Wage losses among spouses of women with nonmetastatic breast cancer.

BACKGROUND: The aim of this study was to evaluate the wage losses incurred by spouses of women with nonmetastatic breast cancer in the 6 months after the diagnosis. METHODS: A prospective cohort study of spouses of women diagnosed with nonmetastatic breast cancer who were recruited in 8 hospitals in the province of Quebec (Canada) was performed. Information for estimating wage losses was collected by telephone interviews conducted 1 and 6 months after the diagnosis. Log-binomial regressions were used to identify personal, medical, and employment characteristics associated with experiencing wage losses, and generalized linear models were used to identify characteristics associated with the proportion of usual wages lost. RESULTS: Overall, 829 women (86% participation) and 406 spouses (75% participation) consented to participate. Among the 279 employed spouses, 78.5% experienced work absences because of breast cancer. Spouses were compensated for 66.3% of their salary on average during their absence. The median wage loss was $0 (mean, $1820) (2003 Canadian dollars). Spouses were more likely to experience losses if they were self-employed or lived 50 km or farther from the hospital. Among spouses who experienced wage losses, those who were self-employed or whose partners had invasive breast cancer lost a higher proportion of wages. CONCLUSIONS: Although spouses took some time off work, for many, the resulting wage losses were modest because of compensation received. Still, the types of compensation used may hide other forms of burden for families facing breast cancer.

Cost effectiveness of the addition of a comprehensive CT scan to the abdomen and pelvis for the detection of cancer after unprovoked venous thromboembolism.

IMPORTANCE: Unprovoked venous thromboembolism (VTE) can be the first manifestation of cancer. It is unclear if extensive screening for occult cancer including a comprehensive computed tomography (CT) scan of the abdomen/pelvis is cost-effective in this patient population. OBJECTIVE: To assess the health care related costs, number of missed cancer cases and health related utility values of a limited screening strategy with and without the addition of a comprehensive CT scan of the abdomen/pelvis and to identify to what extent testing should be done in these circumstances to allow early detection of occult cancers. PARTICIPANTS AND SETTING: Cost effectiveness analysis using data that was collected alongside the SOME randomized controlled trial which compared an extensive occult cancer screening including a CT of the abdomen/pelvis to a more limited screening strategy in patients with a first unprovoked VTE, was used for the current analyses. MAIN OUTCOMES AND MEASURES: Analyses were conducted with a one-year time horizon from a Canadian health care perspective. Primary analysis was based on complete cases, with sensitivity analysis using appropriate multiple imputation methods to account for missing data. RESULTS: Data from a total of 854 patients with a first unprovoked VTE were included in these analyses. The addition of a comprehensive CT scan was associated with higher costs ($551 CDN) with no improvement in utility values or number of missed cancers. