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PubMed2006

Cost-effectiveness of thromboprophylaxis with intermittent pneumatic compression at cesarean delivery.

OBJECTIVE: To evaluate the cost-effectiveness of thromboprophylaxis at cesarean delivery with intermittent pneumatic compression. METHODS: A decision tree model using Markov analysis was developed to compare two approaches to perioperative care at the time of cesarean delivery: 1) no use of perioperative thromboprophylaxis and 2) the use of intermittent pneumatic compression for thromboprophylaxis at the time of cesarean delivery. Postcesarean deep venous thrombosis was estimated to occur in 0.7% of patients (75% of whom were asymptomatic), and result in a 9% chance of postthrombotic syndrome. Mechanical prophylaxis was assumed to decrease the risk of deep venous thrombosis by 70% and to cost 120 dollars. Probability of morbidity and mortality of venous thromboembolism as well as anticoagulation and the costs and utilities for different health state were derived from published studies. Sensitivity analysis was performed over a wide range of variable estimates. RESULTS: Using the assumptions in our base case, routine thromboprophylaxis for cesarean delivery cost 39,545 dollars per quality-adjusted life year. One-way sensitivity analysis revealed that as long as the incidence of postcesarean deep venous thrombosis was at least 0.68%, intermittent pneumatic compression reduced the incidence of deep venous thrombosis by at least 50%, or the cost of intermittent pneumatic compression was less than 180 dollars, the cost-effectiveness of mechanical prophylaxis did not exceed 50,000 dollars per quality-adjusted life year. CONCLUSION: Mechanical thromboprophylaxis is estimated to be a cost-effective strategy under a wide range of circumstances.

Adult↗

PubMed2003

Simulated epidemiological and economic effects of measures to reduce piglet supply during a classical swine fever epidemic in The Netherlands.

The effects of additional measures adopted during a classical swine fever (CSF) epidemic to reduce piglet supply, namely, an insemination ban, abortion of sows and killing of young piglets, are studied using a stochastic, spatial, dynamic epidemiological simulation model of the pig sector in The Netherlands. The piglet supply derived from the epidemiological model is used as input for a sector-level market and trade model that simulates the pig market in The Netherlands. Changes in the economic welfare of different stakeholders are measured, as is the net welfare effect for the economy in The Netherlands. Sensitivity analysis is performed on parameters such as destruction capacity constraints and the duration of the high-risk period. Additional measures to reduce piglet supply are found to have no epidemiological impact, but they do involve larger economic welfare changes for stakeholders and a larger net welfare loss for the economy in The Netherlands. These findings do not support the use of the additional measures. Moreover, sensitivity analysis shows that such measures do not solve the problem of a shortage in rendering capacities.

Abortion, Induced↗

PubMed2000

Management of a positive surgical margin after radical prostatectomy: decision analysis.

PURPOSE: We created and tested a decision analysis model to help determine the preferred management of a positive surgical margin(s) after radical prostatectomy. MATERIALS AND METHODS: We constructed a decision tree modeling surveillance versus immediate prophylactic adjuvant radiation in patients with a positive surgical margin(s) after radical prostatectomy. Literature and institution based estimates were determined for certain factors, including the probability of undetectable prostate specific antigen (PSA) in patients followed expectantly postoperatively and those treated with immediate adjuvant radiotherapy, complications of radiotherapy after prostatectomy and probability of undetectable PSA in those treated with therapeutic radiation for detectable PSA postoperatively. A panel of experts assigned utilities to the various outcomes. Sensitivity analysis was performed to determine threshold values required to change the model outcome. RESULTS: Using average probability estimates from a literature review the decision model recommended initial surveillance. Sensitivity analysis demonstrated that the model depended on the probability of disease recurrence in men followed expectantly after surgery as well as the efficacy of therapeutic radiation. We tested the decision model again for patient groups based on tumor grade, pathological stage, preoperative PSA and number of positive margins. The model recommended initial radiation for patients with low to intermediate grade disease, no evidence of seminal vesicle invasion and multiple positive margins. CONCLUSIONS: The results of our decision analysis imply that immediate radiation may be appropriate for patients with a positive surgical margin(s) and a high likelihood of recurrent local rather than distant disease. This model may be useful to physicians and patients who use individual probability estimates and utility values to determine the preferred course of management after surgery.

