Improving the organization of consultation departments in university hospitals.

RATIONALE: Changes in the demography of doctors require changes in care practices. OBJECTIVES: The aim of this study was to identify factors associated with doctors' workload in the ophthalmology consultation department of a university hospital, with a view to developing methods to improve the organization of hospital outpatient clinics. METHODS: A 10-day cross-sectional survey was carried out in an ophthalmology outpatient clinic (in- and outpatient consultations, including emergencies) specializing in the uveitis care. Demographic and management data for each patient were collected on a structured form. The doctor's workload was assessed, using a scale taking into account the duration of the consultation and the number of diagnostic tests performed, as a function of management complexity. RESULTS: Of the 861 consultations studied, 39.7% were highly complex. The level of complexity of consultations was correlated with the type of referral (phi = 0.602), consultation duration (phi = 0.545), the number of consultations in the previous year (phi = 0.499), and the number of diagnostic tests performed (phi = 0.445). Consultations were longer and diagnostic tests were more frequently performed if patients had been referred by an ophthalmologist, consulted a faculty doctor or a fellow, or presented with uveitis. Consultations were also more complex for patients with at least four previous consultations in the past year. CONCLUSIONS: Type of referral, status of the attending doctor and number of consultations within the course of 1 year were associated with doctors' workload and could be taken into account to predict the duration of complexity of consultations when scheduling appointments.

Parathyroidectomy versus cinacalcet hydrochloride-based medical therapy in the management of hyperparathyroidism in ESRD: a cost utility analysis.

BACKGROUND: Previously, patients with end-stage renal disease (ESRD) with uncontrolled hyperparathyroidism had few options other than parathyroidectomy, which was reserved for patients refractory to medical therapy. Newer calcimimetic agents, such as cinacalcet, may be an alternative, but raise the possibility of indefinite medical treatment that also would increase costs. STUDY DESIGN: Cost utility analysis. SETTING & POPULATION: Base case consisted of prevalent adult US patients with ESRD refractory to management with standard medical therapy. Characteristics were obtained from patients who underwent parathyroidectomy in 2001, and, for purposes of comparison, patients in whom cinacalcet was used were assigned similar characteristics. All data came from preexisting literature and trials or from US Renal Data System analysis files. INTERVENTION: Use of cinacalcet hydrochloride versus parathyroidectomy. PERSPECTIVE & TIME FRAME: Medicare and societal costs and quality-adjusted life-years from the date of parathyroidectomy or use of cinacalcet followed up for 2 years, respectively. MODEL & OUTCOMES: Primary outcomes were cost (measured in US dollars) and cost utility measured using cost per quality-adjusted life-years. RESULTS: At base-case surgical and drug costs, surgical and drug success rates, complication rates/costs, and benefit from correction of hyperparathyroidism, parathyroidectomy was found to be both less expensive and more cost-effective at 7.25 +/- 0.25 months. Parathyroidectomy became more cost-effective at 15.28 to 16.32 months at the upper limit of sensitivity analysis, when drug/surgical costs and success/complication rates/costs were maximally weighted to favor cinacalcet-based medical therapy. LIMITATIONS: We assumed current costs of both cinacalcet and parathyroidectomy and assumed cinacalcet use would be indefinite. CONCLUSIONS: For patients with ESRD with uncontrolled hyperparathyroidism who are good candidates for either drug therapy or surgery, cinacalcet hydrochloride is the most cost-effective modality if the patient is to remain on dialysis therapy for 7.25 +/- 0.25 months. Cinacalcet may be more optimal if used in patients who have high risk of mortality or who would expect to receive a kidney transplant quickly. For other subgroups, parathyroidectomy dominated.

Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis.

OBJECTIVES: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. DESIGN: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. METHODS: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (2002 Euro) discounted at 3% yearly were estimated from the health care system perspective. RESULTS: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of 2688 Euro/QALY versus BNES and VAPS of 17,250 Euro/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. CONCLUSIONS: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.

Radioiodine or surgery for toxic thyroid adenoma: dissecting an important decision. A cost-effectiveness analysis.

