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PubMed1999

Electronic imaging and clinical implementation: work group approach at Mayo Clinic, Rochester.

Electronic imaging clinical implementation strategies and principles need to be developed as we move toward replacement of film-based radiology practices. During an 8-month period (1998 to 1999), an Electronic Imaging Clinical Implementation Work Group (EICIWG) was formed from sections of our department: Informatics Lab, Finance Committee, Management Section, Regional Practice Group, as well as several organ and image modality sections of the Department of Diagnostic Radiology. This group was formed to study and implement policies and strategies regarding implementation of electronic imaging into our practice. The following clinical practice issues were identified as key focus areas: (1) optimal electronic worklist organization; (2) how and when to link images with reports; (3) how to redistribute technical and professional relative value units (RVU); (4) how to facilitate future practice changes within our department regarding physical location and work redistribution; and (5) how to integrate off-campus imaging into on-campus workflow. The EICIWG divided their efforts into two phases. Phase I consisted of Fact finding and review of current practice patterns and current economic models, as well as radiology consulting needs. Phase II involved the development of recommendations, policies, and strategies for reengineering the radiology department to maintain current practice goals and use electronic imaging to improve practice patterns. The EICIWG concluded that electronic images should only be released with a formal report, except in emergent situations. Electronic worklists should support and maintain the physical presence of radiologists in critical areas and direct imaging to targeted subspecialists when possible. Case tools should be developed and used in radiology and hospital information systems (RIS/HIS) to monitor a number of parameters, including professional and technical RVU data. As communication standards improve, proper staffing models must be developed to facilitate electronic on-campus and off-campus consultation.

Diagnostic Imaging↗
PubMed2006

Affective state and decision-making in the Ultimatum Game.

The emerging field of neuroeconomics has provided evidence that emotional as well as cognitive processes may contribute to economic decision-making. Indeed, activation of the anterior insula, a brain area involved in emotional processing, has been shown to predict decision-making in the Ultimatum Game. However, as the insula has also been implicated in other brain functions, converging evidence on the role of emotion in the Ultimatum Game is needed. In the present study, 30 healthy undergraduate students played the Ultimatum Game while their skin conductance responses were measured as an autonomic index of affective state. The results revealed that skin conductance activity was higher for unfair offers and was associated with the rejection of unfair offers in the Ultimatum Game. Interestingly, this pattern was only observed for offers proposed by human conspecifics, but not for offers generated by computers. This provides direct support for economic models that acknowledge the role of emotional brain systems in everyday decision-making.

Adult↗
PubMed2004

Pharmacoeconomic assessment of oseltamivir in treating influenza--the case of otherwise healthy Danish adolescents and adults.

OBJECTIVE: To assess the pharmacoeconomics of treating influenza with oseltamivir in healthy Danish adolescents and adults. METHOD: Cost-effectiveness and cost-utility analyses were used to compare oseltamivir to usual care (symptomatic treatment with over the counter (OTC) medicine), considering both the societal and health care payer's perspectives. The population group studied was otherwise healthy adolescents and adults, aged 13 to 64. Danish data were collected to simulate results that are specific to Denmark. The economic model included first- and second-order Monte Carlo simulations. Sensitivity analyses were conducted to test the robustness of the analyses. MAIN OUTCOME MEASURE: The cost-effectiveness study was expressed as gain in cost per day to return to normal activity, and the cost-utility study as cost per QALY (quality adjusted life years) gained. RESULTS: From a societal perspective, oseltamivir was a dominant treatment compared to usual care. From a health care payer's perspective, the cost-effectiveness ratio was 12.3 euros per gain in day to return to normal activity and 5,063 euros/QALY gained. A sensitivity analysis leaving out hospitalisation, complications, and mortality showed increased cost-effectiveness and cost-utility ratios. However, treatment with oseltamivir remained cost-effective, assuming a willingness to pay for health benefits at 26,174 euros/QALY. CONCLUSION: Pharmacoeconomic analyses of influenza treatment with oseltamivir in an otherwise healthy Danish adolescent/adult population show that this treatment saves money for society and is associated with a relatively low cost from a health care payer's perspective. Treatment of influenza with oseltamivir would be cost-effective for healthy adolescents/adults in Denmark.

Acetamides↗
PubMed2004

Estimating the opportunity costs of biodiversity protection in the Brigalow Belt, New South Wales.

