The design of an observational study of hypertension management, adherence and pressure control in Blood Pressure Success Zone Program participants.

AIMS: The Blood Pressure Success Zone (BPSZ) Program, a nationwide initiative, provides education in addition to a complimentary trial of one of three antihypertensive medications. The BPSZ Longitudinal Observational Study of Success (BPSZ-BLISS) aims to evaluate blood pressure (BP) control, adherence, persistence and patient satisfaction in a representative subset of BPSZ Program participants. The BPSZ-BLISS study design is described here. METHODS: A total of 20,000 physicians were invited to participate in the study. Using a call centre supported Interactive Voice Response System (IVRS), physicians report BP and other data at enrolment and every usual care visit up to 12 +/- 2 months; subjects self-report BPs, persistence, adherence and treatment satisfaction at 3, 6 and 12 months post-BPSZ Program enrolment. In addition to BPSZ Program enrolment medications, physicians prescribe antihypertensive medications and schedule visits as per usual care. The General Electric Healthcare database will be used as an external reference. RESULTS: After 18 months, over 700 IRB approved physicians consented and enrolled 10,067 eligible subjects (48% male; mean age 56 years; 27% newly diagnosed); 97% of physicians and 78% of subjects successfully entered IVRS enrolment data. Automated IVRS validations have maintained data quality (< 5% error on key variables). Enrolment was closed 30 April 2007; study completion is scheduled for June 2008. CONCLUSIONS: The evaluation of large-scale health education programmes requires innovative methodologies and data management and quality control processes. The BPSZ-BLISS design can provide insights into the conceptualisation and planning of similar studies.

Care needs and economic consequences after acute ischemic stroke: the Erlangen Stroke Project.

The objective was to determine the functional outcome, location of care and economic consequences in the first 3 months after ischemic stroke. As part of the Erlangen Stroke Project, (ESPro) information was collected on patients suffering a first-ever ischemic stroke. Three months after the stroke, location of care, dependence on caregivers and function based on Barthel Index: poor (0-55), moderate (60-90) or good function (95-100) were recorded. Data about health services used were combined with cost estimates for Germany (2000 Euros, undiscounted). Of 491 patients hospitalized, 383 were alive 3 months afterwards, 79% residing in the community. The majority of patients with poor function (60%) were still in institutional care. Patients with good function typically accrued the lowest costs, whether in an institution (17 965) or not (11 032) compared with poorer function who were living in an institution (poor: 26 370; moderate: 28,121), or community (poor: 27,207; moderate: 19,350). Hospitalization and rehabilitation services were the major costs accrued at each level of function. Many patients were left requiring a substantial amount of care and the costs associated with providing institutional care has a major impact on the economic consequences of a stroke.

Economic evaluation of therapeutic interventions to prevent Type 2 diabetes in Canada.

AIMS: To compare the health and economic outcomes of using acarbose, an intensive lifestyle modification programme, metformin or no intervention to prevent progression to diabetes in Canadian individuals with impaired glucose tolerance (IGT). METHODS: A model was developed to simulate the course of individuals with IGT under each treatment strategy. Patients remain in the IGT state or transition from IGT to diabetes, to normal glucose tolerance (NGT) or to death. Effectiveness and resource use data were derived from published intervention trials. A comprehensive health-care payer perspective incorporating all major direct costs, reported in 2000 Canadian dollars, was adopted. RESULTS: Over a decade, 70 of the 1000 untreated patients are expected to die and 542 develop diabetes. Intensive lifestyle modification is estimated to prevent 117 cases of diabetes, while metformin would prevent 52 and acarbose 74 cases. The proportion of those who return to NGT also increases with any treatment. While lifestyle modification is more effective, it can increase overall costs depending on how it is implemented, whereas acarbose and metformin reduce costs by nearly $1000 per patient. Lifestyle modification was cost effective, varying from CAD $10 000/LYG vs. acarbose. Acarbose costs somewhat more than metformin, but is more effective: CAD $1798/LYG. CONCLUSION: The results of this model suggest that the treatment of IGT in Canada is a cost-effective way to prevent diabetes and may generate savings. While pharmacological treatments tended to be less costly, intensive lifestyle modification, if maintained, led to the greatest health benefits at reasonable incremental costs.

