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Biomedical subjects

Milton C Weinstein

Publications and source records attributed to Milton C Weinstein.

At least 37 records · Page 2Linked to original sources
PubMed2005

Cost-effectiveness of full medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors slow renal disease progression and reduce cardiac morbidity and mortality in patients with diabetes. Patients' out-of-pocket costs pose a barrier to using this effective therapy. OBJECTIVE: To estimate the cost-effectiveness to Medicare of first-dollar coverage (no cost sharing) of ACE inhibitors for beneficiaries with diabetes. DESIGN: Markov model with costs and benefits discounted at 3%. DATA SOURCES: Published literature and Medicare claims data. TARGET POPULATION: 65-year-old Medicare beneficiary with diabetes. TIME HORIZON: Lifetime. PERSPECTIVE: Medicare and societal. INTERVENTIONS: We evaluated Medicare first-dollar coverage of ACE inhibitors compared with current practice (no coverage) and the new Medicare drug benefit. OUTCOME MEASURES: Costs (2003 U.S. dollars), quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Compared with current practice, first-dollar coverage of ACE inhibitors saved both lives and money (0.23 QALYs gained and 1606 USD saved per Medicare beneficiary). Compared with the new Medicare drug benefit, first-dollar coverage remained a dominant strategy (0.15 QALYs gained, 922 USD saved). RESULTS OF SENSITIVITY ANALYSIS: Results were most sensitive to our estimate of increase in ACE inhibitor use; however, if ACE inhibitor use increased by only 7.2% (from 40% to 47.2%), first-dollar coverage would remain life-saving at no net cost to Medicare. In analyses conducted from the societal perspective, benefits were similar and cost savings were larger. LIMITATIONS: Results depend on accuracy of the underlying data and assumptions. The effect of more generous drug coverage on medication adherence is uncertain. CONCLUSIONS: Medicare first-dollar coverage of ACE inhibitors for beneficiaries with diabetes appears to extend life and reduce Medicare program costs. A reduction in program costs may result in more money to spend on other health care needs of the elderly.

Aged↗
PubMed2005

The projected health benefits of maternal group B streptococcal vaccination in the era of chemoprophylaxis.

While maternal antibiotic prophylaxis has greatly reduced early-onset group B streptococcal (GBS) disease in the United States, a GBS vaccine currently under development could potentially prevent additional GBS cases and preterm births. A decision analytic model was created to compare preventive strategies using adolescent, maternal (prenatal), or postpartum vaccination with selective chemoprophylactic strategies. The current practice of culture-based chemoprophylaxis was predicted to prevent 55% of early plus late-onset GBS infections. Maternal vaccination strategies were superior to current practice, preventing 68-69% of all GBS infections and 4% of very preterm births (<32 weeks gestation). The most effective adolescent vaccination strategy combined vaccination with culture-based chemoprophylaxis for all women and prevented 66% of all GBS infections. All other strategies were similar in efficacy to current practice or inferior. Maternal GBS vaccination is predicted to prevent more cases of neonatal GBS disease than current practice and would prevent approximately one in 25 very preterm births.

Adult↗
PubMed2005

Cost-effectiveness of enfuvirtide in treatment-experienced patients with advanced HIV disease.