The New South Wales Government recently introduced the Native Vegetation Conservation Act to protect the native grassland and woodland of the state. The Act protects biodiversity by preventing farmers from clearing such vegetation on their properties but, as a consequence, reduces farm incomes and land values. An economic model of the relationship between land value and percentage of farm in native vegetation is integrated with an ecological model of the relationship between species lost and percentage of the farms in native vegetation. The integrated framework is applied to estimate the opportunity costs of the Act for one important agricultural area of the state, the northern part of the Brigalow Belt South Bio-Region. If all the vegetation were protected, the reduction in land value would be at least 14.3%, which is an opportunity cost of at least 148.5 dollars m for the area. Both the benefits and costs of biodiversity protection must be accounted for, so risk simulations are then combined with benefit-cost analysis to compare the benefits of biodiversity protection to these costs.

Agriculture↗
PubMed2005

Stochastic efficiency analysis of bovine tuberculosis-surveillance programs in the Netherlands.

We constructed a stochastic bio-economic model to determine the optimal cost-efficient surveillance program for bovine tuberculosis. The surveillance programs differed in combinations of one or more detection methods and/or sampling frequency. Stochastic input variables in the epidemiological module described the dynamics of infection and the probability of detection. By means of an efficiency frontier, the trade-off between the expected cost and the epidemiological risk parameter relating to the outbreak size was evaluated. The surveillance scheme based on visual inspection of lesions on carcasses at slaughter was optimal given the current prevalence of the disease in the Netherlands if the objective was to minimise the expected costs. However, the efficient set also included two other schemes: slaughterhouse inspection in combination with GAMMA-interferon testing of blood samples and slaughterhouse inspection in combination with two-stage tuberculin testing. The choice ultimately will depend on the risk attitude of the decision-maker; a more-stringent surveillance scheme will be enforced if the expected outbreak size is to be constrained. In future scenarios, ELISA testing of bulk-tank milk in combination with the current slaughterhouse inspection procedure would outperform the surveillance scheme of solely slaughterhouse inspection if ELISA testing of bulk-tank milk becomes feasible.

Animals↗
PubMed2005

The cost-effectiveness of influenza vaccination of healthy adults 50-64 years of age.

Influenza can cause significant morbidity and mortality. Influenza vaccination is an effective and safe strategy in the prevention of influenza. Currently the National Health Service (NHS) vaccinates 'at-risk' individuals only. This definition includes everyone over 65 years of age but excludes individuals 50-64 years of age unless they have an additional risk factor, such as underlying heart disease or lung disease. In order to examine the cost-effectiveness of an extension of the vaccination policy to include this age group we constructed an economic model to estimate the costs and benefits of vaccination from both a health service and a societal perspective. Data to populate the model was obtained from the literature and the outcome measure used was the quality adjusted life year (QALY). Influenza vaccination prevented an estimated 4508 cases (95% CI: 2431-7606) per 100,000 vaccinees per influenza season for a net cost to the NHS of pound653,221 (95% CI: 354,575-1,072,257). The net cost increased to pound1,139,069 (95% CI 27,052-2,030,473) when non-NHS costs were included and the estimated cost-per-QALY were pound6174 and pound10,766 for NHS and all costs respectively. Extension of the current immunisation policy has the potential to generate a significant health benefit at a comparatively low cost.

Cost-Benefit Analysis↗
PubMed2002

A cost-utility analysis of interventions for severe proliferative vitreoretinopathy.