Oxybutynin extended release and tolterodine immediate release : a health economic comparison.

OBJECTIVE: To evaluate the cost-effectiveness of a new extended-release (XL) formulation of oxybutynin relative to tolterodine immediate release (IR), currently the most prescribed treatment for overactive bladder in the UK. METHODS: A state-transition model was developed to compare outcomes over 1 year. Effectiveness and treatment persistence data were derived from the OBJECT (Overactive Bladder: Judging Effective Control and Treatment) study, a 3-month clinical trial comparing oxybutynin XL 10 mg/day with tolterodine IR 4 mg/day. The daily costs of oxybutynin XL and tolterodine IR were pound0.82 and pound1.04, respectively. These data and information from the literature were used to project outcomes beyond the trial time. Severity-specific incontinence cost profiles were developed for the UK (2002 costings). RESULTS: After 1 year, 3.1 more patients per 100 treated attained complete continence with oxybutynin XL compared with tolterodine IR, and 5.6% more had less than seven incontinent episodes per week. Over 1 year, patients receiving oxybutynin XL had almost 17 additional incontinence-free days and 95 fewer incontinent episodes. Estimated costs were pound86 lower per patient with oxybutynin XL. If drugs are priced equally, savings decrease to pound21 per patient. Oxybutynin XL maintains its advantage over wide ranges of inputs, and outcomes are similar if analyses are limited to 3 months. CONCLUSION: Base-case analyses suggest that oxybutynin XL provides better effectiveness than tolterodine IR and reduces costs. Results indicate that oxybutynin XL is the dominant therapeutic option under a wide range of alternative inputs and assumptions.

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK.

OBJECTIVE: To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK. METHODS: The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%. RESULTS: Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose. CONCLUSION: In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.

Diabetes in Canada: direct medical costs of major macrovascular complications.

OBJECTIVES: To estimate direct medical costs of managing major macrovascular complications in diabetic patients. METHODS: Costs were estimated for acute myocardial infarction (AMI) and ischemic stroke by applying unit costs to typical resource use profiles. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, provincial physician and laboratory fee schedules, provincial formularies, government reports, and peer-reviewed literature. For each complication, the event costs per patient are those associated with resource use specific to the acute episode and any subsequent care occurring in the first year. State costs are the annual costs per patient of continued management. All costs are expressed in 1996 Canadian dollars. RESULTS: Acute hospital care accounts for approximately half of the first year management costs ($15,125) of AMI. Given the greater need for postacute care, acute hospital care has less impact (28%) on event costs for stroke ($31,076). The state costs for AMI and stroke are $1544 and $8141 per patient, respectively. CONCLUSIONS: Macrovascular complications of diabetes potentially represent a substantial burden to Canada's health care system. As new therapies emerge that may reduce the incidence of some diabetic complications, decision makers will need information to make critical decisions regarding how to spend limited health care dollars. Published literature lacks Canadian-specific cost estimates that may be readily translated into patient-level cost inputs for an economic model. This paper provides two key pieces of the many needed to understand the scope of the economic burden of diabetes and its complications for Canada.

Assessment of health economics in Alzheimer's disease (AHEAD) based on need for full-time care.

OBJECTIVE: To develop a framework for estimating the long-term health and economic consequences of AD based on patient characteristics at a given point in time. METHODS: A pharmacoeconomic model (Assessment of Health Economics in Alzheimer's Disease, AHEAD) was developed based on equations that relate the probability of needing full-time care (FTC) over time to patient characteristics summarized in index scores. These equations were developed from published data on interquartile times until FTC is needed and until death, using nonlinear regressions of the resulting index-specific hazards. These equations were then incorporated into a hidden Markov framework that allows for calculation of expected time to FTC and to death, as well as of the economic consequences of disease progression. There are three major states in the model: not requiring FTC ("pre-FTC"), requiring FTC, and death. RESULTS: Outcomes for five sample patients are derived to illustrate application of the AHEAD model. The impact of altering disease markers in these patients is also considered. CONCLUSION: The need for a generally applicable tool to forecast long-term outcomes based on relatively short-term data is becoming increasingly acute with the advent of new therapies for AD. The AHEAD model provides a relatively simple framework for the prediction of time to FTC requirement based on short-term observed data such as those from clinical trials. Although subject to the uncertainties inherent in modeling, the model nevertheless provides a standard estimation technique that may facilitate comparisons between existing and emerging therapies.

