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PubMed1984

[A retrospective study of duration of illness in a group of nursing home patients with a dementia syndrome].

In this study 127 patients with dementia were investigated, with known age of onset (mean age: 75.6 years), who died between 1979 and 1983 in a psychogeriatric nursing home. The mean period between onset of illness and admission into the nursing home was 4.8 years, while the mean total duration of illness was 7.7 years. These data were compared with the mean life expectancy of the Dutch population (CBS, Life tables of the population of the Netherlands by sex and age). There appeared to be little difference between the survival time from onset of illness and the mean expected life span, controlled for age and sex. After admission however, there was a 53% reduction of life expectancy. Life expectancy from both age at onset and age on admission, was better for women and the eldest patients.

Aged↗
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↗
PubMed2004

Use of frozen semen to avoid human immunodeficiency virus type 1 transmission by donor insemination: a cost-effectiveness analysis.

OBJECTIVE: Reappraisal of current guidelines mandating frozen-thawed semen. DESIGN: Cost-effectiveness analysis comparing the use of frozen semen with the use of fresh semen from the same donors without a second antibody test. SETTING: A Markov model computer simulation. PATIENT(S): A theoretical cohort of 80000 women whose husbands are azoospermic. INTERVENTION(S): Simulation with calculation of costs and payoffs. MAIN OUTCOME MEASURE(S): Total lifetime direct health care costs, costs per live birth, life expectancy, quality adjusted life years (QALY), marginal cost effectiveness (dollar/QALY). RESULT(S): If all 80000 women who undergo donor insemination in the United States each year chose to use fresh semen from donors screened according to the current practice guidelines but without semen cryopreservation, there would be 8881 more births and the mean cost per live birth would be US dollars 15501 less. One recipient would become infected with HIV-1 every 5.1 years, during which time over 180000 noninfected children would be born. The average life expectancy of recipients would be reduced by 2 days, but their quality-adjusted life expectancy would increase by over 1 month. Medicolegal costs to physicians would need to exceed US dollars 780 million per infection to equalize the cost effectiveness of the fresh and frozen policies. CONCLUSION(S): The guidelines should be revised to allow the use of fresh semen by informed recipients.

Adult↗
PubMed1996

How older patients' treatment preferences are influenced by disclosures about therapeutic uncertainty: surgery versus expectant management for localized prostate cancer.

OBJECTIVES: There is an ongoing debate about the proper management of localized prostate cancer in older men. We assessed whether older patients differ in their willingness to accept surgery versus expectant management for a hypothetical early stage, low grade, clinically localized prostate carcinoma, and whether patients' current levels or past history of urologic dysfunction (difficulties initiating urination, failing to empty the bladder, urinary dribbling, getting up at night to urinate, and frequency of sexual activity) influence their decisions. We assessed patients' willingness to choose surgery over expectant management by varying the expected survival benefit in years (ESBs-em) of surgery over expectant management. DESIGN: Structured interviews with a consecutive series of male patients. SETTING: A university-based Department of Veterans Affairs Medical Center. PATIENTS: One hundred forty-eight patients seen consecutively in General Medicine Clinic at the Department of Veterans Affairs Medical Center in Portland, Oregon, were enrolled in the study. Mean age of the patients was 66.3 years (SD = 10.3, range = 30-85); mean level of formal education was 12.6 years (SD = 2.7, range = 6-22). MEASUREMENTS: Patients were asked whether they would accept surgery or expectant management in one of 11 treatment comparisons. We varied the ESBs-em in 1-year increments from 0 years to 10 years. As described to patients, surgery carried a mortality risk at the time of treatment of 1 to 2%. Once any patient indicated a willingness to accept surgery at any of the treatment comparisons or if any patient reported preferring expectant management across all treatment comparisons, the elicitation procedure was stopped. All patients were asked to complete a urological and sexual functioning questionnaire to determine the presence of coexisting urological dysfunction and level of sexual activity both at present and in the past. RESULTS: Of the 148 patients enrolled in the study, 43.2% (64/148) preferred surgery with a zero expected life benefit over expectant management (ESBs-em = 0) and a 1 to 2% chance of dying within 1 month of surgery; 24.3% (36/148) rejected surgery as the expected life benefit of surgery was increased (0 < ESBs-em < or = 10 years); 26.4% (39/148) preferred expectant management even when there was a 10-year expected life benefit of surgery; 4.7% (7/148) preferred that their physician make the decision for them; and 1.4% (2/148) of patients reported that they preferred radiation therapy, an option that was not offered to them explicitly. Our results suggest that older patients are more likely to report a preference for expectant management (OR = 1.07). Further, our results suggest that patients who report current urinary dribbling (OR = 9.03) are much more likely to prefer expectant management but that this preference decreases with the amount of time they have had this problem. Similarly, we find that patients who have difficulty with starting urination are much more likely to prefer surgery (OR = 0.13), and this preference is also mediated by the number of years they have experienced this problem. Treatment choice was not associated with formal education, present health status, or the other urological symptoms we assessed. CONCLUSION: Our study in an older male veteran population showed preferences for a variety of options in prostate cancer. Although the majority of men preferred surgery, a significant number preferred expectant management. Our results show that preferences reflect patients' experiences with physical problems associated with disease and that these experiences need to be explored and considered by patients and their providers when making treatment decisions.