Decision Trees↗

PubMed2005

[Analysis of the usefulness of Candid 1 vaccine in preventing Argentine hemorrhagic fever in children].

OBJECTIVE: To determine the most rational strategy of vaccination with Candid 1 vaccine in order to prevent Argentine hemorrhagic fever among children under 15 years old living an endemic area. METHODS: To analyze the estimated effectiveness, a decision tree model was designed, with two possible options: vaccinate all the children under age 15 in the endemic area ("expanded vaccination") or vaccinate only the children at greater risk ("selective vaccination"). These two options were compared with the alternative of not vaccinating. The evaluation was complemented with a sensitivity analysis to identify the threshold values of the critical variables that could change the decision. The probabilities that were used were taken from earlier clinical and epidemiological trials. RESULTS: According to the model that we used, the expanded vaccination strategy was the best option, with a total expected utility of 9.99998 (out of a maximum possible 10.0). The sensitivity analysis showed that selective vaccination would be the best strategy if the incidence in the population with low risk drops to less than 3 per 1,000,000 population or if the rate of serious adverse reactions to the vaccine reaches more than 9 per 100,000 inhabitants. No variation in the parameters used in the model supported the option of not vaccinating. CONCLUSIONS: Given the risk and benefit parameters that we used, we recommend vaccinating with Candid 1 all the children under age 15 who live in the area endemic for Argentine hemorrhagic fever. The proposed model can be fitted to future needs, and it can help in decision-making by incorporating prospective disease surveillance data. These results can be used as a basis for cost and efficacy studies and for other quantitative analyses.

Adolescent↗

PubMed1994

Medical cost savings from pentoxifylline therapy in chronic occlusive arterial disease.

This article assesses the direct medical cost savings associated with therapeutic dosages of pentoxifylline therapy compared with lower dosages in treating chronic occlusive arterial disease (COAD). The savings accrue from elimination of invasive diagnostic measures or a number of surgical procedures received by patients with COAD during hospital admissions. Findings are based on a secondary analysis of results presented in a previously published report of a population based historical cohort study. Patients in this study were severely enough afflicted by the disease that most were under the care of vascular specialists and many underwent surgery to restore normal blood flow. Costs are based on charges from Medicare expenditures in 4 US states in 1989. A case-mix adjustment procedure was applied and a sensitivity analysis was conducted on key assumptions and variables in the cost savings model. Pentoxifylline therapy reduced average hospital costs per patient by $US1173 per year (1989 dollars). After further adjustment for the costs of outpatient visits, other related drugs and the drug acquisition cost, an overall saving of $US965 would still be realised with a patient who received the full therapeutic dose of pentoxifylline. Sensitivity analysis suggests total annual direct medical cost savings between $US69 and $US3090 per patient. Hence, under the most plausible assumptions regarding choice of procedures, study design and patient population, and considering the possibility that diagnostic and surgical costs are delayed but not prevented, pentoxifylline therapy substantially reduces direct medical costs.

Adult↗

PubMed2001

Enoxaparin for thromboprophylaxis after major trauma: potential cost implications.