Assessment of health economics in Alzheimer's disease (AHEAD): galantamine treatment in Canada.

BACKGROUND: Given the high costs of caring for patients with AD in Canada, it is important to evaluate the costs of new therapies that halt or delay the advancement of AD, relative to the savings associated with delaying disease progression. METHODS: The Assessment of Health Economics in Alzheimer's Disease (AHEAD) model, which uses algorithms to predict the time until patients with AD require full-time care (FTC), was adapted to Canada to compare treatment with galantamine versus no pharmacologic treatment. Data from two clinical trials provided inputs into the algorithms, and forecasts were made for up to 10 years. Drug and health care costs were evaluated according to the stage of disease based on Quebec unit costs along with follow-up data from the Canadian Study of Health and Aging. RESULTS: Galantamine is predicted to reduce the duration of FTC by almost 10%. Approximately 5.6 patients with mild to moderate disease must be placed on treatment to avoid one year of FTC, resulting in savings averaging $788 CAD ($528 USD) per patient. For patients with moderate disease, 3.9 patients must be placed on treatment to avoid one year of FTC, with savings predicted at $3718 CAD ($2533 USD) per patient. CONCLUSION: Galantamine cannot only potentially increase the time before patients require FTC, but may also lead to overall savings because treatment costs are offset by reductions in other health care expenditures.

Healing and relapse rates in gastroesophageal reflux disease treated with the newer proton-pump inhibitors lansoprazole, rabeprazole, and pantoprazole compared with omeprazole, ranitidine, and placebo: evidence from randomized clinical trials.

BACKGROUND: The older proton pump inhibitor (PPI) omeprazole and the newer PPIs lansoprazole, rabeprazole, and pantoprazole are approved for the acute and maintenance treatment of gastroesophageal reflux disease (GERD). OBJECTIVE: On the basis of the results of randomized clinical trials, this study sought to estimate healing and relapse rates in acute and maintenance treatment of GERD with the newer PPIs compared with omeprazole, the histamine2-receptor antagonist ranitidine (the most frequent non-PPI comparator in studies of PPIs), and placebo. METHODS: A search of MEDLINE was conducted to identify randomized, controlled clinical trials that included a PPI in > or =1 treatment arm and assessed the healing of erosive esophagitis endoscopically. The primary outcome for studies of acute therapy was healing rate, and the primary outcome for studies of maintenance therapy was relapse rate. RESULTS: Fifty-three studies were identified, of which 38 involved acute therapy (12 excluded) and 15 maintenance therapy. None of the studies of pantoprazole met the inclusion criteria for maintenance therapy. The 8-week overall healing rate ratios in the comparison of newer PPIs with omeprazole 20 mg/d were as follows: lansoprazole 30 mg/d, 1.02 (95% CI, 0.98-1.06): rabeprazole 20 mg/d, 0.93 (95% CI, 0.87-1.00); and pantoprazole 40 mg/d, 0.98 (95% CI, 0.90-1.07). In the comparison of any PPI with ranitidine 300 mg/d, the ratios were as follows: lansoprazole, 1.62 (95% CI, 1.46-1.76); rabeprazole, 1.36 (95% CI, 1.20-1.54); pantoprazole, 1.60 (95% CI, 1.33-1.96); and omeprazole, 1.58 (95% CI, 1.41-1.78). Relapse rates over 1 year of treatment were similar between lansoprazole and rabeprazole. Compared with ranitidine, there were statistically significant differences in the rates of resolution of heartburn symptoms (P < 0.002), ulcer healing (P < 0.05), and relapse (P < 0.01). Similar results were seen in the comparison of PPIs with placebo in terms of rates of resolution of heartburn symptoms (P < 0.01), ulcer healing (P < 0.001), and relapse (P < 0.006). CONCLUSIONS: In this study, the newer PPIs were of similar efficacy to omeprazole in terms of heartburn control, healing rates, and relapse rates. All the PPIs were superior to ranitidine and placebo in healing erosive esophagitis and decreasing relapse rates.