OBJECTIVE: Enfuvirtide (ENF) has been shown to improve short-term virologic responses when given to highly treatment-experienced patients with advanced HIV disease. Because of the high cost of ENF compared with other antiretroviral agents, our objectives were to determine the potential long-term clinical impact and cost-effectiveness of ENF in these patients. METHODS: We used a computer simulation model of HIV disease to project life expectancy, quality-adjusted life expectancy, cost, and cost-effectiveness of ENF in treatment-experienced patients. Input data were from the T-20 versus Optimized Regimen Only (TORO) 1 and 2 trials, 2 studies comparing ENF plus an optimized background regimen (OBR) with an OBR alone. RESULTS: ENF plus an OBR increased projected discounted quality-adjusted life expectancy from 45.4 months with an OBR alone to 54.9 months, a difference of 9.5 quality-adjusted life-months. At the current annual ENF cost of US 18,500 dollars per year (in 2001 US dollars), the incremental cost-effectiveness ratio for ENF plus an OBR was US 69,500 dollars per quality-adjusted life-year (QALY) compared with an OBR alone. When 48-week virologic suppression rates for ENF plus an OBR were varied from a 50% reduction to a 250% increase in the suppression rate attributable to ENF, gains in quality-adjusted life expectancy ranged from 4.5 to 25.9 quality-adjusted life-months compared with an OBR alone, with cost-effectiveness ratios ranging from US 97,900 dollars per QALY to US 52,300 dollars per QALY gained. If ENF is continued after the HIV RNA level returns to the pretreatment baseline, the cost-effectiveness ratio increases to US 168,200 dollars per QALY. CONCLUSIONS: In highly treatment-experienced patients, ENF plus an OBR provides substantial gains in quality-adjusted life expectancy compared with an OBR alone. Although ENF plus an OBR is less cost-effective than other commonly used interventions in HIV disease, its use may be justified, given the poor prognosis of these patients and their otherwise limited options for antiretroviral therapy.

Adult↗
PubMed2005

Expanded screening for HIV in the United States--an analysis of cost-effectiveness.

BACKGROUND: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy. METHODS: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness. RESULTS: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was 36,000 dollars per quality-adjusted life-year gained. Testing every five years cost 50,000 dollars per quality-adjusted life-year gained, and testing every three years cost 63,000 dollars per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was 38,000 dollars per quality-adjusted life-year gained, whereas testing every five years cost 71,000 dollars per quality-adjusted life-year gained, and testing every three years cost 85,000 dollars per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost 113,000 dollars per quality-adjusted life-year gained. CONCLUSIONS: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

Anti-Retroviral Agents↗
PubMed2005

Cost-effectiveness of dual-chamber pacing compared with ventricular pacing for sinus node dysfunction.

BACKGROUND: Compared with single-chamber ventricular pacing, dual-chamber pacing can reduce adverse events and, as a result, improve quality of life in patients paced for sick sinus syndrome. It is not clear, however, how these benefits compare with the increased cost of dual-chamber pacemakers. METHODS AND RESULTS: We used 4-year data from a 2010-patient, randomized trial to estimate the incremental cost-effectiveness of dual-chamber pacing compared with ventricular pacing and then projected these findings over the patients' lifetimes by using a Markov model that was calibrated to the first 5 years of in-trial data. To assess the stability of the findings, we performed 1000 bootstrap analyses and multiple sensitivity analyses. During the first 4 years of the trial, dual-chamber pacemakers increased quality-adjusted life expectancy by 0.013 year per subject at an incremental cost-effectiveness ratio of 53,000 dollars per quality-adjusted year of life gained. Over a lifetime, dual-chamber pacing was projected to increase quality-adjusted life expectancy by 0.14 year with an incremental cost-effectiveness ratio of approximately 6800 dollars per quality-adjusted year of life gained. In bootstrap analyses, dual-chamber pacing was cost-effective in 91.9% of simulations at a threshold of 50,000 dollars per quality-adjusted year of life and in 93.2% of simulations at a threshold of 100,000 dollars. Its cost-effectiveness ratio was also below this threshold in numerous sensitivity analyses that varied key estimates. CONCLUSIONS: For patients with sick sinus syndrome requiring pacing, dual-chamber pacing increases quality-adjusted life expectancy at a cost that is generally considered acceptable.

Aged↗
PubMed2005

Adjuvant ovarian suppression versus chemotherapy for premenopausal, hormone-responsive breast cancer: quality of life and efficacy tradeoffs.

