs with improved clinical outcomes and lower overall medical care costs at 2 years.     

Vata-L: Visual-Analogue Test Assessing Anosognosia for Language Impairment

Lack of awareness (anosognosia) for one's own language impairments has rarely been investigated, despite hampering language rehabilitation. Assessment of anosognosia by means of self-report is particularly complex, as a patient's language difficulties may seriously prevent or bias the assessment. Other methods, such as measures of self-correction and error detection, have provided valuable information, although they are an indirect form of assessment of anosognosia and are not exempt from methodological criticisms. In this study we report on a new tool, the VATA-L (Visual-Analogue Test for Anosognosia for Language impairment), geared at assessing explicit anosognosia for aphasia. The VATA-L compares the patient's self-evaluation with caregivers’ evaluations of the patient's verbal communication abilities in a series of common situations. By means of non-verbal support and a system of check questions, this test minimizes some of the methodological limitations of existing diagnostic tools (e.g., structured interviews), enhancing reliability, and enabling assessment of patients with aphasia. Finally, normative data provided in the study allow a clearer interpretation of the patient's performance and facilitate assessment of anosognosia.     

A 24-month evaluation of amalgam and resin-based composite restorations: Findings from The National Dental Practice-Based Research Network

BackgroundKnowing which factors influence restoration longevity can help clinicians make sound treatment decisions. The authors analyzed data from The National Dental Practice-Based Research Network to identify predictors of early failures of amalgam and resin-based composite (RBC) restorations.MethodsIn this prospective cohort study, the authors gathered information from clinicians and offices participating in the network. Clinicians completed a baseline data collection form at the time of restoration placement and annually thereafter. Data collected included patient factors, practice factors and dentist factors, and the authors analyzed them by using mixed-model logistic regression.ResultsA total of 226 practitioners followed up 6,218 direct restorations in 3,855 patients; 386 restorations failed (6.2 percent) during the mean (standard deviation) follow-up of 23.7 (8.8) months. The number of tooth surfaces restored at baseline helped predict subsequent restoration failure; restorations with four or more restored surfaces were more than four times more likely to fail. Restorative material was not associated significantly with longevity; neither was tooth type. Older patient age was associated highly with failure (P N/A .001). The failure rate for children was 4 percent, compared with 10 percent for people 65 years or older. Dentist’s sex and practice workload were associated significantly with restoration longevity.ConclusionsIn this prospective cohort study, these factors were significantly predictive of failure for amalgam and RBC restorations: patient’s age, a higher number of surfaces restored at baseline, the dentist’s sex and the practice workload. Material choice was not significantly predictive in these early results.Practical ImplicationsIf clinicians can recognize and identify the risk factors associated with early restoration failure, more effective treatment plans may be offered to the patient.