Tracheoesophageal puncture in the office setting with local anesthesia.

Tracheoesophageal puncture (TEP) with voice prosthesis placement is currently the method of choice for vocal rehabilitation of patients who have undergone total laryngectomy. Occasionally, secondary TEP needs to be performed. We have used a TEP technique that is performed in the clinic setting with local anesthesia and no sedation. The purpose of this study was to review our technique and experience and to evaluate results, complications, and patients' acceptance of the procedure. We performed a retrospective chart review of the records of 14 patients who had undergone total laryngectomy and secondary TEP placement in the clinic setting. The procedure was well tolerated. The voice results were fair to good in 11 of 12 patients. There was 1 complication, a false passage between the trachea and the esophagus. Voicing was immediate in 12 of the 14 cases. We conclude that TEP can be performed in the office setting with local anesthesia. The voice results are excellent, and the procedure is well tolerated by the patient. Proper patient selection and regular follow-up by a speech-language pathologist are important.

Anemia as an independent prognostic factor for survival in patients with cancer: a systemic, quantitative review.

BACKGROUND: Anemia is common in cancer patients, although the prevalence is influenced both by the type of malignancy and the choice of treatment. Individual studies have compared the survival of patients with and without anemia and have shown reduced survival times in patients with various malignancies, including carcinoma of the lung, cervix, head and neck, prostate, lymphoma, and multiple myeloma. The objective of this study was to systematically review, to summarize, and to obtain an overall estimate of the effect of anemia on survival in patients with malignant disease. METHODS: A comprehensive literature review was carried out using the MEDLINE data base and reviewing the reference lists from published studies. Two hundred papers were identified. Of these, 60 papers that reported the survival of cancer patients according to either hemoglobin levels or the presence of anemia were included. Among these papers, 25% related to patients with lung carcinoma, 17% related to patients with head and neck carcinoma, 12% related to patients with multiple myeloma, 10% related to patients with prostate carcinoma, 8% related to patients with cervicouterine carcinoma, 7% related to patients with leukemia, 5% related to patients with lymphoma, and 16% related to patients with other types of malignancies. RESULTS: The relative risk of death increased by 19% (95% confidence interval, 10-29%) in anemic patients with lung carcinoma, by 75% (37-123%) in anemic patients with head and neck carcinoma, by 47% (21-78%) in anemic patients with prostate carcinoma, and by 67% (30-113%) in anemic patients with lymphoma. The overall estimate increase in risk was 65% (54-77%). CONCLUSIONS: Anemia is associated with shorter survival times for patients with lung carcinoma, cervicouterine carcinoma, head and neck carcinoma, prostate carcinoma, lymphoma, and multiple myeloma.

Treatment of migraine in Canada with naratriptan: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of naratriptan for the treatment of migraine in Canada. BACKGROUND: The substantial disability brought on by migraine, coupled with the high prevalence of this disorder, leads to substantial costs. Naratriptan is a newly developed triptan shown to be effective in the treatment of migraine. METHODS: Monte Carlo modeling techniques were used to simulate the experience of Canadian migraineurs over the course of 1 year. Data from a multinational study comparing oral naratriptan 2.5 mg to customary therapies were used in the cost-effectiveness analysis. RESULTS: Naratriptan leads to an annual reduction in symptom duration of 225 hours compared to customary therapy not including other triptans. Reductions in lost productivity yield savings of Can $390 (1998 Canadian dollars) relative to customary therapy, which exceed the increase in drug costs resulting in overall savings of Can $109 per year. CONCLUSIONS: The use of naratriptan in the treatment of migraine is an economically attractive option, leading to savings in overall costs. Increases in drug costs seem acceptable in light of reductions in symptom duration.