PURPOSE: Recent clinical trials suggest that adjuvant ovarian suppression may be an equally effective and less toxic alternative to systemic chemotherapy in premenopausal women with hormone-responsive breast cancer. We used a decision-analytic framework to evaluate tradeoffs between efficacy and quality of life in the choice between these treatments. PATIENTS AND METHODS: We used a Markov state-transition model to simulate clinical practice in a cohort of 40-year-old premenopausal women with newly diagnosed, hormone-responsive early breast cancer. We assessed three adjuvant treatments: chemotherapy, surgical ovarian suppression, and medical ovarian suppression. Outcomes were recurrence-free, overall, and quality-adjusted survival. Quality-adjusted survival reflected effects of cancer, treatment-related side effects, and menopausal symptoms. RESULTS: Assuming equal efficacy, ovarian suppression was superior to chemotherapy when the relative utility of chemotherapy side effects compared with ovarian suppression side effects was less than 0.95. Results were sensitive to assumptions about the likelihood, duration and consequences of treatment-induced menopause. Treatment choice was affected by a 7% proportional increase in the efficacy of one therapy relative to the others, independent of other factors. CONCLUSION: If adjuvant chemotherapy and ovarian suppression have similar efficacy, then there may be a subgroup of women for whom quality-of-life considerations dominate the choice of treatment. However, small differences in the relative efficacy of these therapies have a substantial impact on treatment choice, regardless of side effects and menopausal transitions.

Breast Neoplasms↗
PubMed2005

Routine human immunodeficiency virus testing: an economic evaluation of current guidelines.

BACKGROUND: The Centers for Disease Control and Prevention guidelines recommend human immunodeficiency virus (HIV) counseling, testing, and referral for all patients in hospitals with an HIV prevalence of >or=1%. The 1% screening threshold has not been critically examined since HIV became effectively treatable in 1995. Our objective was to evaluate the clinical effect and cost-effectiveness of current guidelines and of alternate HIV prevalence thresholds. METHODS: We performed a cost-effectiveness analysis using a computer simulation model of HIV screening and disease as applied to inpatients in U.S. hospitals. RESULTS: At an undiagnosed inpatient HIV prevalence of 1% and an overall participation rate of 33%, HIV screening increased mean quality-adjusted life expectancy by 6.13 years per 1000 inpatients, with a cost-effectiveness ratio of 35,400 dollars per quality-adjusted life-year (QALY) gained. Expansion of screening to settings with a prevalence as low as 0.1% increased the ratio to 64,500 dollars per QALY gained. Increasing counseling and testing costs from 53 dollars to 103 dollars per person still yielded a cost-effectiveness ratio below 100,000 dollars per QALY gained at a prevalence of undiagnosed infection of 0.1%. CONCLUSION: Routine inpatient HIV screening programs are not only cost-effective but would likely remain so at a prevalence of undiagnosed HIV infection 10 times lower than recommended thresholds. The current HIV counseling, testing, and referral guidelines should now be implemented nationwide as a way of linking infected patients to life-sustaining care.

Centers for Disease Control and Prevention, U.S.↗
PubMed2005

The cost effectiveness of gonorrhea screening in urban emergency departments.

BACKGROUND: The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical. GOAL: The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests. STUDY: We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs. RESULTS: Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs. CONCLUSION: Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

Adolescent↗
PubMed2005

Optimal frequency of CD4 cell count and HIV RNA monitoring prior to initiation of antiretroviral therapy in HIV-infected patients.

