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At least 1,639 records · Page 91Linked to original sources
PubMed2001

Use of genotypic resistance testing to guide hiv therapy: clinical impact and cost-effectiveness.

BACKGROUND: Genotypic sequencing for drug-resistant strains of HIV can guide the choice of antiretroviral therapy. OBJECTIVE: To assess the cost-effectiveness of genotypic resistance testing for patients acquiring drug resistance through failed treatment (secondary resistance) and those infected with resistant virus (primary resistance). DESIGN: Cost-effectiveness analysis with an HIV simulation model incorporating CD4 cell count and HIV RNA level as predictors of disease progression. DATA SOURCES: Published randomized trials and data from the Multicenter AIDS Cohort Study, the national AIDS Cost and Services Utilization Survey, the Red Book, and an institutional cost-accounting system. TARGET POPULATION: HIV-infected patients in the United States with baseline CD4 counts of 0.250 x 10(9) cells/L. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: Genotypic resistance testing and clinical judgment, compared with clinical judgment alone, in two contexts: after initial treatment failure (secondary resistance testing) and before initiation of antiretroviral therapy (primary resistance testing). OUTCOME MEASURES: Life expectancy, quality-adjusted life expectancy, and cost-effectiveness in dollars per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: Secondary resistance testing increased life expectancy by 3 months, at a cost of $17 900 per QALY gained. The cost-effectiveness of primary resistance testing was $22 300 per QALY gained with a 20% prevalence of primary resistance but increased to $69 000 per QALY gained with 4% prevalence. RESULTS OF SENSITIVITY ANALYSIS: The cost-effectiveness ratio for secondary resistance testing remained under $25 000 per QALY gained, even when effectiveness and cost of testing and antiretroviral therapy, quality-of-life weights, and discount rate were varied. CONCLUSIONS: Genotypic antiretroviral resistance testing following antiretroviral failure is cost-effective. Primary resistance testing also seems to be reasonably cost-effective and will become more so as the prevalence of primary resistance increases.

Anti-HIV Agents↗
PubMed2003

Cost-effectiveness of pap smear screening for vaginal cancer after total hysterectomy for benign disease.

OBJECTIVE: To examine the cost effectiveness of Papanicolaou screening for cancer after total hysterectomy for benign disease. MATERIALS AND METHODS: Decision analysis including Markov modeling applied to women aged 40 or older with a history of total hysterectomy for benign disease. We derived expected discounted costs and life expectancy. RESULTS: Maximum gain in life expectancy between no screening and any screening strategy was approximately 3 weeks. Cost effectiveness in dollars per life-year gained was > or =$143,875 more than no screening for strategies starting at age 50, and over $12 million for aged 40 or more screening strategy. None of the sensitivity analyses caused the incremental cost effectiveness of any strategy to come to less than $100,000 per life year gained compared with no screening. CONCLUSIONS: Despite significant costs for any strategy, Pap smear screening after total hysterectomy for benign disease provides essentially no gain in life expectancy. In absence of risks for genital cancer, such screening is not cost effective.

Journal Article↗
PubMed2000

Watchful waiting with periodic liver biopsy versus immediate empirical therapy for histologically mild chronic hepatitis C. A cost-effectiveness analysis.

BACKGROUND: Not all patients with histologically mild chronic hepatitis C progress to cirrhosis. OBJECTIVE: To compare no antiviral treatment, periodic liver biopsy with subsequent antiviral treatment for moderate hepatitis or cirrhosis, and immediate antiviral therapy. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Clinical trial data and published studies. TARGET POPULATION: Hepatitis C virus-infected patients with histologically mild hepatitis. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: Immediate combination antiviral treatment or biopsy every 3 years plus combination antiviral therapy for moderate hepatitis or cirrhosis. OUTCOME MEASURES: Life expectancy, quality-adjusted life expectancy, and costs. RESULTS OF BASE-CASE ANALYSIS: Over 20 years, biopsy every 3 years with treatment of moderate hepatitis would avoid treatment in 50% of the cohort and would result in an 18% likelihood of cirrhosis compared with 16% for immediate treatment and 27% for no antiviral therapy. Immediate antiviral treatment should increase life expectancy by 1.0 quality-adjusted life-year compared with biopsy management. Over an average lifetime, biopsy management would lead to six liver biopsies costing $6200; immediate antiviral treatment would cost $5100 less than biopsy management because of savings related to biopsy and prevention of future hepatitis C-related morbidity. Immediate therapy was cost-effective compared with biopsy management and had a cost-effectiveness ratio of $7000 compared with no antiviral therapy. RESULTS OF SENSITIVITY ANALYSIS: When age, sex, genotype, and estimates of histologic progression or compliance with follow-up are varied, immediate therapy should result in an increase of at least 0. 8 quality-adjusted life-year compared with biopsy management. CONCLUSION: For histologically mild chronic hepatitis C, initial combination treatment compared with periodic liver biopsy should reduce the future risk for cirrhosis, prolong life, and be cost-effective.