Adult↗
PubMed1997

Health expectancy calculations: a novel approach to studying population health in Bulgaria.

The measurement of life expectancy in terms of either good or poor health is a novel approach to studying the health of the population in Bulgaria. The pilot study reported here-carried out among people aged > or = 60 years in a middle-sized Bulgarian town-was designed to obtain information on the years of functional restrictions expected among the elderly. In accordance with the answers to a series of questions (recommended by WHO), subjects were categorized as disabled, handicapped, or having different states of perceived health. The indicators "disability-free life expectancy", "handicap-free life expectancy" and "healthy life expectancy" (based on self-perceived health) were calculated according to Sullivan's method. The results show, for example, that 8.0 of the 16.0 years that men aged 60 years may expect to live, on average, will be free of disability. For men aged 80 years the figures are 1.3 of 5.5 years. For women at 60 years and 80 years the results are 7.3 and 0.5 disability-free years of 19.2 and 7.3 expected life years, respectively. Similar results were found for handicap-free life expectancies and healthy life expectancies. At all ages, the proportion of life in a condition free of disability, free of handicap, or in perceived good health is substantially lower for women than for men. Women may expect to live longer, but a greater proportion of their life will be spent in poor health. The approach presented here for measuring the health status of the elderly may be helpful as an aid to planning medical and social care and for the development of public health policies.

Aged↗
PubMed2005

The income-associated burden of disease in the United States.

In this study, we estimate the total burden of disease associated with income in the US. We calculate the relationships between income and life expectancy, health-adjusted life expectancy, annual years of life lost (YLLs), and health adjusted life years (HALYs). We used the 2000 US Medical Expenditure Panel Survey to derive quality of life estimates by income and age, the 1990-1992 US National Health Interview Survey linked to National Death Index data through the end of 1995 to derive mortality risks by income and by age, and 2000 US mortality data from the National Center for Health Statistics to derive current mortality estimates for the US population by age-group. The bottom 80% of adult income earners' life expectancy is 4.3 years and 5.8 HALYs shorter relative to those in the top 20% of earnings. This translates into the loss of 11 million YLLs and 17.4 million HALYs each year. Compared with persons living above the poverty threshold, those living below the poverty threshold live an average of 3.2 million fewer HALYs per year-a difference of 8.5 HALYs per individual between age 18 and death. The income-associated burden of disease appears to be a leading cause of morbidity and mortality in the US.

Adolescent↗
PubMed1996

Disability as a public health outcome in the aging population.

Improvements in life expectancy in the twentieth century have resulted from major declines in mortality at younger ages, but it is less well recognized that mortality declines at older ages have also played a substantial role in prolonging expectation of life. A person reaching age 65 in 1900 could expect to live an additional 11.9 years. Life expectancy at age 65 rose to 14.4 years by 1960 and then increased by about three years in the next three decades, reaching 17.5 years in 1992 (56, 70). As a greater proportion of the population survives to very old ages, the public health impact of the burden of disease and disability and related utilization of medical care and need for supportive and long-term care has become an important concern. In particular, the ability of the older person to function independently in the community is a critically important public health issue. A growing body of research in the last decade has addressed the measurement of disability, factors related to its onset, consequences of disability, and the potential for preventive interventions. This article summarizes the state of the art in these areas and discusses their public health relevance.

Activities of Daily Living↗
PubMed1994

[Do hormones determine our fate?].