OBJECTIVE: To determine the cost-effectiveness of enoxaparin compared with low-dose-heparin (LDH) for thromboprophylaxis after major trauma and to assess the economic significance of major bleeding as a complication of the use of low-molecular-weight heparin (LMWH). DESIGN: Decision model analysis of the cost and efficacy of enoxaparin at preventing venous thromboembolism (VTE) and the risk and costs of major hemorrhage related to LMWH. The primary outcome was deep vein thromboses (DVTs) averted. Model estimates were based on data from prospective trials of LMWH and other studies of the financial ramifications of DVT and pulmonary embolism. SETTING AND PATIENTS: Hypothetical cohort of 1,000 critically ill trauma patients requiring thromboprophylaxis. INTERVENTIONS: In the model, patients were managed with either LMWH or LDH. MEASUREMENTS AND MAIN RESULTS: The marginal cost-effectiveness of enoxaparin was calculated as the savings resulting from cases of DVT averted less the additional costs of both 1) LMWH and 2) major bleeding. This result is expressed as cost (or savings) per DVT prevented. Sensitivity analysis of the impact of the major clinical inputs on the cost-effectiveness was performed. The base case assumed that the incidence of DVT with LDH was 14.7%, that LMWH resulted in a relative risk reduction of DVT of 50%, but that enoxaparin nearly quadrupled the risk of bleeding. Despite the higher costs of enoxaparin, this tactic yielded a net savings of $391.23 per DVT prevented. For sensitivity analysis, model inputs were adjusted by 25% individually and then simultaneously. This demonstrated the model to be most sensitive to the calculated cost of a DVT. With the efficacy of LMWH reduced by 25% of the base-case estimate, enoxaparin resulted in a cost of $311.77 per DVT avoided. When all variables were skewed against LMWH, total outlays were trivial (approximately $85 per patient in the cohort). Neither the rate of increased bleeding with LMWH nor the costs incurred as a result of bleeding significantly altered the model's financial outcomes. CONCLUSIONS: Reliance on enoxaparin represents a strategy for the prevention of VTE after trauma that may result in savings. Neither concerns about the higher cost of enoxaprin relative to LDH nor the financial implications of major bleeding should preclude the use of LWMH for thromboprophylaxis in trauma patients. Further studies are warranted to confirm the efficacy of enoxaparin.

Anticoagulants↗

PubMed2006

Cost utility of substituting enoxaparin for unfractionated heparin for prophylaxis of venous thrombosis in the hospitalized medical patient.

BACKGROUND: Both heparin and enoxaparin are effective for the prevention of venous thromboembolism (VTE) in medical patients. On the basis of price, heparin appears preferable because it is less expensive. However, choosing enoxaparin may have greater cost utility when the outcomes of heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are considered. OBJECTIVE: To determine the cost utility of substituting enoxaparin for heparin from payer and institutional perspectives. DESIGN: A decision analysis model was used. Cost data were based on Medicare reimbursement and the medication and laboratory costs for a multi-institutional healthcare system. Quality-adjusted life years (QALYs) saved by preventing HIT/HITT through the use of enoxaparin were based on published data. Costs are expressed on a per-day basis, and the incremental cost of enoxaparin over that of heparin was used in the calculation of cost/QALY. A sensitivity analysis also was performed. SETTING: Inpatient medicine. PATIENTS: All medical patients for whom VTE prophylaxis was appropriate. INTERVENTIONS: Substitution of enoxaparin for heparin. MEASUREMENT: Cost/QALY. RESULTS: From a payer perspective, using enoxaparin resulted in a decrease in cost of 28.61 dollars over that of heparin and saved 0.00629 QALYs in the base case, resulting in a savings of 4550.17 dollars/QALY. The sensitivity analysis showed this finding of decreased cost and increased effectiveness to be consistent. From an institutional perspective, the use of heparin generally appeared less costly but was dependent on medication price, length of stay required, and bed utilization. CONCLUSIONS: From a payer and, by extrapolation, a societal perspective, cost-utility analysis supports the use of enoxaparin in place of heparin for the prevention of VTE in medical inpatients. From an institutional perspective, the decision is more complicated, but in most cases, the use of enoxaparin also is supported.

Costs and Cost Analysis↗

PubMed2000

Cost-effectiveness analysis of a family physician delivered smoking cessation program.