Sumatriptan: economic evidence for its use in the treatment of migraine, the Canadian comparative economic analysis.

The objective of this study was to evaluate economic and health effects of sumatriptan relative to customary therapy in Canada. The relationship between treatment and functionality was established based on analysis of existing data from a multinational study. A Monte Carlo model was developed to simulate 1 year for each of customary therapy and six sumatriptan formulations. Costs are expressed in 1998 Canadian dollars. Sumatriptan is expected to reduce the time spent with migraine symptoms and resulting time lost. Under customary therapy, the annual cost of lost time is estimated at pound908 ($1973). With sumatriptan, these costs ranged from pound406 ($882) with subcutaneous sumatriptan to pound577 ($1254) with nasal sumatriptan 10 mg, saving pound331-502 ($719-1091) in the annual cost of time lost. All these benefits are expected to be obtained at an additional drug cost ranging from pound869 ($1889) for subcutaneous sumatriptan to pound278 ($605) for sumatriptan suppository. The cost of sumatriptan treatment is significantly offset by a substantial reduction of costs associated with time lost due to migraine symptoms.

Economic analysis of initial HIV treatment. Efavirenz- versus indinavir-containing triple therapy.

OBJECTIVE: To compare the clinical and economic outcomes associated with triple therapy containing efavirenz or indinavir and 2 nucleoside reverse transcriptase inhibitors (NRTIs; zidovudine and lamivudine) in HIV-positive patients. DESIGN AND SETTING: An economic model based on viral load and CD4+ cell counts to predict long term outcomes such as progression to AIDS and AIDS-related death was developed and then analysed using data from a randomised clinical trial. Cost estimates from the healthcare system perspective were based on data from 6 state, all-payor databases, the AIDS Cost and Services Utilisation Study, and other literature. Analyses were carried out for time horizons between 5 and 15 years. PATIENTS AND INTERVENTIONS: HIV-positive patients with limited exposure to NRTIs. Initial regimens consisted of efavirenz or indinavir, each combined with 2 NRTIs. A maximum of 2 switches to other regimens was permitted. MAIN OUTCOME MEASURES AND RESULTS: The efavirenz-containing triple therapy regimen was predicted to prolong survival at a savings of up to 10,923 US dollars (1998 values) relative to initial therapy with the indinavir-containing regimen. Patients who receive efavirenz are expected to have 11% greater survival at 5 years and fewer treatment failures (28 vs 52%, at 2 years). Overall, the economic and health benefits predicted for the efavirenz-containing regimen were robust to reasonable variation in key parameters. CONCLUSIONS: The superior clinical trial outcomes for efavirenz-containing regimens should translate into substantial economic and health benefits.

Predicting treatment costs after acute ischemic stroke on the basis of patient characteristics at presentation and early dysfunction.

BACKGROUND: Given the pressure on healthcare budgets, assessing the cost of managing a disease has become a major research focus; yet collection of these data are labor intensive and difficult. Understanding the predictors of cost provides an efficient means of incorporating such information in decision-making concerning new therapies. METHODS: Data from two 12-week multinational trials that collected information on a variety of neurological, functional, and cost parameters for 1341 ischemic stroke patients were examined by means of multiple linear regression. Because the intent is for the model to be predictive, only patient characteristics that can be known at the time of patient presentation or shortly thereafter were evaluated for inclusion in the model. RESULTS: The Barthel Index was the strongest predictor of cost in all models evaluated. Other major predictors, either directly or through their impact on survival, were stroke subtype, neurological impairment, congestive heart failure, and country. A good model fit was obtained, judging by the model statistics (model F:=84, 3 df, P:<0.0001) and the accuracy of the predictions (<3% difference between mean actual and predicted cost). CONCLUSIONS: Through the use of key patient characteristics, this regression model allows for prediction of the cost of stroke care, which may be helpful in the context of therapeutic decisions and budgetary planning purposes. It also provides insight into how specific treatments, through their impact on clinical characteristics, can modify the cost of stroke treatment.

Secondary prevention fallacy: pitfalls in comparing with primary.