The hormonal system is a communication system between cells and organs. Hence it is not surprising that it influences almost all physiological functions and, at least partially, our behaviour and fate. The sexual phenotype is determined by the sex hormones. Normally, the phenotype is in accordance with gonadal and genetic sex, but occasionally, as a consequence of enzymatic defects in the biosynthesis of sex hormones or of androgen resistance, gonadal and genetic sex are in discordance with the phenotype, the latter determining generally the civil sex and the sex of rearing. Whereas the gender role is generally determined by the sex of rearing and the phenotype, itself under hormonal influence, homo- and transsexuality constitute notorious exceptions to this rule. Although several authors consider homo- and transsexuality to be the consequence of an impairment in androgenic impregnation in the perinatal period, there are at present no convincing arguments for an hormonal origin for either homo- or transsexuality, although such a possibility can't be excluded either. Besides their role in psychosexual behaviour, sex hormones play also a role in our life expectancy. Indeed, although maximal life expectancy of man is genetically determined, a major determinant of individual life expectancy is cardiovascular pathology. The latter is partly responsible for the difference in life expectancy between men and women, cardiovascular mortality increasing rapidly at menopause and being halved by oestrogen replacement therapy. Also atherogenesis as such is, to a large extend, under hormonal control. Indeed insulin resistance and hyperinsulinism, which develop as a corollary of the aging process, is an important cause of atherosclerosis as well as of hypertension. Other hormones also play an important role in our behaviour. We can mention here the role of the thyroid hormones in the physical and mental development of children as well as in the regression of the intellectual functions in hypothyroidism; the role of growth (and sex) hormones in the clinical symptomatology of aging; the memory enhancing effects of the antidiuretic hormone; the role of growth factors (as well as of sex hormones) in tumorigenesis; the role of corticoids (and sex hormones) in the modulation of immunological processes etc. In brief, hormones influence all aspects of our life.

Aging↗
PubMed2004

Cost-effectiveness of positron emission tomography for non-small cell lung carcinoma in Canada.

BACKGROUND: Several studies over the past decade have demonstrated that 2-fluoro-2-D-[18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is more accurate than computed tomography (CT) for the staging of non-small cell lung carcinoma (NSCLC). This study uses quantitative decision tree modeling and sensitivity analysis to assess the cost-effectiveness of both a CT- and a CT+PET-based management strategy for staging NSCLC in Canada. Both management costs and life expectancy are determined. MATERIAL/METHODS: Two patient management scenarios were compared--one using CT alone and one using both CT and PET. A survey of recent literature was used to construct a meta-analysis of available studies for the accuracies of CT and PET in staging NSCLC. Life expectancies were determined from recent Canadian statistics, and expected life expectancies with disease were calculated from knowledge of published survival rates. Management costs were determined from: estimates of the installation cost of PET facilities in Canada; management costs from our institutions; and recently published Canadian cost estimates of various procedures. RESULTS: A cost savings of 1455 Canadian dollars per person is expected for the CT+PET strategy, along with an increase in life expectancy (3.1 days), when compared with the CT alone strategy. This cost savings remained in favour of the CT+PET strategy when subjected to a rigorous sensitivity analysis. CONCLUSIONS: PET may be a cost effective means of staging NSCLC in Canada.

Carcinoma, Non-Small-Cell Lung↗
PubMed1994

Screening for prostate cancer. A decision analytic view.

OBJECTIVE: To determine the clinical and economic effects of screening for prostate cancer with prostate-specific antigen (PSA), transrectal ultrasound (TRUS), and digital rectal examination (DRE). DESIGN: Decision analytic cost-utility analysis comparing four screening strategies with a strategy of not screening. We assumed that the cancer detection rate and stage distribution were predicted by each combination of tests and that localized cancer was treated with radical prostatectomy. For each strategy, we calculated life expectancy, quality-adjusted life expectancy (QALE), and cost-utility ratios for unselected and high-prevalence populations. DATA: Probabilities and rates for clinical events were gathered from published data. We assessed utilities by the time-trade-off method using urologists, radiation oncologists, and internists as subjects. The Clinical Cost Manager at the New England Medical Center provided cost data. RESULTS: In unselected men between the ages of 50 and 70 years, screening with PSA or TRUS prolonged unadjusted life expectancy but diminished QALE. Screening with DRE alone yielded no reduction in mortality at any age. All programs increased costs. Results were sensitive only to assumptions about the efficacy of treatment. In high-prevalence populations, screening produced a similar pattern: gains in unadjusted life expectancy, losses in QALE, and increased costs. CONCLUSIONS: Our analysis does not support using PSA, TRUS, or DRE to screen asymptomatic men for prostatic cancer. Screening may result in poorer health outcomes and will increase costs dramatically. Assessment of comorbidity, risk attitude, and valuation of sexual function may identify individuals who will benefit from screening, but selecting high-prevalence populations will not improve the benefit of screening.