OBJECTIVES: The objectives were to present a cost-effectiveness analysis of a smoking cessation program delivered by physicians and compare results to other smoking cessation interventions. METHODS: Retrospective effectiveness figures from a previous evaluation of the smoking cessation program were supplemented with estimates based on researched assumptions. Net abstinence rates were determined for smokers, depending on their stage of readiness to quit, that is, "prepared," "contemplative," and "precontemplative," leading to an assessment of the number of smokers achieving abstinence as a result of the Smokescreen intervention. Costs were calculated from the perspectives of smokers, family physicians, organizers, trainers, and all parties combined. Assumptions were varied with a sensitivity analysis. RESULTS: Baseline costs per additional abstainer were $183 based on physicians' intervention costs at 1995 prices. This is the figure most comparable to previously conducted economic evaluations of smoking cessation interventions. Sensitivity analysis varying the perspective and under optimistic and pessimistic assumptions about effectiveness produced a wide variety of estimates. The decision to include or exclude training costs had a particularly important bearing on the estimates. However, under reasonable assumptions the cost per additional quitter compares favorably to smoking and other medical and health care interventions worldwide. CONCLUSIONS: The program appears cost-effective when compared to other smoking cessation and health promotion interventions and illustrates the potential for retrospective cost-effectiveness analysis of interventions.

Adolescent↗

PubMed1999

Applied pharmacoeconomics: evaluation and use of pharmacoeconomic data from the literature.

The evaluation and use of published pharmacoeconomic data are discussed. The pharmacoeconomic literature is a vast and powerful source of information for pharmacists and others who must make decisions about services and products. Published studies can provide data quickly and inexpensively, but they may not necessarily meet criteria for quality and may not be generalizable to a specific situation. Guidelines are available that are intended to standardize study methods, minimize potential bias, and increase the comparability and credibility of data. Before relying on a published study, decision-makers should ensure that it meets criteria related to objective, perspective, pharmacoeconomic method, design, interventions, costs, outcomes, discounting, results, sensitivity analysis, extrapolation of conclusions, and sponsorship. A sound study can be used to support decisions in such diverse areas as individual patient treatment, formulary management, drug-use guideline development, disease management initiatives, and pharmaceutical service evaluation. A decision-maker may be able to use the results by applying them at face value, employing a sensitivity analysis, performing a meta-analysis, incorporating the data into a pharmacoeconomic model, or reproducing the study on a smaller scale. The selection of an application strategy should be based on the potential impact of the decision on the quality and cost of care, with more rigorous and complex strategies reserved for more extreme impacts. Published pharmacoeconomic data can help pharmacists make better and more informed decisions about pharmaceutical services and products.

Data Collection↗

PubMed1997

Using a cost-construction model to assess the cost of educating undergraduate medical students at the University of Texas--Houston Medical School.

PURPOSE: To assess the cost of educating undergraduate medical students at the University of Texas-Houston Medical School (UT-Houston) in 1994-95 through the use of a cost-construction model developed elsewhere and adapted for UT-Houston. METHOD: The cost-construction model identified the cost of the entire program as well as instructional costs (the cost of activities related to direct-contact teaching), educational costs (instructional costs plus the costs of general supervision), and milieu costs (educational costs plus the costs of research). The model predicted these costs based on student contact hours, student enrollment, full-time-equivalent (FTE) faculty and residents required, professional-activity profiles, faculty and resident salaries, and supporting resource costs. Sensitivity analysis was used to explore the effects of such factors as institutional overhead, joint products, volunteer faculty, residents, and varying assumptions about the percentage of time the faculty dedicated to direct-contact teaching. RESULTS: The four-year undergraduate medical program at UT-Houston had a total cost of $82,692,280. For an average class of 200 students, the annual per-student instructional, educational, and milieu component costs were $43,993, $57,370, and $90,660, respectively. The program required 201 FTE faculty members and 258 FTE residents. Sensitivity analysis revealed the financial effects of the various factors, some of which increased costs and some of which decreased costs. CONCLUSION: Although the cost-construction model is conceptually straightforward, there are several inherent complexities and aspects open to debate that must be understood in its application: for example, assumptions regarding faculty time; assumptions regarding the allocation of faculty time to various activities; the definition of those activities; the difficulty of separating costs; the difficulty of accurately defining total educational costs; and so on. However, this study provides a starting point for identifying the distinct costs associated with an undergraduate medical school program and should encourage further discussion and research.

Costs and Cost Analysis↗

PubMedDate not supplied

Second line pharmacological management of paroxysmal and persistent atrial fibrillation in france: a cost analysis.