CONTEXT: Guidelines regarding the frequency of CD4 cell count and HIV RNA monitoring in HIV-infected patients vary, with recommended strategies ranging from every 2 to every 6 months. OBJECTIVE: To determine optimal CD4 cell count and HIV RNA monitoring frequency in HIV-infected patients prior to antiretroviral therapy initiation. DESIGN: Cost-effectiveness (CE) analysis using an HIV simulation model incorporating CD4 cell count and HIV RNA as immunological and virological predictors of clinical outcomes. SETTING: Hypothetical clinical setting. PATIENTS: Simulated cohort based on initial clinical presentation of HIV-infected patients in the US. INTERVENTION: CD4 cell count and HIV RNA monitoring at frequencies ranging from every 2 to 24 months prior to antiretroviral initiation, as well as accelerated monitoring frequencies as CD4 cell counts approach a specified treatment threshold. OUTCOME MEASURES: Life expectancy, quality-adjusted life expectancy and costs. RESULTS: For patients presenting with median CD4 cell count 546/mm3 and median HIV RNA 4.8 log10 copies/ml, incremental CE ratios ranged from US$37800/quality-adjusted life year (QALY) gained for a constant testing frequency of every 18 months compared with every 24 months, to US$303300/QALY gained for a constant testing frequency of every 2 months compared with every 4 months when starting treatment at a CD4 cell count of 350/mm3. Monitoring every 12 months until a warning CD4 cell count threshold of 450/mm3 followed by every 3 months until 350/mm3 had an incremental CE ratio of US$74700/QALY gained. When starting antiretroviral therapy at CD4 cell count 200/mm3, monitoring every 12 months until 300/mm3 followed by every 2 months until treatment initiation yielded an incremental CE ratio of US$52200/QALY gained compared with the next best strategy. Increasing monitoring frequency as CD4 cell counts approached a treatment threshold yielded greater incremental clinical benefit for less cost than strategies using a constant frequency. CONCLUSIONS: Monitoring HIV-infected patients every 12 months until 100 CD4 cells/mm3 prior to a specified treatment threshold followed by more frequent monitoring every 2 or 3 months until antiretroviral therapy initiation is both more effective and cost-effective than the current standard of care.

Anti-HIV Agents↗
PubMed2004

A therapeutic HIV vaccine: how good is good enough?

The goal of a therapeutic HIV vaccine is to attenuate HIV disease progression in those already infected. Our objective was to establish comparative efficacy and cost-effectiveness thresholds at which a therapeutic vaccine would make a valuable contribution to HIV care. Using an HIV computer simulation model, we compared therapeutic vaccination with HIV standard of care without vaccination. Input data were obtained from the literature. Base case and sensitivity analyses related to vaccine magnitude, penetrance, durability, and cost. In the base case (0.5 log magnitude, 25% penetrance, 3-year durability, and US$ 4000 per series), vaccination increased quality-adjusted life expectancy (QALE) by 0.50 months compared to no vaccination (cost-effectiveness ratio US$ 89,900 per quality-adjusted life year (QALY)). Increasing vaccine penetrance to 50% increased the projected QALE benefit to 0.91 months (cost-effectiveness ratio US$ 45,500/QALY). Even modestly effective therapeutic HIV vaccines may produce small but meaningful increases in life expectancy and compare favorably to alternative uses of scarce HIV care resources.

AIDS Vaccines↗
PubMed2004

Projected clinical benefits and cost-effectiveness of a human papillomavirus 16/18 vaccine.

BACKGROUND: Human papillomavirus (HPV) vaccine may be commercially available in a few years. We explored the clinical benefits and cost-effectiveness of introducing an HPV16/18 vaccine in a population with an organized cervical cancer screening program. METHODS: A computer-based model of the natural history of HPV and cervical cancer was used to project cancer incidence and mortality, life expectancy (adjusted and unadjusted for quality of life), lifetime costs, and incremental cost-effectiveness ratios (i.e., the additional cost of a strategy divided by its additional clinical benefit compared with the next most expensive strategy) associated with different cancer prevention policies, including vaccination (initiated at age 12 years), cytologic screening (initiated at 18, 21, 25, 30, or 35 years), and combined vaccination and screening strategies. We assumed that vaccination was 90% effective in reducing the risk of persistent HPV16/18 infections and evaluated alternative assumptions about vaccine efficacy, waning immunity, and risk of replacement with non-16/18 HPV types. RESULTS: Our model showed that the most effective strategy with an incremental cost-effectiveness ratio of less than 60 dollars-000 per quality-adjusted life year is one combining vaccination at age 12 years with triennial conventional cytologic screening beginning at age 25 years, compared with the next best strategy of vaccination and cytologic screening every 5 years beginning at age 21 years. This triennial strategy would reduce the absolute lifetime risk of cervical cancer by 94% compared with no intervention. These results were sensitive to alternative assumptions about the underlying patterns of cervical cancer screening, duration of vaccine efficacy, and natural history of HPV infection in older women. CONCLUSIONS: Our model predicts that a vaccine that prevents persistent HPV16/18 infection will reduce the incidence of HPV16/18-associated cervical cancer, even in a setting of cytologic screening. A program of vaccination that permits a later age of screening initiation and a less frequent screening interval is likely to be a cost-effective use of health care resources.