Aged↗
PubMed2004

Willingness of patients to switch from conventional to daily hemodialysis: looking before we leap.

PURPOSE: To evaluate the willingness of patients with end-stage renal disease to switch from conventional hemodialysis to short daily hemodialysis, and to determine what health benefits clinical trials of daily hemodialysis would have to document for patients to switch regimens. METHODS: We studied all patients receiving conventional hemodialysis (defined as three times per week) at three dialysis centers in Philadelphia during a 4-month period. Patients indicated their willingness to switch to daily hemodialysis (defined as six 2- to 3-hour in-center treatments per week) in each of 21 scenarios presented via an interactive computer display. We used conjoint analysis to determine how patients' decisions were influenced by four attributes of daily hemodialysis: predicted life expectancy, quality of life, number of annual hospitalizations, and weekly transportation time to and from the dialysis center. RESULTS: Of 126 patients interviewed, 55 (44%) would not choose daily hemodialysis regardless of its health benefits. The remaining 71 patients (56%) indicated that they would consider switching if daily hemodialysis was shown to yield certain health benefits. Patients were more willing to switch to daily hemodialysis as the associated life expectancy and average quality of life increased, and as the number of annual hospitalizations and weekly transportation time decreased (all P <0.001). CONCLUSION: Although daily hemodialysis has received broad support from nephrologists, funding agencies, and lawmakers as the emerging standard of care for patients with end-stage renal disease, upcoming clinical trials would have to document substantial health benefits in order for patients to switch to daily hemodialysis, and many patients may still decline this regimen regardless of the documented benefits.

Adult↗
PubMed1997

Prognostic factors in idiopathic (primary) osteomyelofibrosis.

BACKGROUND: Prognostic variables for idiopathic (primary) osteomyelofibrosis (IMF) are ill-defined because of the lack of large control studies based on uniform diagnostic criteria. METHODS: A retrospective clinicopathologic study was performed on 250 consecutively recruited patients (115 males and 135 females) with an established diagnosis of IMF. In contrast to previous studies, the current study cohort encompassed the full spectrum of initial to advanced stages of the disease process according to laboratory data and particularly histology. Because of the relatively high patient age on admission (median, 66.5 years), relative survival rates with corresponding life expectancies and disease specific life loss were calculated. Moreover, a classification and regression tree (CART) analysis was performed to segregate the study patients into subgroups with significantly different prognosis. RESULTS: Analysis of the life expectancy and the proportion of deaths attributable to IMF showed a global reduction in life expectancy of 31%. Further calculation disclosed a consistently greater impact of disease in older patients. Age, hemoglobin level on admission, and leukocyte and thrombocyte counts remained as the most relevant parameters for prognosis in multivariate consideration (CART analysis) and facilitated a clear-cut separation into three risk groups. The life expectancy of low risk patients was approximately 10 times higher than that of high risk patients (22.07 years vs. 2.25 years). CONCLUSIONS: These results are in keeping with the assumption that features signaling bone marrow insufficiency are associated with a worsening of survival. Generalization, indicated by myeloid metaplasia, can occur at every stage, even in so-called hypercellular phases of IMF. Conversely, myelofibrosis alone is not necessarily predictive of poor survival.

Analysis of Variance↗
PubMed1996

Decision tree sensitivity analysis for cost-effectiveness of FDG-PET in the staging and management of non-small-cell lung carcinoma.