OBJECTIVES: Despite optimal pharmacological treatment a large proportion of patients with atrial fibrillation (Afib) are not arrhythmia-free, and remain at risk for complications such as stroke and cardiac morbidity. If first-line treatment fails, most patients receive second-line pharmacological treatment. The emergence of new technologies aimed at restoring and maintaining sinus rhythm, such as catheter ablation techniques, has increased the interest in the economic aspects of second-line pharmacological treatment. The objective was therefore to calculate the 5-year direct medical costs of second-line pharmacological management of paroxysmal and persistent Afib in France. METHODS: The analysis was based on clinical and economic literature and the input of cardiologists-electrophysiologists. The analysis included probabilities of stroke, sudden cardiac death, other cardiac and noncardiac death, direct medical costs of drugs, follow-up and complications from the healthcare payer's perspective. Included treatment strategies were (1) rhythm control with class Ic and III antiarrhythmics and (2) rate control, consisting of digoxin combined with a beta-blocker or calcium antagonist. Both strategies included aspirin or anticoagulation therapy. RESULTS: The average total 5-year cost of Afib was 16,539 Euro (FF 108,486) per patient. The result was stable to sensitivity analysis on incidence of stroke and type of stroke prevention. The main cost drivers were follow-up visits and hospitalizations and the cost of congestive heart failure. Both items being subject to some variation, they were submitted to sensitivity analysis showing minimal 5-year costs still over 14,483 Euro (FF 95,000). CONCLUSIONS: Afib management places high demands on medical resources mainly through its complications and comorbidity.

Journal Article↗

PubMedDate not supplied

Comparison of the cost-effectiveness of stress myocardial SPECT and stress echocardiography in suspected coronary artery disease considering the prognostic value of false-negative results.

BACKGROUND: The prognoses of patients with false-negative test results by myocardial single photon emission computed tomography (SPECT) and by stress echocardiography are known to be different; the prognosis with false-negative SPECT is better in suspected and proven coronary artery disease (CAD). METHODS AND RESULTS: Three strategies by which to diagnose CAD were compared for their cost-effectiveness when considering the prognostic value of false-negative results: (1) stress myocardial SPECT by dipyridamole or adenosine followed by coronary angiography (CAG), (2) exercise stress echocardiography followed by CAG, and (3) dobutamine stress echocardiography followed by CAG. Delta quality-adjusted life-year (QALY) was calculated for the three strategies separately when annual mortality and infarction rates were 0.5% and 0.5% for myocardial SPECT and 2% and 2% for stress echocardiography, respectively. Costs were estimated and costs per DeltaQALY were calculated according to the pretest likelihood of CAD (pCAD). The myocardial SPECT followed by CAG strategy was the most cost-effective in the patients with a pCAD of 0.3 or greater, and the dobutamine echocardiography followed by CAG strategy was the most cost-effective in patients with a pCAD of 0.2 or lower. This was the case when we assumed that the nondiagnostic test rate of dobutamine echocardiography was 9% (in contrast to 0% by myocardial SPECT and 18% by exercise echocardiography). Sensitivity analysis showed that the cost-effectiveness of dobutamine echocardiography followed by CAG was best only if the prognosis of false-negative results of dobutamine echocardiography was better. The cost-effectiveness of exercise echocardiography was dubious because of the high nondiagnostic rate with inadequate exercise. CONCLUSIONS: When the lower event rates of (false) negative SPECT were considered, the relatively expensive myocardial SPECT strategy was more cost-effective than the cheaper stress echocardiography strategy in patients with a pCAD of 0.3 or greater. According to sensitivity analysis, the prognostic value of false-negative results and the nondiagnostic test rate were important determinants of stress myocardial study cost-effectiveness.

Coronary Angiography↗

PubMed2005

Identification and impact of outcome selection bias in meta-analysis.

