Lower extremity amputation prevention in Singapore: economic analysis of results.

INTRODUCTION: The aim of the study was to determine the cost-effectiveness of the Lower Extremity Amputation Prevention (LEAP) strategy in comparison to standard clinical practice for treating patients with critical limb ischaemia (CLI). METHODS: A retrospective cost-effectiveness analysis of the LEAP programme relative to pre-LEAP practice was performed from the perspective of Singapore hospitals. The cost incorporated in the analysis included direct medical costs incurred during the admission. Outcomes included the number of amputations, number of deaths and length of hospital stay after the initial treatment. RESULTS: During the study period, the LEAP group had a lower amputation rate (29 percent versus 76 percent, p-value is 0.00001), lower related death rate (one percent versus 19 percent, p-value is 0.00001) and fewer in-hospital days per patient (17.8 days versus 23.16 days, p-value is 0.048) as compared to the standard clinical practice group. The implementation of the LEAP strategy generated cost savings of S$2,566 per patient during admission when compared with the pre-LEAP approach. The results were robust to variations in input parameters. CONCLUSION: The LEAP strategy dominated standard practice in the management of patients with diabetes mellitus and CLI. The implementation of the LEAP strategy significantly improved patient outcomes and reduced hospital costs.

The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery.

BACKGROUND: The selective antithrombotic fondaparinux is more effective than the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism (deep-vein thrombosis [DVT] or pulmonary embolism) in patients undergoing major orthopedic surgery, but its cost-effectiveness is undetermined. OBJECTIVES: To evaluate the cost-effectiveness of fondaparinux relative to enoxaparin as prophylaxis against venous thromboembolism (VTE) for patients undergoing total hip replacement, total knee replacement or hip fracture surgery in the UK. PATIENTS/METHODS: A decision analysis model was created simulating the impact of fondaparinux and enoxaparin on patient outcomes and costs over various time points up to 5 years following surgery. The main outcome measures were treatment costs per patient and the incidence of clinical VTE and VTE-related deaths. A weighted (combined) cohort reflects the proportion of patients undergoing these procedures in 2000/2001. RESULTS: In the combined cohort, compared with enoxaparin, fondaparinux is expected to produce 20 fewer clinical VTE events and 3.2 fewer VTE-related deaths per 1000 procedures at 5 years. Cost savings at 5 years are pound 27 per patient with fondaparinux (discounted at 6% per year). In each of the three surgical groups, fondaparinux leads to lower expected costs per patient and to a smaller number of VTE events and VTE-related deaths. RESULTS are sensitive to the price difference between fondaparinux and enoxaparin and variation in the rate of late DVT. The analysis is robust to variations in all other key parameters. CONCLUSIONS: Compared with enoxaparin, fondaparinux is more effective and reduces costs to the healthcare system. At current prices, fondaparinux is the recommended strategy in the UK for prophylaxis following major orthopedic surgery.

Cost-utility analysis of imatinib mesilate for the treatment of advanced stage chronic myeloid leukaemia.

Imatinib mesilate (Glivec), Novartis Pharmaceuticals) is a novel therapy for the treatment of chronic myeloid leukaemia (CML). We evaluated the cost-effectiveness of imatinib (600 mg daily) when used for the treatment of patients in advanced stages of CML (accelerated phase and blast crisis) against conventional therapies of combination chemotherapy (DAT) and palliative care in hospital or at home. A Markov model simulated the transitions of hypothetical patient cohorts and outcomes were modelled for 5 years from the start of treatment. Costs were estimated from the perspective of the UK National Health Service. Over 5 years, a patient in accelerated phase will, on average, accrue an additional 2.09 QALYs with imatinib compared to conventional therapies, while patients in blast crisis will accrue an additional 0.58 quality-adjusted life-years (QALYs) with imatinib compared to conventional therapies. The costs per additional QALY gained from treatment with imatinib compared with conventional therapies were pound 29344 (accelerated phase) and pound 42239 (blast crisis). The results were particularly sensitive to the price of imatinib, improvements in quality of life, and the duration of haematological responses. We conclude that treatment of CML with imatinib confers considerably greater survival and quality of life than conventional treatments but at a cost.