UNLABELLED: Preliminary studies have shown that PET is more accurate than CT for the staging of non-small-cell lung carcinoma (NSCLC). However, the potential effect of PET on the management of these patients and its cost-effectiveness has not been rigorously studied. Thus, we have used decision tree sensitivity analysis to assess the cost-effectiveness of a PET based strategy for staging of NSCLC. METHODS: Two decision strategies for selection of potential surgical candidates were compared; thoracic CT alone or thoracic CT and thoracic PET. The first decision tree was conservatively constructed by requiring mediastinoscopy (biopsy) to confirm imaging results so that no patient with surgically curable disease would miss the opportunity for surgery in either strategy. A second less conservative tree in which only nonconcordant results are biopsied was also tested. The various paths of each strategy are dependent on numerous parameters which were determined from a review of the medical literature. Life expectancy was calculated using the declining exponential approximation of life expectancy and reduced based on procedural mortality. Costs were based on mean costs at our institution. For all possible outcomes of each strategy, the expected cost and projected life expectancy were determined. The effect of changing one or more parameters on the expected cost and life expectancy were studied using a sensitivity analysis. RESULTS: The CT + PET strategy in the conservative decision tree showed a saving of $1154 per patient without a loss of life expectancy (increase of 2.96 days) as compared to the alternate strategy of CT alone. Both these effects were the result of improved staging of lung carcinoma prior to the decision for surgery. The CT + PET strategy in the less conservative decision tree showed a savings of $2267 per patient but misses 1.7% of potentially operable patients. CONCLUSION: These results show through rigorous decision tree analysis, the potential cost-effectiveness of using FDG PET in the management of NSCLC. These results form a basis for detailed study of the results obtained from multicenter trials on the accuracy of PET in NSCLC management. Furthermore, the techniques utilized for decision tree analysis have broad range of applicability to the entire field of nuclear medicine.

Carcinoma, Non-Small-Cell Lung↗
PubMed1999

Laparotomy versus no laparotomy in the management of early-stage, favorable-prognosis Hodgkin's disease: a decision analysis.

PURPOSE: To perform a decision analysis that compared the life expectancy and quality-adjusted life expectancy of early-stage, favorable-prognosis Hodgkin's disease (HD) managed with and without staging laparotomy, incorporating data on treatment outcomes of HD in the modern era. METHODS: We constructed a decision-analytic model to compare laparotomy versus no laparotomy staging for a hypothetical cohort of 25-year-old patients with clinical stages I and II, favorable-prognosis HD. Markov models were used to simulate the lifetime clinical course of patients, whose prognosis depended on the true pathologic stage and initial treatment. The baseline probability estimates used in the model were derived from results of published studies. Quality-of-life adjustments for procedures and treatments, as well as the various long-term health states, were incorporated. RESULTS: The life expectancy was 36.67 years for the laparotomy strategy and 35.92 years for no laparotomy, yielding a net expected benefit of 0.75 years for laparotomy staging. The corresponding quality-adjusted life expectancies for the two strategies were 35.97 and 35.38 quality-adjusted life years (QALYs), respectively, resulting in a net expected benefit of laparotomy staging of 0.59 QALYs. Sensitivity analysis showed that the decision of laparotomy versus no laparotomy was most heavily influenced by the quality-of-life weight assigned to the postlaparotomy state. CONCLUSION: Our model predicted that on average, for a 25-year-old patient, proceeding with staging laparotomy resulted in a gain in life expectancy of 9 months, or 7 quality-adjusted months. These results suggest that a role remains for surgical staging in the management of early-stage HD.

Adult↗
PubMed1998

Counting and discounting gained life-years.

The life expectancy gain produced by a reduction in mortality can be determined by three different methods with respect to the timing of the gained life-years. One method adds the life expectancy gain to the expected end of life. Another method places the gain at the time of occurrence of the mortality reduction. A third method distributes the gained life-years over the maximum lifespan according to the differences in survival probabilities after and before the reduction in mortality. The three methods are all used in the literature together with a quasi-deterministic and a probabilistic approach to the notion of life expectancy. The counted numbers of gained life-years are the same, but due to different timing of life expectancy gains the discounted numbers are different. Several discounting models are identified when combining the three methods of counting with the deterministic and the probabilistic approaches to life expectancy. Some are symmetrical, some are not. However, most importantly, they come out with potentially very large differences in the discounted number of gained life-years. They differ by a factor of approximately (1 + r)e(a)-1, where r is a constant discount rate and e(a) is remaining life expectancy at age a, when the reduction of mortality occurs. For a new-born, discounting at 7% p.a., one discounting model provides a present value that is 150 times larger than another discounting model, the other models being in between. The various counting and discounting models for life expectancy gains are presented formally, graphically, and with numerical examples using Danish male mortality data. We show how three different discounting models provide large differences in discounted life expectancy gains and hence cost-effectiveness ratios in an economic evaluation of a colorectal cancer screening programme in Denmark. These different discounting models co-exist in the evaluation literature. Choice of method is rarely made explicit. Sensitivity analysis with respect to this choice is even rarer. We argue that one counting-discounting model is sufficient and that this should be to discount the differences between the two survival probability curves.