Adult↗
PubMed2004

HER-2 testing and trastuzumab therapy for metastatic breast cancer: a cost-effectiveness analysis.

PURPOSE: Trastuzumab therapy has been shown to benefit metastatic breast cancer patients whose tumors exhibit HER-2 protein overexpression or gene amplification. Several tests of varying accuracy and cost are available to identify candidates for trastuzumab. We estimated the cost-effectiveness of alternative HER-2 testing and trastuzumab treatment strategies. PATIENTS AND METHODS: We performed a decision analysis using a state-transition model to simulate clinical practice in a hypothetical cohort of 65-year-old metastatic breast cancer patients. Outcomes were quality-adjusted life-years (QALYs), lifetime cost, and incremental cost-effectiveness ratio (ICER). Interventions included testing with the HercepTest (DAKO, Carpinteria, CA) immunohistochemical assay alone, fluorescence in situ hybridization (FISH) alone, and both tests, followed by trastuzumab and chemotherapy for patients with positive test results and chemotherapy alone for patients with negative test results. RESULTS: In the base case, initial HercepTest with FISH confirmation of all positive results had an ICER of $125,000 per QALY gained. The incremental cost-effectiveness of initial FISH was $145,000 per QALY gained. Other strategies yielded the same or poorer effectiveness at a higher cost, or lower effectiveness at a lower cost, but with a less favorable ICER. These findings persisted under a range of assumptions, and only changes in test characteristics substantially altered results. CONCLUSION: It is more cost-effective to use FISH alone or as confirmation of all positive HercepTest results, rather than using FISH to confirm only weakly positive results or using HercepTest alone. When multiple tests are available to identify treatment candidates, test characteristics may have a substantial impact on the aggregate costs and effectiveness of treatment.

Aged↗
PubMed2004

Cost analysis of "bridging therapy" with low-molecular-weight heparin versus unfractionated heparin during temporary interruption of chronic anticoagulation.

Patients on long-term anticoagulation who require interruption of therapy for surgery may receive "bridging therapy" with continuous-infusion unfractionated heparin or low-molecular-weight heparin (LMWH). We estimated the costs of bridging therapy with: (1) LMWH self-administered at home, (2) LMWH administered by a nurse to patients at home, and (3) continuous-infusion unfractionated heparin in the hospital. For surgeries requiring an overnight stay, bridging costs are estimated to be 672, 933, and 3,816 US dollars, respectively, for each of these strategies.

Ambulatory Care↗
PubMed2004

When does quality-adjusting life-years matter in cost-effectiveness analysis?