The systematic review community has become increasingly aware of the importance of addressing the issues of heterogeneity and publication bias in meta-analyses. A potentially bigger threat to the validity of a meta-analysis appears relatively unnoticed. The within-study selective reporting of outcomes, defined as the selection of a subset of the original variables recorded for inclusion in publication of trials, can theoretically have a substantial impact on the results. A cohort of meta-analyses on the Cochrane Library was reviewed to examine how often this form of within-study publication bias was suspected and explained some of the evident funnel plot asymmetry. In cases where the level of suspicion was high, sensitivity analysis was undertaken to assess the robustness of the conclusion to this bias. Although within-study selection was evident or suspected in several trials, the impact on the conclusions of the meta-analyses was minimal. This paper deals with the identification of, sensitivity analysis for, and impact of within-study selective reporting in meta-analysis.

Clinical Trials as Topic↗

PubMed2006

[The efficiency (cost-effectiveness) of palivizumab as prophylaxis against respiratory syncytial virus infection in premature infants with a gestational age of 32-35 weeks in Spain].

OBJECTIVES: To evaluate the efficiency (cost-effectiveness) of palivizumab in preventing severe respiratory syncytial virus (RSV) infection in premature infants with a gestational age of 32-35 weeks (GA 32-35) and two or more risk factors (RF) in Spain. METHODS DESIGN: decision tree model using data from the scientific literature and the FLIP I and FLIP II studies (cohort of 326 infants with GA 32-35 and two or more RF who received palivizumab) sponsored by the Spanish Society of Neonatology. Main effectiveness measure: quality-adjusted life years (QALY) gained. PERSPECTIVES: the national health service (NHS), which includes direct costs (administration of palivizumab and hospital admissions), and the societal perspective, which also includes indirect costs (the child's future lost productivity). Discount: 3 % annually for effectiveness and indirect costs. Sensitivity analysis: construction of 37 scenarios modifying variables related to effectiveness and costs. RESULTS: Prophylaxis with palivizumab in premature infants with GA 32-35 and two or more RF produced an incremental cost-effectiveness ratio (ICER) of 13,849 euro/QALY from the NHS perspective, and an ICER of 4,605 euro/QALY from the societal perspective. In the sensitivity analysis, from the NHS perspective the ICER ranged from 5,351 euro/QALY (most favorable scenario) to 23,276 euro/QALY (least favorable scenario). CONCLUSIONS: Palivizumab is a cost-effective therapy as prophylaxis against RSV in infants with GA 32-35 and two or more RF. Its use is efficient from the NHS perspective, since the cost of a QALY, even in the least favorable scenarios, is lower than the threshold of 30,000 Euro/QALY considered socially acceptable in Spain.

Antibodies, Monoclonal↗

PubMed2025

Efficacy of Janus kinase inhibitor combined with phototherapy in non-segmental vitiligo: systematic review and meta-analysis.

BACKGROUND: Vitiligo is a chronic autoimmune disease causing skin depigmentation and psychosocial issues. Non-segmental vitiligo often shows limited response to standard therapies. The IFN-γ-JAK-STAT pathway plays a key role, and combining JAK inhibitors with NB-UVB may improve repigmentation. AIM: To evaluate the efficacy of JAK inhibitors (baricitinib or tofacitinib) plus NB-UVB versus NB-UVB without JAK inhibitors in adult NSV. METHODS: PubMed, Cochrane, and ClinicalTrials.gov were searched till August 2024 for randomized controlled trials. Four studies, comprising 217 adults (121 in the combination group and 96 in the control group), were analyzed using RevMan 5.4. Bias was assessed via Newcastle-Ottawa, Cochrane ROB-2, and ROBINS-I tools. RESULTS: Combination therapy significantly reduced total VASI compared to controls (MD = -4.96, 95% CI [-9.29, -0.63], p = 0.02), with a greater effect on sensitivity analysis (MD = -6.84, p = 0.0007). Significant reductions were seen in face/neck (MD = -0.17, p = 0.002), trunk (MD = -3.62, p = 0.0001); acral (MD = -0.85, p = 0.0002) and extremity (MD = -4.61, p < 0.00001) regions after sensitivity analysis. Patients were more likely to achieve ≥50% (RR = 6.87, p < 0.00001) and ≥75% (RR = 15.13, p = 0.006) repigmentation. CONCLUSIONS: JAK inhibitor plus NB-UVB markedly improves the repigmentation in adult NSV compared to NB-UVB alone.