PURPOSE: The purpose of this study was to report a reference case, patient preference-based, incremental, cost-utility analysis for treatments of retinal detachment associated with severe proliferative vitreoretinopathy (PVR). DESIGN: Computer-based economic model utilizing data from the Medicare health insurance system in the United States. METHODS: A cost-utility analysis compared vitreoretinal surgery using expanding gases and silicone oil therapy to the natural course of retinal detachment associated with severe PVR. The model applies long-term published visual data from the Silicone Study Group, time tradeoff utility analysis, decision analysis with Markov modeling, and discounting of costs and health benefits as per the Panel on Cost-Effectiveness in Health and Medicine. The major outcome measure was in year 2000 United States dollars per quality-adjusted life-year (dollars/QALY) gained. RESULTS: Vitreoretinal surgery for retinal detachment complicated by severe PVR, as compared with no treatment, resulted in a mean gain of 0.128-0.200 discounted (3% annual rate) quality-adjusted life-years per treated patient. Silicone oil (dollars/QALY gained of 40,252 dollars) was slightly more cost-effective than perfluoropropane (C(3)F(8)) gas (dollars/QALY gained of 46,926 dollars) in eyes with PVR without previous vitrectomy, whereas C(3)F(8) gas (dollars/QALY gained of 46,162 dollars) was more cost-effective than silicone oil (dollars/QALY gained of 62,383 dollars) with previous vitrectomy and PVR. Sensitivity analysis resulted in a dollars/QALY gained of 13,347 dollars when 10% of opposite eyes had a severe visual loss to 202,128 dollars when a discount rate of 10% was utilized and opposite eyes initially had good vision. CONCLUSIONS: The incremental expense of interventions for retinal detachment associated with PVR is cost-effective when compared with other widely accepted interventional therapies across diverse medical specialties.

Computer Simulation↗
PubMed1999

Pharmacoeconomic comparison of an albumin-furosemide complex versus sequential therapy for renal insufficiency.

The purpose of this economic analysis was to develop an economic model using intra-institutional cost data for acute, oliguric renal insufficiency treated with either an albumin-furosemide complex or albumin followed by furosemide (sequential therapy). The perspective of this study was from the standpoint of the institution (University Medical Center, a teaching hospital). The decision tree and sensitivity analyses demonstrated that the albumin-furosemide complex would be more effective and less costly than sequential therapy for a range of outcome probabilities. Using effectiveness assumptions from published literature, the complex could avoid dialysis in 27% of patients compared with 8% of patients receiving sequential therapy. The complex would also be less costly ($7778 vs $8748). In terms of cost-effectiveness, the complex is $28,807 per averted dialysis compared with $109,350 for sequential therapy.

Acute Disease↗
PubMed1998

Economic implications of chronic sinusitis.

An approach to cost analysis useful in understanding the economic implications of surgical intervention on chronic sinusitis is break-even time analysis. The break-even time is the time until cost savings associated with improved health status after surgery equal the up-front costs of the operation itself. Data from 100 consecutive patients undergoing sinus operation were obtained by survey before surgery and at quarterly intervals for 1 year with statistically validated outcome measures (Medical Outcome Study Short Form 36-Item Health Survey, Chronic Sinusitis Survey). Direct and indirect costs were obtained or derived for this cohort. The cost of sinus medications, including over-the-counter remedies, nasal steroid sprays, and antibiotics, averaged $1220 per patient per year before surgery and $629 after surgery (p < 0.0001), which is a 48% reduction. Surgical costs averaged $6490 per patient. Economic modeling predicted a break-even time of approximately 7 years assuming a 3% surgical revision rate per year, a 3% decrease in sickness-related disability, and a 5% discount rate. The model was sensitive to changes in the total cost of operation, the surgical revision rate, and the anticipated disability benefit. We conclude that significant direct and indirect medical cost savings may be achieved after surgical intervention for chronic sinusitis and these savings eventually break even with the total cost of surgery itself.

Absenteeism↗
PubMed2004

Economic evaluation of enoxaparin for the prevention of venous thromboembolism in acutely ill medical patients.

OBJECTIVE: To conduct an economic evaluation of the prevention of venous thromboembolism in acutely ill medical patients. METHOD: We used a previously described economic model created in the context of the UK National Health Service and applied it to St. Thomas' Hospital, London. A clinical review to determine the number of medical admissions that would require thromboprophylaxis at St. Thomas' Hospital, based on the inclusion criteria of a medical thromboprophylaxis trial (MEDENOX), was conducted. Costs and effectiveness were determined, based on the provision of thromboprophylaxis to 2000 medical patients. RESULTS: Comparing treatment with low-molecular-weight heparin (enoxaparin, 40 mg once daily), unfractionated heparin (5000 IU twice daily), or no prophylaxis, the highest cost of thromboprophylaxis was associated with unfractionated heparin (199,000 pounds sterling = 4306,000 Euros), compared with enoxaparin (198,000 pounds sterling = 305,000 Euros) or no prophylaxis (176,000 pounds sterling = 271,000 Euros). The model suggested that enoxaparin thromboprophylaxis would result in fewer thromboembolic-related events. Using sensitivity analysis, incorporating certain St. Thomas'-specific costs showed enoxaparin compared with unfractionated heparin or no thromboprophylaxis was cost saving. The cost savings of 65,000 pounds sterling ( = 100,000 Euros) and 31,000 pounds sterling ( = 48,000 Euros) respectively are based on maximum uptake of thromboprophylaxis. CONCLUSIONS: The graded implementation of enoxaparin thromboprophylaxis over a four-year period would require funding redistribution. The funding Health Authority would save overall but St. Thomas' would require an increase in drug expenditure across the clinical directorates of 35,000 pounds sterling ( = 54,000 Euros) after 4 years.