PURPOSE: This paper investigates the impact of quality-of-life adjustment on cost-effectiveness analyses, by comparing ratios from published studies that have reported both incremental costs per (unadjusted) life-year and per quality-adjusted life-year for the same intervention. METHODS: A systematic literature search identified 228 original cost-utility analyses published prior to 1998. Sixty-three of these analyses (173 ratio pairs) reported both cost/LY and cost/QALY ratios for the same intervention, from which we calculated medians and means, the difference between ratios (cost/LY minus cost/QALY) and between reciprocals of the ratios, and cost/LY as a percentage of the corresponding cost/QALY ratio. We also compared the ratios using rank-order correlation, and assessed the frequency with which quality-adjustment resulted in a ratio crossing the widely used cost-effectiveness thresholds of 20, 000 US dollars, 50,000 US dollars, and 100,000 US dollars/QALY or LY. RESULTS: The mean ratios were 69,100 US dollars/LY and 103,100 US dollars/QALY, with corresponding medians of 24,600 US dollars/LY and 20,400 US dollars/QALY. The mean difference between ratios was approximately -34,300 US dollars (median difference: 1300 US dollars), with 60% of ratio pairs differing by 10,000 US dollars/year or less. Mean difference between reciprocals was 59 (QA)LYs per million dollars (median: 2.1). The Spearman rank-order correlation between ratio types was 0.86 (p<0.001). Quality-adjustment led to a ratio moving either above or below 50,000 US dollars/LY (or QALY) in 8% of ratio pairs, and across 100,000 US dollars in 6% of cases. CONCLUSIONS: In a sizable fraction of cost-utility analyses, quality adjusting did not substantially alter the estimated cost-effectiveness of an intervention, suggesting that sensitivity analyses using ad hoc adjustments or 'off-the-shelf' utility weights may be sufficient for many analyses. The collection of preference weight data should be subjected to the same scrutiny as other data inputs to cost-effectiveness analyses, and should only be under-taken if the value of this information is likely to be greater than the cost of obtaining it.

Cost-Benefit Analysis↗
PubMed2004

Metastatic colorectal carcinoma: cost-effectiveness of percutaneous radiofrequency ablation versus that of hepatic resection.

PURPOSE: To evaluate the relative cost-effectiveness of radiofrequency (RF) ablation and hepatic resection in patients with metachronous liver metastases from colorectal carcinoma (CRC) and compare the outcomes, cost, and cost-effectiveness of a variety of treatment and follow-up strategies. MATERIALS AND METHODS: A state-transition decision model for evaluating the (societal) cost-effectiveness of RF ablation and hepatic resection in patients with CRC liver metastases was developed. The model tracks the presence, number, size, location, growth, detection, and removal of up to 15 individual metastases in each patient. Survival, quality of life, and cost are predicted on the basis of disease extent. Imaging, ablation, and resection affect outcomes through detection and elimination of individual metastases. Several patient care strategies were developed and compared on the basis of cost, effectiveness, and incremental cost-effectiveness (expressed as dollars per quality-adjusted life-year [QALY]). Extensive sensitivity analysis was performed to evaluate the impact of alternative scenarios and assumptions on results. RESULTS: A strategy permitting ablation of up to five metastases with computed tomographic (CT) follow-up every 4 months resulted in a gain of 0.65 QALYs relative to a no-treat strategy, at an incremental cost of $2400 per QALY. Compared with this ablation strategy, a strategy permitting resection of up to four metastases, one repeat resection, and CT follow-up every 6 months resulted in an additional gain of 0.76 QALYs at an incremental cost of $24 300 per QALY. Across a range of model assumptions, more aggressive treatment strategies (ie, ablation or resection of more metastases, treatment of recurrent metastases, more frequent follow-up imaging) were superior to less aggressive strategies and had incremental cost-effectiveness ratios of less than $35 000 per QALY. Findings were insensitive to changes in most model parameters; however, results were somewhat sensitive to changes in size thresholds for RF ablation, the number of metastases present, and surgery and treatment costs. CONCLUSION: RF ablation is a cost-effective treatment option for patients with CRC liver metastases. However, in most scenarios, hepatic resection is more effective (in terms of QALYs gained) than RF ablation and has an incremental cost-effectiveness ratio of less than $35 000 per QALY.

Aged↗
PubMed2004

Cost effectiveness of thromboprophylaxis with a low-molecular-weight heparin versus unfractionated heparin in acutely ill medical inpatients.