OBJECTIVE: To examine the cost effectiveness of therapeutic strategies for toxic thyroid adenoma. DESIGN: Markov state transition decision analytic model. SETTING: Ambulatory and inpatient. PATIENTS: Hypothetical cohort of 40- year-old women with toxic thyroid adenomas. Patient age was varied in sensitivity analyses. Data on the prevalence of coincident thyroid cancer, complications, and treatment efficacies were derived from a systematic review of the literature. INTERVENTIONS: Thyroid lobectomy after a 3 month-course of antithyroid drugs (ATDs), high-dose (<555 MBq) radioactive iodine (RAI), low-dose (>555 MBq) RAI, and lifelong ATDs. MEASUREMENTS AND MAIN RESULTS: Outcomes were measured in quality-adjusted life years (QALYs). Costs were estimated from the health care system perspective. Future costs and effectiveness were discounted at 3% per year. For a 40- year-old woman, surgery was the most effective, while low-dose RAI was the least costly. The marginal cost-effectiveness of surgery versus low-dose RAI was $13,183 per QALY. Surgery was less costly and more effective than lifelong ATDs. RAI was more effective than surgery if surgical mortality exceeded 0.90% (base-case 0.001%). Surgery provided relatively inexpensive gains (<$50,000 per QALY) in quality-adjusted life expectancy in patients less than 74 years of age. CONCLUSIONS: For most patients less than 60 years of age, surgery is an effective strategy with a reasonable cost. However, for any given patient, surgical mortality, therapeutic costs and preference must be considered in choosing an appropriate therapy.

Association between first injection risk behaviors and hepatitis C seropositivity among injecting drug users.

HCV infection is rapidly acquired after drug addicts first inject drug intravenously. The risk behaviors accompanying the first intravenous substance injection are not well known. We used in 1997 a structured questionnaire to investigate the relationships between risk behaviors at the first injection and current reported HCV status. We interviewed 151 injecting drug users from four treatment centers and one prison in Paris. Risk markers for reported HCV seroconversion were explored by use of logistic regression models. One hundred and forty-three injecting drug users (95%) agreed to participate in the study. At the first injection, 50% shared preparation equipment; 22% borrowed and 26% lent injecting equipment. At the time of the study, 46% reported that they were HCV-positive. Sharing preparation equipment (odds ratio=3.1; 95% confidence interval: 1.2-7.8) and lending injection equipment (odds ratio=3.0; 95% confidence interval: 1.1-8.5) during the first injection were independently associated with reported HCV seropositivity. The high-risk behaviors accompanying the first intravenous injection of drugs justifies the implementation of specific prevention measures, aimed at young drug users who have not started to inject.

Managing toxic thyroid adenoma: a cost-effectiveness analysis.

OBJECTIVE: To examine the cost-effectiveness of therapeutic strategies for patients with toxic thyroid adenoma. DESIGN: A decision analytic model was used to examine strategies, including thyroid lobectomy after a 3-month course of antithyroid drugs (ATDs), radioactive iodine (RAI), and lifelong ATDs followed by either RAI (ATD-RAI) or surgery (ATD-surgery) in patients suffering severe drug reactions. METHODS: Outcomes were measured in quality-adjusted life years. Data on the prevalence of co-incident thyroid cancer, complications and treatment efficacies were derived from a systematic review of the literature (1966-2000). Costs were examined from the health care system perspective. Costs and effectiveness were examined at their present values. Discounting (3% per year), variations of major cost components, and every variable for which disagreements exist among studies or expert opinion were examined by sensitivity analyses. RESULTS: For a 40-year-old woman, surgery was both the most effective and the least costly strategy (Euro 1391),while ATD-RAI cost the most (Euro 5760). RAI was more effective than surgery if surgical mortality exceeded 0.6% (base-case 0.001%). RAI become less costly for women of more than 72 years (more than 66 in discounted analyses). For women of 85, ATD-RAI may be more effective than RAI and have an inexpensive marginal cost-effectiveness ratio (Euro 4975) if lifelong follow-up results in no decrement in quality of life. CONCLUSIONS: Age, surgical mortality, therapeutic costs and patient preference must all be considered in choosing an appropriate therapy.

Injection risk behaviors at the first and at the most recent injections among drug users.

Risk behaviors at the first intravenous substance injection are unknown. A structured questionnaire was used to investigate the circumstances of the first injection and the changes in risk behaviors between the first and the most recent injections in a group of 143 intravenous drug users (IDUs). When they first injected most subjects were not alone, the initiator was an IDU (94%) who prepared the injection (76%) and did it (79%). The proportions of IDUs sharing preparation equipment (58 vs. 14%), borrowing (23 vs. 2%) and lending injecting equipment (26 vs. 4%) decreased between the first and the most recent injection.