Referral processes and wait times in primary care.

OBJECTIVE: To evaluate the response times to requests for consultations from FPs and the wait times for patient appointments. DESIGN: Mailed invitation to participate in a survey about non-FP specialist consultation requests from April 28 to May 9, 2014. SETTING: Hamilton, Ont. PARTICIPANTS: All active physicians with community practices from the Department of Family Medicine at St Joseph's Healthcare Hamilton and Hamilton Health Sciences. MAIN OUTCOME MEASURES: All non-FP specialist consultation requests for a 2-week period. RESULTS: Thirty-four practices (9.6% response rate) collected data on 816 consultation requests. Requests for referrals were most commonly made to the following 5 specialties: dermatology, surgery, gastroenterology, orthopedics, and obstetrics and gynecology. Overall, 36.4% of the requests for consultation received no response from the non-FP specialist's office by the end of the follow-up period. The mean wait time for a patient appointment was 60.1 days (range 23.3 to 168.5 days). Five specialties had particularly lengthy wait times of 105.9 to 168.5 days. CONCLUSION: Allowing 5 to 7 weeks for a response from a non-FP specialist, there was still a 36.4% nonresponse rate (similar to a pilot survey administered in 2010). Patient and physician frustration is certainly heightened and more office time and energy is expended when no acknowledgment of a referral is received within 7 weeks. This gives our community wait times much longer than those reported by any of the national bodies.

Role of family physicians in an urban hospital: Tracking changes between 1977, 1997, and 2014.

OBJECTIVE: To investigate changes in family doctors' attitudes about and participation in hospital activities and inpatient care in an urban hospital family medicine department from 1977 to 1997 and 2014. DESIGN: Cross-sectional survey design. SETTING: The Department of Family Medicine at St Joseph's Healthcare Hamilton in Ontario. PARTICIPANTS: Family physicians affiliated with the Department of Family Medicine at St Joseph's Healthcare Hamilton were surveyed in 2014. Data were compared with findings from similar surveys administered at this institution in 1977 and 1997. MAIN OUTCOME MEASURES: Family physicians' roles in hospital activities, attitudes toward the role of the family physician in the hospital setting, and the barriers to and facilitators of maintaining this role. RESULTS: A total of 93 physicians returned completed surveys (37.3% response rate). In 2014, half of the respondents provided some inpatient care. This patient care was largely supportive and newborn care (71.7% and 67.4%, respectively). In 2014, 47.3% believed the quality of care would suffer (compared with 92.1% in 1977 and 87.5% in 1997) if they were not involved in patient care in the hospital. There was also a considerable shift away from the 1977 and 1997 perception that the family physician had a role as patient advocate: 92.0% and 95.3%, respectively, compared with only 49.5% in the 2014 survey. CONCLUSION: Family physicians' hospital activities and attitudes continued to change from 1977 to 1997 and 2014 in this urban hospital setting. Most of the respondents had stopped providing direct inpatient care, with a few continuing to provide supportive care. Despite this, most respondents still see a role for the Department of Family Medicine within the hospital as a focus for identifying with their family physician community, a place to interact with other specialist colleagues, and a source of some continuing medical education.

How dead is dead? Qualitative findings from participants of combined traditional and lead-time time trade-off valuations.

PURPOSE: The EuroQol Valuation Technology (EQ-VT) uses traditional time trade-off (tTTO) for health states better than dead and lead-time TTO (LT-TTO) for states worse than dead to elicit a value (-1.0 to +1.0) for each health state. In the Canadian EQ-5D-5L Valuation study which used the EQVT platform, we observed an unexpected peak in frequency of "0" values and few negative values, particularly in the range of 0 to -0.5. To better understand this finding, we sought to explore respondents' thought processes while valuing a health state, and their understanding of the tTTO and LT-TTO exercises. METHODS: Qualitative semi-structured interviews were conducted with EQVT task respondents. Questions focused on valuations of health states as: (a) Same as dead in tTTO, (b) Worse than dead in tTTO but changed to same as dead in LT-TTO, (c) Worse than dead in LT-TTO, and (d) Worse than dead in LT-TTO with trading off all 10 years. Data were analyzed using content and thematic analysis. RESULTS: Mean age of participants (N = 70) was 40 ± 18.1 years, 60% female, and 76% Caucasian. Participants provided similar reasons for valuing a health state same as or worse than dead. Many participants expressed confusion about worse than dead valuations, distinction between same as and worse than dead, and the transition from tTTO to LT-TTO. A few indicated that the addition of 10 years of full health in the LT-TTO influenced their valuations. CONCLUSIONS: The transition from tTTO to LT-TTO in the EQVT was confusing to participants, whereby some health state valuations around this transition appeared to be arbitrary.