A basic tenet of our culture is the idea that preventing ills is better than curing them. This principle is entrenched in many proverbs and popular admonitions: 'A stitch in time saves nine', 'An ounce of prevention is worth a pound of cure'. These well-worn sayings crisply convey our sense that it is preferable to intervene before a bad event occurs than to wait and try to mitigate it afterwards. Yet, economic analyses have demonstrated that in healthcare this does not hold: 'primary prevention' does not provide as good value-for-money as 'secondary prevention'. Is this reversal of folk wisdom correct? Or, instead, is it a result of faults in the application of the relatively new methodology of cost-effectiveness analyses?

Alzheimer's disease and other dementia in nursing homes: levels of management and cost.

OBJECTIVE: To estimate comparative management levels and the annual cost of caring for a nursing home resident with and without dementia. METHOD: Data from the 1995 Massachusetts Medicaid nursing home database were used to examine residents with Alzheimer's disease, other types of dementia, and no dementia to determine care and dependency levels. Massachusetts Medicaid 1997 per-diem rates for each of 10 designated management levels were applied accordingly to residents in each level to estimate annual care costs. Costs from this analysis are reported in 1997 U.S. dollars. RESULTS: Of the 49,724 nursing home residents identified, 26.4% had a documented diagnosis of dementia. On average, a resident with dementia requires 229 more hours of care annually than one without dementia, resulting in a mean additional cost of $3,865 per patient with dementia per year. CONCLUSIONS: Dementia increases the care needs and cost of caring for a nursing home resident.

Does electronic implementation of questionnaires used in asthma alter responses compared to paper implementation?

BACKGROUND: Electronic implementation of questionnaires has many advantages, but there may be concerns that it alters versions that were validated on paper. OBJECTIVE: To determine whether electronic implementation alters responses to the SF-36 and asthma quality of life questionnaire (AQLQ), compared to paper implementation. METHODS: Patients with asthma presenting to a pneumologist were asked for consent to participate. Each patient completed both forms of each questionnaire. The order of presentation was alternated sequentially, with the first patient completing the electronic version first. Each patient waited at least 2 hours between completions to minimize recollection of answers. For both the SF-36 and AQLQ, intraclass correlations coefficients were calculated to compare patients' scores, for each scale and overall, on the electronic and paper versions. RESULTS: Sixty-eight patients (mean age: 48 years, 50 females) of 311 contacted were enrolled. Overall intraclass correlation coefficients for the SF-36 and AQLQ were excellent (0.965 and 0.991 respectively). For paper versions, eight questions (AQLQ) and 24 (SF-36) were left blank and nine questions (SF-36) were answered incorrectly by patients selecting more than one answer. Electronic data for one patient could not be retrieved. CONCLUSION: Collecting SF-36 and AQLQ data electronically can decrease the number of spoiled responses without altering the results. Successful implementation depends on proper instruction of the respondent in the handling of the electronic instrument.

Are the WOSCOPS clinical and economic findings generalizable to other populations? A case study for Belgium. The WOSCOPS Economic Analysis Group. West of Scotland Coronary Prevention Study.

AIMS: As the West of Scotland Coronary Prevention Study (WOSCOPS) was conducted in Scotland, a country well-known for its high cardiovascular risk, the generalizability of its findings on pravastatin's clinical and economic effects has been questioned. This study examines the legitimacy of this concern, using Belgium as a case study. METHODS AND RESULTS: Local information on the prevalence and clustering of risk factors in individual patients was used in a risk equation to estimate the reference risk in Belgium. In contrast to prevailing beliefs, this risk was shown to coincide with the trial population's risk. As the relative risk reduction documented in a trial should apply across populations, the health benefits observed in WOSCOPS can clearly be extrapolated. This information in combination with local costs was then used to assess the economic efficiency of primary prevention with pravastatin in Belgium by means of a previously developed model. In parallel with the original estimates for the United Kingdom, the cost-effectiveness ratios remain well within the range of what is considered strong to moderate evidence for adoption and appropriate utilization, over a wide range of input values. CONCLUSION: This study demonstrates that the clinical and economic findings from WOSCOPS can indeed be generalized to other populations.