Adult↗
PubMed2004

The total lifetime costs of smoking.

BACKGROUND: Net costs of smoking in a lifetime perspective and, hence, the economic interests in antismoking policies have been questioned. It has been proposed that the health-related costs of smoking are balanced by smaller expenditure due to shorter life expectancy. METHOD: A dynamic (life cycle) method taking differences in life expectancy into account. Main outcome measures were direct and indirect lifetime health costs for ever-smokers and never-smokers, and cost ratios (ever-smokers to never-smokers). The estimations were based on annual disease rates of use of the healthcare services, smoking relative risks, smoking prevalences, and costs. RESULTS: Annual direct and indirect costs of ever-smokers were higher than for never-smokers in all age groups of both genders. The direct and indirect cost ratios were highest at age 45 for women, and at age 35 and 40 for men, respectively. Taking life expectancy differences into account, direct and indirect lifetime health costs for men aged 35, discounted by 5% per year were 66% and 83% higher in ever-smokers than in never-smokers. Corresponding results for women were 74% and 79%, respectively. The results are insensitive to a broad range of relative risk-estimates and discount rates including no discounting. Excess costs of ever-smokers disappear if the inclusion of smoking-related diseases is narrowed to that of previous studies. CONCLUSION: Smoking imposes costs to society even when taking life expectancy into consideration--both in direct and indirect costs.

Adult↗
PubMed1999

Heart failure treatments: issues of safety versus issues of quality of life.

Congestive heart failure is an important cause of morbidity and mortality in western countries. The profound impact that congestive heart failure has on life expectancy and quality of life has been a continuous stimulus for the development of new drugs for the treatment of this condition. Despite favourable effects on (aspects of) quality of life in short term studies, several of these new agents have been shown to reduce survival in mortality trials. However, patients with severe congestive heart failure may experience such incapacitating symptoms that the question should be raised as to whether an improvement in quality of life makes the increased risk of mortality associated with these new agents acceptable. Drugs which improve quality of life at the expense of an increased risk of mortality can be of value in the treatment of patients with severe congestive heart failure. However, this is only the case if the probability of improvement in quality of life and prolongation of life expectancy for those using the drug exceeds the probability of improvement in quality of life and prolongation of life expectancy for those not using the drug. Unfortunately, most clinical trials in which both mortality and quality of life are evaluated fail to provide information on this composite probability. Despite disappointing results of some recent mortality trials on new pharmacological treatments of congestive heart failure, sound and well designed clinical trials on innovative heart failure treatments in which these composite probabilities are also assessed should be carried out.

Heart Failure↗
PubMed2000

Cost-effectiveness of combination therapy for naive patients with chronic hepatitis C.

BACKGROUND/AIMS: The higher initial cost of combination therapy is a factor which may discourage its use in naive patients with histologically mild or moderate chronic hepatitis C. However, chronic hepatitis C is a slowly progressive disease associated with a decrease in life expectancy and quality of life. The objective of this study was to determine if the incremental sustained response rate of combination therapy is sufficient to outweigh its extra cost. METHODS: Chronic hepatitis C progression was studied using a Markov model in which cohorts of patients were treated with combination therapy for 6-12 months or with interferon for 12 months. The sustained virological response rates applied were 43, 35 and 19%, respectively, for combination therapy for 12 months, for 6 months and for interferon for 12 months. Costs for each clinical state were calculated according to clinical practice in Spain. RESULTS: In a 30-year-old patient with moderate chronic hepatitis C, combination therapy for 12 months increases life expectancy by 4.1 years compared with interferon for 12 months. In mild disease, the increase in life expectancy is lower. The cost per life-year saved in patients with chronic hepatitis C ranges from 880 to 64.421 euros depending on the age of the patient, the degree of hepatic lesion and the type and duration of therapy. Compared to other treatments accepted as standard practice in other therapeutic areas, combination therapy for chronic hepatitis C is cost-effective. CONCLUSIONS: In patients of any age with moderate chronic hepatitis C and those with mild disease under 50 years of age, combination therapy for 12 months is the most cost-effective schedule, whereas in older patients with mild hepatitis, combination therapy for 6 months is the preferred option based on cost-effectiveness criteria.

Adult↗