Adult↗
PubMed1996

Prophylactic replacement of Björk-Shiley convexo-concave heart valves: an easy-to-use tool to aid decision-making in individual patients.

OBJECTIVE: To develop an easy-to-use tool for decision-making on prophylactic replacement of Björk-Shiley convexo-concave heart valves. DESIGN: Decision analysis comparing elective replacement with observation. SETTING: Referral centres for patients with artificial heart valves. PATIENTS: Quantitative estimates were obtained from a follow up study conducted in The Netherlands, including 2303 patients with a mean follow up of 6.6 years and from recently published studies. INTERVENTION: Elective valve replacement with a new artificial heart valve. MAIN OUTCOME MEASURE: Loss of life-expectancy. RESULTS: A simple graph was constructed to present the loss of life-expectancy caused by strut fracture for combinations of basal life-expectancy (life-expectancy without strut fracture) and lethal fracture risk (strut fracture risk multiplied by lethality of fracture). This loss can be compared directly with the loss of life-expectancy caused by surgical mortality. This quantitative approach takes into account individual patient characteristics, such as age, gender, cardiac comorbidity, and position of the valve, but the final estimation of surgical mortality also requires clinical judgement. The calculations can be made easily by hand or with a simple computer application. CONCLUSIONS: This decision support tool enables the direct estimation of the gain or loss of life-expectancy that is likely with replacement of a Björk-Shiley convexo-concave heart valve. It can be used to evaluate individual patients as well as groups of patients, and allows for easy incorporation of revisions of fracture risk estimates.

Adult↗
PubMed2003

Cost-utility analysis of preoperative radiotherapy in patients with rectal cancer undergoing total mesorectal excision: a study of the Dutch Colorectal Cancer Group.

PURPOSE: To compare the societal costs and the (quality-adjusted) life expectancy of patients with rectal cancer undergoing total mesorectal excision (TME) with or without short-term preoperative radiotherapy (5 x 5 Gy). PATIENTS AND METHODS: We used a Markov model to project the clinical and economic outcomes of preoperative radiotherapy. Data on local recurrence rates, quality of life, and costs were obtained from the patients of a multicenter randomized clinical trial. In this trial, 1,861 patients with resectable rectal cancer from 108 hospitals were randomly assigned for TME surgery with or without preoperative radiotherapy. Outcome measures of the model were life expectancy, quality-adjusted life expectancy, lifetime costs per patient, and the incremental cost-effectiveness ratio. RESULTS: The base case model estimates that the loss of quality of life due to preoperative radiotherapy is outweighed by the gain in life expectancy. Life expectancy increases by 0.67 years; quality-adjusted life expectancy, by 0.39 years; and costs, by $9,800 per patient. The corresponding cost-effectiveness ratio is $25,100 per quality-adjusted life year. Sensitivity analyses indicate that the cost-effectiveness ratio remains acceptable under a wide range of assumptions. CONCLUSION: Assuming that the reduced local recurrence rate does lead to a survival advantage, the cost-utility analysis estimates that the improved survival outweighs the impaired quality of life and the increased costs. We conclude that short-term preoperative radiotherapy in patients with rectal cancer undergoing TME is both effective and cost-effective.

Adult↗
PubMed1991

Gender differences in health-related quality of life.