Acute Disease↗
PubMed2005

Cost-effectiveness of orlistat for the treatment of overweight and obese patients in Ireland.

OBJECTIVE: To assess the cost-effectiveness of orlistat plus a calorie-controlled diet compared with a calorie-controlled diet alone for the treatment of overweight and obese patients in Ireland. DESIGN: Economic modelling techniques using published international efficacy data and Irish cost data were used to estimate the cost-effectiveness of orlistat in obese patients when only responders to treatment (ie achieve 5% weight loss after 3 months of treatment) continue orlistat after 3 months. The model incorporated known relationships between weight loss and quality of life (utility) gain, and weight loss and reduction in risk of type 2 diabetes (T2DM) to predict the impact of weight loss on quality-adjusted-life-years (QALYs) gained and on the onset of T2DM. The costs associated with each treatment arm included the acquisition cost of orlistat, cost of a calorie-controlled dietary programme and monitoring and treatment costs associated with T2DM. An Irish health-care perspective was taken for the analysis, based on 2003 costs. SUBJECTS: Weight loss data on 1386 patients from five pivotal orlistat clinical trials with at least 12 months duration were pooled (two American and three primarily European studies). All the studies were randomized, placebo-controlled, multicentre trials with a similar design. The inclusion criteria were BMI > or =28 kg / m(2), age > or =18 y, no diagnosed T2DM and the ability to lose 2.5 kg in weight during the introductory period. MEASUREMENTS: Cost effectiveness was modelled from these data and presented as incremental cost per QALY. RESULTS: When orlistat treatment plus a calorie-controlled diet was compared with a calorie-controlled diet alone, the incremental cost per year was euro 478. The number needed to treat (NNT) to gain one QALY was estimated to be 35. The incremental cost per QALY gained was within the range considered cost-effective at euro 16,954. Sensitivity analysis demonstrated an incremental cost per QALY of euro 11,000-35,000 under a variety of assumptions. CONCLUSIONS: Our model suggests that orlistat is effective and cost-effective in obese patients, if after 3 months of treatment, only treatment responders continue treatment.

Adult↗
PubMed2001

Botulinum toxin type A in the management of equinus in children with cerebral palsy: an evidence-based economic evaluation.

INTRODUCTION: The aim of this study was to compare two methods of conservative management of calf spasticity and equinus gait--intramuscular injection of botulinum toxin type A (BTX-A) and serial casting. An economic evaluation framework was adopted to assess whether BTX-A offers value for money in the management of equinus gait due to calf spasticity in children with cerebral palsy. Short- to medium-term health care costs and outcomes were estimated for the comparison. This study was embarked upon to provide clinical and economic data as part of an application to the Pharmaceutical Benefits Advisory Committee (PBAC) for the reimbursement of BOTOX by the Australian Commonwealth Government. This is the primary mechanism for reimbursement of pharmaceuticals in Australia, as they are not routinely reimbursed through health insurance companies. The perspective of the analysis was that of the Australian health system. METHODOLOGY: Randomized controlled trials (RCTs) exist comparing one treatment cycle of BTX-A with serial casting (Corry et al., 1998; Flett et al., 1999). A long-term prospective study provided data on multiple cycles of BTX-A treatment in a more naturalistic setting (Boyd et al., 1999). A simple economic modelling approach was used to establish resource utilization by treatment arm. Only direct medical costs were considered (BTX-A, medical personnel time and medical consumables). MAIN MEASURES: Clinical efficacy was obtained from the randomized controlled trials (Corry et al., 1998; Flett et al., 1999). Patient/parent preference was obtained from long-term follow-up (Corry et al., 1998) and a preference questionnaire (Flett et al., 1999). Australian treatment patterns and patient demographics were obtained from the naturalistic study (Boyd et al., 1999). RESULTS: The RCTs demonstrated equivalent efficacy of BTX-A and serial casting; however, with BTX-A the effect lasted longer and was clearly the preferred treatment. For patients with hemiplegia the costs of an episode of treatment with BTX-A or serial casting are ($AUD) $595 and $435, respectively, and thus the additional costs associated with BTX-A are $160. The corresponding costs for patients with diplegia are $1045 for BTX-A treatment and $870 for serial casting and thus the additional cost associated with BTX-A is $175. With an overall treatment duration of 3.7 years and an average treatment interval of 10 months, patients would receive an average of 5.4 treatments. Thus, for patients with hemiplegia the total additional cost, discounted at 5% annually, for BTX-A is $793. For patients with diplegia the total additional cost for BTX-A is $867. CONCLUSIONS AND CLINICAL INTERPRETATIONS: BTX-A is an effective, safe and acceptable treatment modality and is associated with only a modest increase in direct medical costs per child per year. BTX-A can be considered a valuable and cost-effective treatment in the conservative management of equinus due to calf spasticity in children with cerebral palsy. This conclusion is supported by the acceptance of the Pharmaceutical Benefits Advisory Committee (PBAC) recommendation that BOTOX should attract a full Government subsidy in Australia.