Can the general public use vignettes to discriminate between Alzheimer's disease health states?

BACKGROUND: Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer's disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states. METHODS: We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer's Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson's r to assess correlations between health utility and QoL-AD scores. RESULTS: Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p <0.0001). Mean health utility scores were 0.65 (mild), 0.51 (moderate), and 0.25 (severe). Mean QoL-AD scores were 26.7 (mild), 23.0 (moderate), and 17.4 (severe). The correlations between health utility and QoL-AD scores were moderate to strong (r ≥ 0.62). CONCLUSIONS: Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.

Measuring health-related quality-of-life for Alzheimer's disease using the general public.

PURPOSE: Little research exists to indicate whether the general public can provide proxy health-related quality-of-life (HRQoL) estimates for persons with Alzheimer's disease (AD). We investigated (1) whether the general public can differentiate between mild, moderate, and severe AD and (2) whether the general public's proxy HRQoL estimates are correlated with current health status. METHODS: We conducted computer-assisted personal interviews. The computer randomly assigned each participant to read a vignette describing mild, moderate, or severe AD. Participants answered the EQ-5D-5L and Quality-of-life-Alzheimer's Disease (QoL-AD), while imagining living in the health state described in their assigned vignette. Participants also answered the EQ-5D-5L based on their health state at the time of the interview. RESULTS: We interviewed 100 participants. EQ-5D-5L utilities were 0.7413 (mild), 0.6159 (moderate), and 0.4456 (severe) (P < 0.001). Mean QoL-AD scores were 32.5 (mild), 24.0 (moderate), and 21.8 (severe) (P < 0.0001 for severe vs. mild, moderate vs. mild; P > 0.05 for severe vs. moderate). Participants' EQ-5D-5L utility scores were weakly correlated (r ≤ 0.28) across both administrations of the instrument. CONCLUSIONS: The general public can differentiate between the three stages of AD, and their HRQoL estimates for AD are weakly correlated with their current health status.

Triple therapy for the management of COPD: a review.

Triple therapy for COPD consists of a long-acting anti-cholinergic bronchodilator, a long-acting beta-agonist bronchodilator, and an inhaled corticosteroid. Guidelines from the Canadian Thoracic Society advocate triple therapy for some patients with moderate-to-severe COPD. The objective of this review was to evaluate the evidence based clinical efficacy of triple therapy compared to dual bronchodilator therapy (long-acting anti-cholinergic bronchodilator + beta-agonist bronchodilator) or long-acting anti-cholinergic bronchodilator monotherapy for managing COPD. A systematic literature search was conducted to identify relevant clinical evaluations of triple therapy in the management of moderate to severe COPD. Databases searched included: Medline; EMBASE; CINAHL and PubMed (non-Medline records only). Of 2,314 publications, 4 articles evaluated triple therapy for the management of COPD. Hospitalization rates for COPD exacerbations, reported in 2 trials, were significantly reduced with triple therapy compared to long-acting anti-cholinergic bronchodilator monotherapy, with reported relative risks of 0.53 (95% CI: 0.33, 0.86, p = 0.01) and 0.35 (95% CI: 0.16-0.78, p = 0.011). Exacerbation data is inconsistent between the two trials reporting this outcome. Lung function, dyspnea and quality of life data show statistical significant changes with triple therapy compared to long-acting anti-cholinergic bronchodilator monotherapy but the changes do not reach clinical importance. Triple therapy does decrease the number of hospitalizations for severe/acute COPD exacerbations compared with long-acting anti-cholinergic bronchodilator monotherapy. There is insufficient evidence to determine if triple therapy is superior to dual bronchodilator therapy.

Cost-utility of Intravenous Immunoglobulin (IVIG) compared with corticosteroids for the treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in Canada.