In 1986 the life expectancy at birth was 71.3 years for males and 78.3 years for females--providing a 7-year advantage for women. Although women live longer, it has been reported that they paradoxically experience more physical and psychological illnesses. In this article, we estimate the expected well-years or quality-adjusted life years for men and women in the general population. The data were obtained in a random sample of 1,034 residents of San Diego. The well-life expectancy uses standard life expectancies with adjustments for quality of life. The well-life expectancy for men was 59.8 years; for women, it was 62.7 years. Thus, the quality adjustment had significantly more impact on women (15.6 years) than on men (11.5 years). Age-specific estimates of health-related quality of life suggested a male advantage before age 45 and a female advantage after age 45. The benefits of well-years of life as a public health statistic are discussed.

Adult↗
PubMed2003

Biological evidence for limits to the duration of life.

Projections of duration of life for humans based on mathematical models have led some researchers to claim that there is no lower limit to death rates or upper limit to life expectancy, and that a life expectancy of 100 will be achieved in the 21st century. To assess the biological plausibility of these claims, we examined temporal aspects of biological phenomena in three mammalian species. Our examination revealed that: (1) physiological declines associated with reproduction consistently occur at ages that are less than one-third of the median age at death, (2) physiological parameters associated with aging in humans lose eighty percent of their functional capacity by age 80, and (3) young versus old individuals can be distinguished by the pathologies detected at death. The biological evidence suggests that organisms operate under warranty periods that limit the duration of life of individuals and the life expectancy of populations. We use these findings to discuss the issue of limits to the duration of life and the validity of mathematical models used to forecast human longevity.

Age Factors↗
PubMed2006

Cost-effectiveness analysis of computerized tomography in the routine follow-up of patients after primary treatment for Hodgkin's disease.

PURPOSE: To estimate the clinical benefits and cost effectiveness of computed tomography (CT) in the follow-up of patients with complete response (CR) after treatment for Hodgkin's disease (HD). PATIENTS AND METHODS: We developed a decision-analytic model to evaluate follow-up strategies for two hypothetical cohorts of 25-year-old patients with stage I-II or stage III-IV HD, treated with doxorubicin, bleomycin, vinblastine, and dacarbazine-based chemotherapy with or without radiation therapy, respectively. We compared three strategies for observing asymptomatic patients after CR: routine annual CT for 10 years, annual CT for 5 years, or follow-up with non-CT modalities only. We used Markov models to calculate life expectancy, quality-adjusted life expectancy, and lifetime costs. Baseline probabilities, transition probabilities, and utilities were derived from published studies. Cost data were derived from the Medicare fee schedule and medical literature. We performed sensitivity analyses by varying baseline estimates. RESULTS: Annual CT follow-up is associated with minimal survival benefit. With adjustments for quality of life, we found a decrement in quality-adjusted life expectancy for early-stage patients followed with CT compared with non-CT modalities. Sensitivity analyses showed annual CT for 5 years becomes more effective than non-CT follow-up if the specificity of CT is 80% or more or if the disutility associated with a false-positive CT result is less than 0.01 quality-adjusted life years (QALYs). For advanced-stage patients, annual CT for 5 years is associated with a very small quality-adjusted survival gain over non-CT follow-up with an incremental cost-effectiveness ratio of 9,042,300 dollars/QALY. CONCLUSION: Our analysis suggests that routine CT should not be used in the surveillance of asymptomatic patients in CR after treatment for HD.

Adult↗
PubMed2005

[Health and disease in the Netherlands: the Dutch National Public Health Compass as a source of information].

--The Dutch National Public Health Compass has been available on the Internet (www.nationaalkompas.nl) since 2001. This website, developed and managed by the National Institute for Public Health and the Environment, contains data and information on the population's health status, its determinants, prevention and care. The Compass brings together information from various data sources, research and expert opinions. --On the basis of this Compass, an overview has been made of the health of the Dutch population. --Both the life expectancy and the healthy life expectancy in the Netherlands increased after 1980. --Mortality from coronary heart disease, cerebrovascular accidents and lung cancer decreased, but they are still the most important causes of death. --Especially psychological disorders (alcohol dependence, anxiety disorders and depression), coronary heart disease and COPD are associated with a significant decrease in quality of life. --There are important health differences in the Netherlands between rich and poor, urban and rural areas, natives and immigrants. --The difference in life expectancy between men and women will decrease from more than 5 years in 2000 to less than 4 years in 2020. --A permanent facility for the provision of accurate public-health information is of great importance. The collaboration of registration holders and experts in maintaining the Compass is and will remain essential so that an integral overview of the health of the Dutch population can also be made in the future.