Botulinum Toxins, Type A↗
PubMedDate not supplied

Responsibility-centered management: a 10-year nursing assessment.

In 1988-89, Indiana University became the first public university to implement responsibility-centered management (RCM) comprehensively. This article describes and assesses the implementation of RCM on the core campus of Indiana University School of Nursing in Indianapolis. It describes how RCM encouraged an information-rich environment, particularly with the advent of economic modeling; decision making linked to strategic goals/objectives; and a performance-based reward structure (e.g., merit pay increases and incentive plans). It ends with a discussion about the worth of RCM and the changes that frame-work produced, particularly in reconceptualizing the roles of the business officer and dean. The most profound consequence of RCM may be the effect it has in encouraging rethinking of what it means to be a school of nursing at this point in time.

Benchmarking↗
PubMed2002

Establishing value in managed care: cost-effectiveness or budgetary impact?

In the managed care setting, pharmacy benefit managers face considerable challenges when making decisions regarding drug coverage. Although scientifically valid data may be available from randomized, double-blind, placebo-controlled trials, this type of information does not shed light on potential differences between medications in the same class. Furthermore, properly designed, comparative trials are rarely conducted. Randomized naturalistic or pragmatic pharmacoeconomic studies can provide valuable information but are likewise infrequently performed. Economic modeling is an alternative but is not widely accepted because of the potential for bias. Retrospective analyses of information from patient surveys or existing databases are emerging as more popular methods of supporting informed formulary decisions. In the absence of a large-scale, prospective, naturalistic, pharmacoeconomic study, an alternative indication of product superiority can be derived from a continuum of different types of studies (from basic science to clinical trials to retrospective pharmacoeconomic analysis) conducted in a variety of patient care settings. The consistency with which a product demonstrates superiority across all types of studies is critical and is a crucial determinant of whether a health care provider would be likely to use the information for the purpose of decision making.

Cost-Benefit Analysis↗
PubMed2005

Use of chromium picolinate and biotin in the management of type 2 diabetes: an economic analysis.

This paper addresses the potential economic benefits of chromium picolinate plus biotin (Diachrome) use in people with Type 2 diabetes (T2DM). The economic model was developed to estimate the impact on health care systems' costs by improved HbA1C levels with chromium picolinate plus biotin (Diachrome). Lifetimes cost savings were estimated by adjusting a benchmark from the literature, using a price index to adjust for inflation. The cost of diabetes is highly dependent on the HbA1C level with higher initial levels and higher annual increments increasing the cost. Improvement in glycemic control has proven to be cost-effective in delaying the onset and progression of T2DM, reducing the risk for diabetes-associated complications and lowering utilization and cost of care. Chromium picolinate plus biotin (Diachrome) showed greater improvement of glycemic control in poorly controlled T2DM patients (HbA(1C) > or = 10%) compared to their better controlled counterparts (HbA(1C) < 10%). This improvement was additive to that achieved by oral hypoglycemic medications and correlates to calculated levels of cost savings. Average 3-year cost savings for chromium picolinate plus biotin (Diachrome) use could range from 1,636 dollars for a poorly controlled patient with diabetes without heart diseases or hypertension, to 5,435 dollars for a poorly controlled patient with diabetes, heart disease, and hypertension. Average 3-year cost savings was estimated to be between 3.9 billion dollars and 52.9 billion dollars for the 16.3 million existing patients with diabetes. Chromium picolinate plus biotin (Diachrome) use among the 1.17 million newly diagnosed patients with T2DM each year could deliver lifetime cost savings of 42 billion dollars, or 36,000 dollars per T2DM patient. Affordable, safe, and convenient, chromium picolinate plus biotin (Diachrome) could prove to be a cost-effective complement to existing pharmacological therapies for controlling T2DM.