OBJECTIVES: Intravenous immunoglobulin (IVIG) has demonstrated improvement in chronic inflammatory demyelinating polyneuropathy (CIDP) patients in placebo controlled trials. However, IVIG is also much more expensive than alternative treatments such as corticosteroids. The objective of the paper is to evaluate, from a Canadian perspective, the cost-effectiveness of IVIG compared to corticosteroid treatment of CIDP. METHODS: A markov model was used to evaluate the costs and QALYs for IVIG and corticosteroids over 5 years of treatment for CIDP. Patients initially responding to IVIG could remain a responder or relapse every 12 week model cycle. Non-responding IVIG patients were assumed to be switched to corticosteroids. Patients on corticosteroids were at risk of a number of adverse events (fracture, diabetes, glaucoma, cataract, serious infection) in each cycle. RESULTS: Over the 5 year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared to corticosteroid treatment to be $124,065 and 0.177 respectively. The incremental cost per QALY gained of IVIG was estimated to be $687,287. The cost per QALY of IVIG was sensitive to the assumptions regarding frequency and dosing of maintenance IVIG. CONCLUSIONS: Based on common willingness to pay thresholds, IVIG would not be perceived as a cost effective treatment for CIDP.

Cost-utility analysis of infliximab and adalimumab for refractory ulcerative colitis.

OBJECTIVE: To evaluate cost-utility of infliximab and adalimumab for the treatment of moderate-to-severe ulcerative colitis (UC) refractory to conventional therapies in Canada. METHODS: A Markov model was constructed to evaluate incremental cost-utility ratios (ICUR) of 5 mg/kg and 10 mg/kg infliximab and adalimumab therapies compared to 'usual care' in treating a hypothetical cohort of patients (aged 40 years and weighing 80 kg) over a five-year time horizon from the perspective of a publicly-funded health care system. Clinical parameters were derived from the Active Ulcerative Colitis Trials 1 and 2. Costs were obtained through provincial drug benefit plans. ICUR was the main outcome measure and both deterministic and probabilistic sensitivity analyses were conducted. RESULTS: Compared to the strategy A ('usual care') in the base case analysis, the ICURs were CA$358,088/QALY for the strategy B ('5 mg/kg infliximab + adalimumab') and CA$575,540/QALY for the strategy C ('5 mg/kg and 10 mg/kg infliximab + adalimumab'). The results were sensitive to: the remission rates maintained in responders to 'usual care' and to 5 mg/kg infliximab, the rate of remission induced by adalimumab in non-responders to 5 mg/kg infliximab, early surgery rate, and utility values. When the willingness to pay (WTP) was less than CA$150,000/QALY, the probability of 'usual care' being the optimal strategy was 1.0. The probability of strategy B being optimal was 0.5 when the WTP approximated CA$400,000/QALY. CONCLUSIONS: The ICURs of anti-TNF-alpha drugs were not satisfactory in treating patients with moderate-to-severe refractory UC. Future research could be aimed at the long-term clinical benefits of these drugs, especially adalimumab for patients intolerant or unresponsive to infliximab treatment.

Automated telephone reminder messages can assist electronic diabetes care.

Telephone reminder systems have been used to assist in the treatment of many chronic diseases. However, it is unclear if these systems can increase medication and appointment adherence in patients with diabetes without direct patient-provider telephone contact. We tested the feasibility of using an automated telephone reminder system (ATRS) to deliver reminder messages to 253 adults with diabetes enrolled in a randomized controlled trial. Eighty-four percent of the patients were able to register using voice recognition and at least one reminder was delivered to 95% of registered patients over a period of 7.5 months. None of the demographic features studied predicted a patient's ability to enroll or to receive reminder calls. At the end of the study, 63% of patients indicated that they wished to continue to receive ATRS calls. The level of system use as determined by the number of received reminder calls was not associated with a change in the number of physician visits or diabetes-related laboratory tests during follow-up. The clinical benefits and sustainability of ATRS remain unproven, but our results indicate that an automated reminder system can be effective for providing messages to a large group of older patients with diabetes.

Exploring patient demographic and clinical characteristics associated with lipid-lowering pharmacotherapy use in primary care.