Actuarial Analysis↗
PubMedDate not supplied

Cost-effectiveness of repeat medical procedures: kidney transplantation as an example.

The constraints on medical-care resources can give rise to the question of the cost-effectiveness of permitting repeat medical procedures when some patients may die without undergoing even a first procedure. Using kidney transplantation as an example, this study estimates the cost-effectiveness of patients' having available the option of a repeat medical procedure in the event the first procedure fails. Specifically, the analysis examines the effect on transplant candidates of having the option of kidney retransplantation, if and when retransplantation might be needed. Data sources include the U.S. Renal Data System (USRDS) Case-Mix Severity Study, Health Care Financing Administration (HCFA) data, and a MEDLINE search. Outcome measures include life expectancy, quality-adjusted life expectancy, lifetime costs of medical care, and marginal cost-effectiveness from a societal perspective. By avoiding lifelong dialysis after graft failure, first-transplant candidates gain an average of 47 quality-adjusted days with a retransplantation policy, despite the prolongation of time to first transplant by an average of 30 quality-adjusted days. The lifetime cost of medical care per first-transplant candidate is $1,210 higher with a retransplantation policy compared with the no-retransplantation policy; its societal cost-effectiveness is estimated to be $9,656 per quality-adjusted life-year saved. The retransplantation policy provides the greatest improvement in quality-adjusted life expectancy for younger candidates. In the case of kidney transplantation, the cost-effectiveness of a repeat transplant, on average, compares favorably with those of other medical strategies in common practice. As resources become increasingly constrained, this study demonstrates a framework for considering the cost-effectiveness of repeat medical procedures.

Adolescent↗
PubMed2001

The effect of perioperative aspirin therapy in peripheral vascular surgery: a decision analysis.

Patients who undergo infrainguinal revascularization surgery are at increased risk for perioperative thrombotic complications. Aspirin decreases thrombotic events in the nonoperative setting; however, aspirin is often discontinued to avoid perioperative hemorrhagic complications. We used a decision analysis to determine whether aspirin should be discontinued before infrainguinal revascularization surgery. Two strategies were compared: aspirin cessation 2 wk before surgery and aspirin continuation throughout the perioperative period. Clinical events examined included myocardial infarction, thrombotic cerebrovascular accident, hemorrhagic cerebrovascular accident, gastrointestinal hemorrhage, and incisional hemorrhagic complications. Event rates and effect of aspirin were obtained by using MEDLINE. The outcomes were perioperative mortality, life expectancy, and quality-adjusted life expectancy. According to the model, continued aspirin use decreased perioperative mortality rates from 2.78% to 2.05%. Continued aspirin use increased life expectancy from 14.83 to 14.89 yr and increased quality-adjusted life expectancy from 14.72 to 14.79 yr. Aspirin increased the number of hemorrhagic complications by 2.46%, primarily because of an increased incidence of non-life-threatening complications.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2006

Gender and the burden of disease attributable to obesity.

OBJECTIVES: We estimated the burden of disease in the United States attributable to obesity by gender, with life expectancy, quality-adjusted life expectancy, years of life lost annually, and quality-adjusted life years lost annually as outcome measures. METHODS: We obtained burden of disease estimates for adults falling into the following body-mass index categories: normal weight (23 to <25), overweight (25 to <30), and obese (> or = 30). We analyzed the 2000 Medical Expenditure Panel Survey to obtain health-related quality-of-life scores and the 1990-1992 National Health Interview Survey linked to National Death Index data through the end of 1995 for mortality. RESULTS: Overweight men and women lost 270,000 and 1.8 million quality-adjusted life years, respectively, relative to their normal-weight counterparts. Obese men and women lost 1.9 million and 3.4 million quality-adjusted life years, respectively, per year. Much of the burden of disease among overweight and obese women arose from lower health-related quality of life and late life mortality. CONCLUSIONS: Relative to men, women suffer a disproportionate burden of disease attributable to overweight and obesity, mostly because of differences in health-related quality of life.