Humans↗

PubMed2000

Cost analysis of antibiotic prophylaxis for PEG.

BACKGROUND: There are conflicting recommendations regarding the prophylactic use of antibiotics in patients undergoing placement of percutaneous endoscopic gastrostomy tubes. The purpose of this decision analysis was to assess the cost-effectiveness of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. METHODS: A decision tree was modeled using the data of 7 published prospective placebo-controlled trials. Infectious complications were classified as grade I (requiring local care), grade II (requiring intravenous antibiotics), or grade III (requiring surgery). Medication costs were estimated from the United States average wholesale prices of the 1998 Red Book. Physician and facility costs were estimated based on the 1998 Medicare costs. A one-way sensitivity analysis was performed by varying the probability rates of the complications associated with percutaneous endoscopic gastrostomy and the costs of their treatment. RESULTS: The average cost of prophylactic antibiotics was $13.10. Antibiotic prophylaxis led to expected cost savings of $76.72 per percutaneous endoscopic gastrostomy. A sensitivity analysis suggested that antibiotic prophylaxis for percutaneous endoscopic gastrostomy was the preferred strategy unless the average probability of grade III complications dropped below an improbably low threshold value of 0.09%. CONCLUSION: Antibiotic prophylaxis in percutaneous endoscopic gastrostomy is a cost-effective strategy.

Antibiotic Prophylaxis↗

PubMed2006

Conflict between datasets and phylogeny of centipedes: an analysis based on seven genes and morphology.

Although the phylogeny of centipedes has found ample agreement based on morphology, recent analyses incorporating molecular data show major conflict at resolving the deepest nodes in the centipede tree. While some genes support the classical (morphological) hypothesis, others suggest an alternative tree in which the relictual order Craterostigmomorpha, restricted to Tasmania and New Zealand, is resolved as the sister group to all other centipedes. We combined all available data including seven genes (totalling more than 8 kb of genetic information) and 153 morphological characters for 24 centipedes, and conducted a sensitivity analysis to evaluate where the conflict resides. Our data showed that the classical hypothesis is obtained primarily when nuclear ribosomal genes exert dominance in the character data matrix (at high gap costs), while the alternative tree is obtained when protein-encoding genes account for most of the cladogram length (at low gap costs). In this particular case, the addition of genetic data does not produce a more stable hypothesis for deep centipede relationships than when analysing certain genes independently, but the overall conflict in the data can be clearly detected via a sensitivity analysis, and support and stability of shallow nodes increase as data are added.

Animals↗

PubMed2003

Management of the second episode of spontaneous pneumothorax: a decision analysis.

BACKGROUND: Optimal management for patients presenting a second episode of spontaneous pneumothorax remains controversial. The aim of this study was to compare two possible treatment strategies, video-assisted thoracic surgery (VATS) and conservative management, in order to assess which of the two was better adapted for the treatment of the second episode of spontaneous pneumothorax. METHODS: The authors propose a decision analytic model including a cost-effectiveness study to compare two clinical strategies: VATS (reference strategy) and conservative management (alternative strategy). Data were obtained from a Medline search for English language articles and cost estimates were derived from the financial and public health departments of our hospital. The model was analyzed to determine the baseline strategy leading to the highest expected effectiveness and the lowest expected cost. RESULTS: Conservative management offered a slight advantage in expected effectiveness value (99.99 vs 99.93 for VATS). VATS produced the lowest expected cost (4347 vs 7536 for conservative management). The incremental cost-effectiveness ratio was 57,750. Within the ranges tested, the sensitivity analysis presented consistent results in terms of effectiveness and advocated conservative management as the best strategy. In terms of cost, with the exception of length of stay, the sensitivity analysis was insensitive in estimating the different probabilities, and favored VATS over conservative management. CONCLUSIONS: In the management of the second episode of spontaneous pneumothorax, VATS offers substantial savings in cost for only a slight decrease in effectiveness, when compared with conservative management.

Cost-Benefit Analysis↗