BACKGROUND: Lipid-lowering therapeutics, particularly HMG Co-A reductase inhibitors, can be beneficial in primary and secondary cardiovascular prevention. The Canadian population frequently uses these medications but the manner in which they are used in community-based practice is unknown. OBJECTIVES: To assess the patient characteristics associated with lipid lowering drug use in community-based clinical practice across four geographic regions in Canada. To assess amongst lipid-lowering drugs users the proportion of patients that would meet accepted dyslipidemia management guidelines. To assess the community-based effectiveness of anti-hyperlipidemic drugs. METHODS: Patients filling a prescription for any anti-hyperlipidemia therapy in selected pharmacies in Ontario (ON), Quebec (PQ), British Columbia (BC) and Nova Scotia (NS). All eligible patients were interviewed over the telephone. Physicians who were providing healthcare to the participating patients were requested to provide information from the patient's medical record. RESULTS: The mean patient age was > 60 yr in all four provinces. There were some differences amongst the four provinces pertaining to patient characteristics, prescription patterns and therapeutic indicators, but not to outcomes. Anti-hyperlipidemia therapy was associated with a 1.81 mmol/L decrease in LDL-Cholesterol (P < 0.001); however only 73% of patients achieved target LDL-Cholesterol concentrations. A lag time of 1.96 yr (P < 0.0001) was observed from the diagnosis of dyslipidemia until the drug treatment was initiated. Patients had an average of 2.8 cardiovascular (CV) risk factors and 86% of patients had at two or more CV risk factors. Thirty-nine percent (95% CI, 36% - 42%) of the patients were being treated for secondary prevention. Thirteen percent (11-16%) of patients who were being treated for primary prevention had diabetes. Metabolic syndrome was observed in 32% (29-35%) of patients. CONCLUSION: Almost all patients fulfilled guideline requirements for the use of anti-hyperlipidemic therapy. Although the use of pharmacotherapy was associated with a lowering of LDL cholesterol more aggressive management is required to attain target LDL cholesterol concentrations.

Development of Clinical Vignettes to Describe Alzheimer's Disease Health States: A Qualitative Study.

AIMS: To develop clinical descriptions (vignettes) of life with Alzheimer's disease (AD), we conducted focus groups of persons with AD (n = 14), family caregivers of persons with AD (n = 20), and clinicians who see persons with AD in their practices (n = 5). METHODS: Group participants read existing descriptions of AD and commented on the realism and comprehensibility of the descriptions. We used thematic framework analysis to code the comments into themes and develop three new vignettes to describe mild, moderate, and severe AD. RESULTS: Themes included the types of symptoms to mention in the new vignettes, plus the manner in which the vignettes should be written. Since the vignette descriptions were based on focus group participants' first-hand knowledge of AD, the descriptions can be said to demonstrate content validity. CONCLUSION: Members of the general public can read the vignettes and estimate their health-related quality-of-life (HRQoL) as if they had AD based on the vignette descriptions. This is especially important for economic evaluations of new AD medications, which require HRQoL to be assessed in a manner that persons with AD often find difficult to undertake. The vignettes will allow the general public to serve as a proxy and provide HRQoL estimates in place of persons with AD.

Between-country heterogeneity in EQ-5D-3L scoring algorithms: how much is due to differences in health state selection?

BACKGROUND: EQ-5D-3L scoring algorithms vary amongst countries, not only in the values of regression coefficients but also in the independent variables included in the regression model (hereafter referred to as model specification). It is unclear how much of this variation is due to differences in health state selection, the relative frequencies with which health states were valued, and model diagnostics, rather than to genuine differences in population preferences. METHODS: Using aggregate data from a recent review, we noted all model specifications that were used. For each country the country's own model was re-fitted, as were all other model specifications. This was done twice: once using all valued health states for each country, and again using a common set of 17 health states for all countries. Goodness of fit was assessed using the following model diagnostics: mean absolute error (MAE), mean squared error (MSE) and rho (the Pearson correlation coefficient between predicted and observed mean utilities), both with and without leave-one-out cross-validation. RESULTS: Thirteen countries contributed data. Even when using a common set of health states, the preferred model varied across countries. However, choice of health states did impact the preferred model specification: when using cross-validation, the preferred specification changed in five of ten countries when moving from 17 health states to all valued health states. The relative frequency with which health states were valued had little impact on the preferred model. CONCLUSIONS: Variation in choices of health states to value is responsible for some, but not all, of the observed heterogeneity in model specification. Relative frequency of health state valuation and choice of model diagnostic has a limited impact on model preference, however, use of cross-validation has a substantial impact. The use of cross-validation, implemented through omitting health states rather than respondents, is recommended as one approach to assessing model fit.

Comparing EQ-5D valuation studies: a systematic review and methodological reporting checklist.