Adult↗
PubMed1998

The universality of bioenergetic disease. Age-associated cellular bioenergetic degradation and amelioration therapy.

During the present century there has been a dramatic change in life expectancy in advanced societies, now exceeding 80 years. As distinct from life expectancy, life potential is said to be at least 120 years, so that the continuing increase in knowledge has the potential for further major changes in the survival of humans conceivably in the near future. This presentation will be concerned with one aspect of the development of biomedical advances related in part to a concept of an "age-related universality of bioenergetic disease," and its potential amelioration and proposed impact on age-related disease and lifestyle. Aging is a complex biological process associated with a progressive decline in the physiological and biochemical performance of individual tissues and organs, leading to age-associated disease and senescence. Consideration of the progressive accumulation of mitochondrial DNA mutation with age and the tissue/cellular bioenergy decline associated with the aging process has led us to the proposal of a "universality of bioenergetic disease" and the potential for a redox therapy for the condition. This concept envisages that a tissue-bioenergetic decline will be intrinsic to various diseases of the aged and thereby contribute to their pathology, in particular, heart failure, degenerative brain disease, muscle and vascular diseases, as well as other syndromes. The information and concepts embodied in this proposal will be reviewed under the following headings: (1) mitochondrial DNA deletion mutation in some tissue is very extensive and shows mosaicism; (2) age-associated tissue/cellular bioenergy mosaic closely corresponds to the mtDNA profile; (3) cellular bioenergy as a function of mitochondrial bioenergy, glycolysis, and plasma membrane oxidoreductase; (4) redox therapy for the reenergization of cells, tissues, and whole organs. A redox therapy based on coenzyme Q10 has demonstrated profound alteration in heart function of old rats; no significant effect was observed with young rats.

Aged↗
PubMed1994

Angiographic screening and elective surgery of familial cerebral aneurysms: a decision analysis.

Up to 6% of cerebral aneurysms may be familial. Because the pattern of inheritance and the prevalence of aneurysms within families are unknown, the management of family members at risk of harboring a cerebral aneurysm is currently empirical. We established the prevalence of aneurysms in the second generation of individuals with familial cerebral aneurysms and determined the possible benefit of angiographic screening and elective surgery of such individuals by using a simple decision analysis model. Four consecutive families were identified in whom the mother and a child had a ruptured cerebral aneurysm. A total of 19 siblings at risk in the second generation were identified. Fifteen underwent elective cerebral angiography: one had a cerebral aneurysm and two had an infundibulum at the origin of the posterior communicating artery. Including the previously known aneurysms, the prevalence of aneurysms in the second generation was thus established at 29.4%. A decision analysis was performed with 2% as the annual risk of rupture, 72.7% as the risk of death or disability with rupture, 0.1% as the risk of angiography, and 6.5% as the risk of surgery. The benefit in years of survival free of sequelae resulting from angiographic screening and elective surgery (intervention) over natural history was computed for life expectancy corresponding to each quinquennial age group from age 15 to 100 years. Intervention equaled natural history, in terms of years of survival expected with each choice, at a life expectancy of 10.6 years, corresponding to age 76.5 years for men and 80 years for women, and produced a net gain of at least 1 year for patients whose life expectancy was 32 years or more, corresponding to age 53.5 years for women and 49 years for men. Greater benefit was achieved with increasing life expectancy (younger age). The prevalence of aneurysms in the second generation when a mother and child have an aneurysm is 29.4%. Intervention produces a benefit of at least 1 year of survival free of sequelae over natural history in such individuals if their life expectancy is 32 years or more.

Adolescent↗
PubMed1991

Results of two methods to determine health expectancy in The Netherlands in 1981-1985.