Biotin↗
PubMed1999

Financing a future for public biological data.

MOTIVATION: The public web-based biological database infrastructure is a source of both wonder and worry. Users delight in the ever increasing amounts of information available; database administrators and curators worry about long-term financial support. An earlier study of 153 biological databases (Ellis and Kalumbi, Nature Biotechnol., 16, 1323-1324, 1998) determined that near future (1-5 year) funding for over two-thirds of them was uncertain. More detailed data are required to determine the magnitude of the problem and offer possible solutions. METHODS: This study examines the finances and use statistics of a few of these organizations in more depth, and reviews several economic models that may help sustain them. RESULTS: Six organizations were studied. Their administrative overhead is fairly low; non-administrative personnel and computer-related costs account for 77% of expenses. One smaller, more specialized US database, in 1997, had 60% of total access from US domains; a majority (56%) of its US accesses came from commercial domains, although only 2% of the 153 databases originally studied received any industrial support. The most popular model used to gain industrial support is asymmetric pricing: preferentially charging the commercial users of a database. At least five biological databases have recently begun using this model. Advertising is another model which may be useful for the more general, more heavily used sites. Microcommerce has promise, especially for databases that do not attract advertisers, but needs further testing. The least income reported for any of the databases studied was $50,000/year; applying this rate to 400 biological databases (a lower limit of the number of such databases, many of which require far larger resources) would mean annual support need of at least $20 million. To obtain this level of support is challenging, yet failure to accept the challenge could be catastrophic. CONTACT: lynda@tc.umn. edu

Computational Biology↗
PubMed2000

An economic evaluation of occupational health.

There is an increasing need to evaluate the costs and benefits of an occupational health service (OHS). However, measuring benefits from an OHS is inherently difficult. Instead, an economic model can be constructed to present the minimum threshold benefits required for OHSs to be cost-effective, given what is known about costs. This model assumes that the benefits of an OHS are to maximize health and morale of employees; maximize performance and increase productivity; minimize medico-legal costs; enhance workplace safety; and reduce sickness absence. A certain distribution across these benefits can be assumed for each OHS. The overall required value of all benefits brought about by use of an OHS is in the range 158-199 Pounds per year. The plausibility of results can be assessed using known data and judgement. Despite many uncertainties it is likely that the minimum benefit thresholds will be achieved overall.

Cost-Benefit Analysis↗
PubMed2004

Systematic review of the management of patients with haemophilia A and inhibitors.

The London Directorate of Health and Social Care Research and Development Group recently commissioned the School of Health and Related Research at the University of Sheffield to perform a systematic review of the management of patients with haemophilia A and inhibitors. The main areas of the review were the epidemiology of inhibitors, the role and effectiveness of immune tolerance induction, and the control of acute bleeding. In addition, an economic model of the different treatment strategies was constructed. Among the findings was that the overall prevalence of inhibitors in unselected haemophilic populations is 5-7%, with the cumulative inhibitor risk varying from 0% to 39%. The prevalence of inhibitors was inversely related to the size of the reported population. Immune tolerance induction was considered desirable, with evidence suggesting that the Bonn protocol may be more effective than either the Malmo or low-dose protocols. Immunosuppressive drug regimens on their own were ineffective. Activated prothrombin complex concentrates (aPCC) were more effective than non-aPCC. Recombinant activated factor VII was also effective, but there were no randomized trials comparing this agent with aPCC. Porcine factor VIII was highly effective in both treating acute bleeding episodes and preventing bleeding after surgery.

Disease Management↗