BACKGROUND: There has been a growing interest around the world in developing country-specific scoring algorithms for the EQ-5D. This study systematically reviews all existing EQ-5D valuation studies to highlight their strengths and limitations, explores heterogeneity in observed utilities using meta-regression, and proposes a methodological checklist for reporting EQ-5D valuation studies. METHODS: . We searched Medline, EMBASE, the National Health Service Economic Evaluation Database (NHS EED) via Wiley's Cochrane Library, and Wiley's Health Economic Evaluation Database from inception through November 2012, as well as bibliographies of key papers and the EuroQol Plenary Meeting Proceedings from 1991 to 2012 for English-language reports of EQ-5D valuation studies. Two reviewers independently screened the titles and abstracts for relevance. Three reviewers performed data extraction and compared the characteristics and scoring algorithms developed in the included valuation studies. RESULTS: . Of the 31 studies included in the review, 19 used the time trade-off (TTO) technique, 10 used the visual analogue scale (VAS) technique, and 2 used both TTO and VAS. Most studies included respondents from the general population selected by random or quota sampling and used face-to-face interviews or postal surveys. Studies valued between 7 and 198 total states, with 1-23 states valued per respondent. Different model specifications have been proposed for scoring. Some sample or demographic factors, including gender, education, percentage urban population, and national health care expenditure, were associated with differences in observed utilities for moderate or severe health states. CONCLUSIONS: . EQ-5D valuation studies conducted to date have varied widely in their design and in the resulting scoring algorithms. Therefore, we propose the Checklist for Reporting Valuation Studies of the EQ-5D (CREATE) for those conducting valuation studies.

Eliciting preferences to the EQ-5D-5L health states: discrete choice experiment or multiprofile case of best-worst scaling?

Choice-based methods have been used widely in assessing healthcare programs. This study compared the binary discrete choice experiment (DCE) and the multiprofile case of best-worst scaling (BWS) in eliciting preferences for the EQ-5D-5L. Forty-eight EQ-5D-5L health states were selected using a Bayesian efficient design and grouped into 24 pairs for the DCE tasks and 8 sets for the BWS tasks (each set has three health states). A total of 100 participants completed 12 pairs and 8 sets in a random order. A probit regression model and ranked order logistic regression model were used to estimate the latent utilities from the DCE and BWS, respectively. Both tasks were well understood by the majority of participants. The DCE tasks were relatively easier and took a shorter time to complete. The intraclass correlation coefficient (ICC) of the DCE was higher than that of the BWS. The variances associated with the latent utilities estimated from the DCE were larger than those from the BWS. The DCE is more feasible and reliable than the BWS in valuing the EQ-5D-5L. Future studies could focus on comparing the consistency and accuracy of these techniques in predicting the health utilities of the EQ-5D-5L.

Cost-effectiveness of pharmaceutical management for osteoarthritis pain: a systematic review of the literature and recommendations for future economic evaluation.

BACKGROUND AND OBJECTIVE: Osteoarthritis (OA) is a highly prevalent and chronic condition characterized by pain and physical disability. Currently, many treatments are available, and they primarily target pain relief. The objectives of this study were to systematically review economic evaluations for pharmaceutical management of OA pain and to provide methodological recommendations for future economic evaluation. METHODS: Published literature was identified by searching the following bibliographic databases: MEDLINE (1948-16 November 2011) with In-Process records and EMBASE (1980-2011 Week 47) via Ovid; The Cochrane Library (Issue 4 of 4, 2011) and the Health Economic Evaluations Database (HEED) via Wiley; and PubMed (for non-MEDLINE records). The main search terms were OA and economic evaluations. Two reviewers independently screened all identified articles and extracted the data from those included in the final review. RESULTS: Twelve articles reporting the cost-effectiveness of various pharmaceuticals were included, with five being trial-based and seven being model-based economic evaluations. The mean health economics quality score of the included articles was 84 (minimum-maximum: 63-99). These evaluations varied in study design, treatments compared, and outcomes measured. CONCLUSION: The existing economic evaluations on pharmaceutical management of OA pain were of acceptable quality. Comparability of economic evaluations could be improved by selecting standard comparators, adopting a longer time horizon, and directly measuring health utilities.

Self-reported physician adherence to guidelines for measuring blood pressure.

BACKGROUND: Diagnosis of hypertension, treatment, and follow-up depend on accurate measurement. This research study attempted to determine whether family physicians are all measuring blood pressure (BP) according to Canadian guidelines. METHODS: A short survey was mailed to all physicians within the Department of Family Medicine, St. Joseph's Healthcare, Hamilton, Ontario, Canada. RESULTS: Fifty-one percent of the surveys were completed and returned. Eleven of the recommendations were followed "always or most of the time." BP is measured manually by 63% of the respondents, and the most frequent barrier to following the recommendations was time. CONCLUSION: The results of the survey indicated that measurement of BP according to Canadian Hypertension Education Program recommendations was felt to be important and conducted in most cases, but there is room for improvement.

Cost-effectiveness of catheter ablation for rhythm control of atrial fibrillation.