Health expectancy is a measure providing summarizing information on mortality on one hand and morbidity and/or disability on the other hand. In this article health expectancy is determined with two approaches: method 1 leads to life expectancy free of disability at birth and at other ages; method 2 leads to life expectancy in good health. Results of the various calculations show that according to method 1 life expectancy free of disability at birth for men in the Netherlands was 58.8 years and for women 57.3 years (based on data from the period 1981-1985). Results of method 2 are different from method 1; life expectancy in good health for men was 58.9 years and for women 60.7 years. Results of both methods are compared with studies which have been carried out in other countries. The comparison shows that method 1 leads to results which deviate from the other studies while results of method 2 are to a large extent similar to the other studies. Reasons are given which explain why the results of method 1 deviate from the other studies. In spite of the fact that the two methods lead to different outcomes, the conclusion is drawn that the difference in health expectancy between men and women is much smaller than the difference in total life expectancy between men and women. The difference in total life expectancy by sex in the period 1981-1985 was 6.7 years.

Adolescent↗
PubMed1986

[Impact of alcoholism mortality on the entire population and on the active French population].

Starting from the estimation of alcohol assigned deaths in the different causes of death of the CIM, 8th revision, the impact of alcoholism on the active and total french populations is measured using two demographic indices, life expectancy and active life expectancy, and the data of the year 1978. This impact is the same as accidents' one; for men it is more than double of the result obtained when "Alcoholic psychosis and alcoholism" and "Cirrhosis" causes of death are considered alone.

Alcoholism↗
PubMedDate not supplied

Mortality comparisons of First Nations to all other Manitobans: a provincial population-based look at health inequalities by region and gender.

BACKGROUND: To examine inequalities in health status of Registered First Nations Manitobans compared to all other Manitobans. METHODS: Three mortality indicators--premature mortality rate (PMR) defined as an age- and sex-adjusted rate of death before age 75 years; life expectancy from birth; and potential years of life lost (PYLL)--are compared between Registered First Nations (RFN) people and all other Manitobans (AOM) by geographical areas of Manitoba. Data were derived from the Population Health Research Data Repository, linked to the federal Status Verification System (SVS) files for the years 1995 through 1999. RESULTS: First Nations experienced double the PMR compared to all other Manitobans (6.6 versus 3.3 deaths per thousand, p < 0.05), an eight-year gap in life expectancy (males: 68.4 versus 76.1 years; females 73.2 versus 81.4 years), and over twice the PYLL (males 158.3 versus 62.5 years of life lost per thousand; females 103.3 versus 36.5). RFN male life expectancy was geographically-related (better health status in the north), and inversely related to the corresponding regional AOM life expectancy (r = -0.61, 9 df, one-tailed, p < 0.03). As regional percentage of RFN decreased, male life expectancy decreased (r = 0.77, 9 df, one-tailed, p < 0.003). In contrast, RFN female indicators showed no such relationship. CONCLUSION: The inequality in health status between RFN and all other Manitobans is large, but also shows differential geographical and gender effects.

Female↗
PubMed1996

Hormone replacement therapy.

More than 40 million women in the United States are now going through or are past menopause. Another 3.5 million or more will reach midlife in the next decade. As their life expectancy increases (mean life expectancy of women is now approximately 84 years), so does the need for therapeutic regimens related to reproductive function and aging in woman. Few medical treatments available to menopausal and postmenopausal women have as much potential benefit as well as possible health risks as hormone replacement therapy (HRT). Despite the increasing amount of scientific data available regarding the benefits of HRT, a degree of uncertainty still remains, both in the minds of some women, and with some health professionals, regarding the risks associated with long-term therapy. Even though the literature is voluminous, contradictory, and unclear, health providers must be able to keep abreast of current knowledge about the benefits, risks, and unknowns of these drugs. The purpose of this article is to provide a review and an update on the types of hormones available for HRT, their pharmacology and pharmacokinetics, and their risks, benefits, and contraindications. Newer products, specially compounded formulas, new regimens, and new modes of delivery that offer women alternatives and allow care to be individualized are described. In addition, some of the ongoing management dilemmas that practitioners face with the woman who chooses HRT are presented with practical solutions and suggestions.

Contraindications↗