OBJECTIVE: To compare the cost effectiveness of prophylaxis with a low-molecular-weight heparin with that of prophylaxis with unfractionated heparin for the prevention of venous thromboembolism in acutely ill medical inpatients. STUDY DESIGN: Cost-effectiveness analysis based on decision-tree model. PARTICIPANTS AND METHODS: A hypothetical cohort of 10 000 patients was assumed to receive either (1) prophylaxis with enoxaparin, a low-molecular-weight heparin, 40 mg daily; (2) prophylaxis with unfractionated heparin, 5000 IU twice daily; or (3) no prophylaxis. We developed a decision-analytic model with parameter estimates derived from published clinical trials and other secondary sources. Then, for each strategy, we estimated the risks of venous thromboembolism, complications of prophylaxis and treatment (heparin-induced thrombocytopenia and bleeding), mortality, and costs of prophylaxis and treatment within a 30-day period. RESULTS: In a hypothetical cohort of 10 000 inpatients, expected numbers of deaths attributable to venous thromboembolism or drug complications related to both prophylaxis for and treatment of VTE over a 30-day period were 37 with enoxaparin prophylaxis, 53 with unfractionated heparin prophylaxis, and 81 with no prophylaxis. In 2001, corresponding expected costs of prevention, diagnosis, and management of VTE were $3 502 000 for enoxaparin, $3 772 000 for unfractionated heparin, and $3 105 000 for no prophylaxis. The incremental cost per death averted with enoxaparin prophylaxis versus no prophylaxis was $9100. Enoxaparin dominated unfractionated heparin by being both more effective and less costly in the base-case analysis, as well as in sensitivity analyses in which equal efficacy and equal risks of bleeding were assumed. CONCLUSIONS: Thromboprophylaxis with this low-molecular-weight heparin represents a cost-effective use of healthcare resources in acutely ill medical inpatients and dominates thromboprophylaxis with unfractionated heparin.

Acute Disease↗
PubMed2003

Projecting the cost-effectiveness of adherence interventions in persons with human immunodeficiency virus infection.

PURPOSE: To explore the cost-effectiveness of interventions to improve adherence to combination antiretroviral therapy in patients with human immunodeficiency virus (HIV) infection. METHODS: A simulation model of HIV infection, incorporating CD4 cell count and HIV ribonucleic acid levels as predictors of disease progression, was used to estimate the lifetime costs and quality-adjusted life expectancy associated with clinical interventions to improve adherence to antiretroviral therapy (e.g., directly observed therapy, automatic medication dispensers, beepers, portable alarms) in a clinical trial cohort with early disease (mean CD4 count, 350 cells/microL), a clinical trial cohort with advanced disease (mean CD4 count, 87 cells/microL), and an urban cohort (mean CD4 count, 217 cells/microL). Data were from clinical trials, national databases, and published literature. RESULTS: For relatively healthy patients with early disease, interventions that reduced virologic failure rates by 10% increased quality-adjusted life expectancy by 3.2 months, whereas those that reduced failure by 80% increased quality-adjusted life expectancy by 34.8 months, as compared with standard care. The cost-effectiveness ratio was below 50000 US dollars per quality-adjusted life-year (QALY) for interventions costing 100 US dollars per month provided that failure rates were reduced by at least 10%, and for those costing 500 US dollars per month provided that failure rates were reduced by more than 50%. For both patients with advanced disease and those from an urban cohort, adherence interventions costing about 500 US dollars per month (e.g., directly observed therapy) had to reduce failure by about 25% to have cost-effectiveness ratios below 50000 US dollars per QALY. CONCLUSION: In patients with lower baseline levels of adherence or advanced disease, even very expensive, moderately effective adherence interventions are likely to confer cost-effectiveness benefits that compare favorably with other interventions.

Antiretroviral Therapy, Highly Active↗