Objective. The objective of this study is to evaluate the cost-effectiveness of catheter ablation for rhythm control compared to antiarrhythmic drug (AAD) therapy in patients with atrial fibrillation (AF) who have previously failed on an AAD. Methods. An economic model was developed to compare (1) catheter ablation and (2) AAD (amiodarone 200 mg/day). At the end of the initial 12 month phase of the model, patients are classified as being in normal sinus rhythm or with AF, based on data from a meta-analysis. In the 5-year Markov phase of the model, patients are at risk of ischemic stroke each 3-month model cycle. Results. The model estimated that, compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes, and 0.144 more QALYS over the 5-year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost-effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90, respectively. Conclusion. Based on current evidence, pulmonary vein ablation for treatment of AF is cost-effective if decision makers willingness to pay for a QALY is $59,194 or higher.

Comparative effectiveness of catheter ablation strategies for rhythm control in patients with atrial fibrillation: a meta-analysis.

BACKGROUND: Pulmonary vein isolation (PVI) forms the basis of catheter ablation strategies for atrial fibrillation (AF). Ablation of additional sites has been used to increase the efficacy of ablation procedures in restoring and maintaining normal sinus rhythm. OBJECTIVE: The aim of this paper was to compare the effectiveness of PVI versus PVI plus adjuvant atrial ablations (PVI+) in patients with AF. METHODS: A systematic search using bibliographic databases and gray literature was undertaken. Randomized and non-randomized controlled trials evaluating clinical efficacy, effectiveness, or safety of ablation procedures in adults with AF were included in this review. RESULTS: Of 3,204 potential citations identified by the original search, 21 randomized controlled trials and three non-randomized trials were included. Meta-analysis results reveal that in the first year after ablation, AF patients who underwent PVI+ strategies had a significantly higher rate of maintaining sinus rhythm than those who underwent PVI alone (RR 1.10, 95 % CI 1.02, 1.17). However, a subgroup meta-analysis was statistically significant for only PVI+ left atrial (LA) linear ablations (RR 1.16, 95 % CI 1.04, 1.29). The pooled success rates were higher in PVI+ group for both paroxysmal (RR 1.14, 95 % CI 1.06, 1.24) and non-paroxysmal AF (RR 1.53, 95 % CI 1.10, 2.14). CONCLUSION: PVI+ strategies, particularly PVI+ LA ablations, appear to result in higher success rates than PVI alone in the first year after the procedure. Studies of longer duration are needed to evaluate the long-term benefits and safety of different adjunctive ablation approaches for rhythm control in AF patients.

Canadian cost- utility analysis of intravenous immunoglobulin for acute childhood idiopathic thrombocytopenic purpura.

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is a hematological disorder and can be classified as acute or chronic. The main goal of treatment for acute childhood ITP is the prevention of potentially fatal bleeding complications, the most serious of which is intracranial hemorrhage (ICH). Treatment options for acute childhood ITP include splenectomy, corticosteroids, and blood products such as intravenous immunoglobulin. OBJECTIVES: The objective was to evaluate, from a Canadian perspective, the cost-effectiveness of intravenous immunoglobulin (IVIG) compared to alternative inpatient treatments for acute childhood idiopathic thrombocytopenic purpura (ITP). METHODS: A Markov model with a lifelong time horizon was used to evaluate the costs and quality-adjusted life years (QALYs) for 5 treatments for children hospitalized for ITP: 1) no treatment; 2) IVIG; 3) Anti-D; 4) prednisone; and 5) methylprednisolone. The model predicted the probability of intracranial hemorrhage for each treatment strategy based on the time children spent with platelet counts <20,000µL. The time patients spent with platelet counts <20,000µL with each treatment was estimated by pooling data from published randomized clinical trials. In the basecase analysis, the cohort was assumed to weigh 20kg. Cost and utility model variables were based upon various literature sources. Parameter uncertainty was assessed using probabilistic sensitivity analysis. RESULTS: The treatment strategies that comprised the efficiency frontier were prednisone, Anti-D and IVIG. The incremental cost per QALY was $53,333 moving from prednisone to Anti-D and $53,846 moving from Anti-D to IVIG. Results were sensitive to patient weight. If patient weight is 10kg, IVIG dominates all other strategies and if weight is increased to 30kg, the cost per QALY of IVIG is $163,708. CONCLUSION: Based on common willingness to pay thresholds, IVIG might be considered a cost effective treatment for acute childhood ITP. Cost effectiveness is highly dependent on patient weight.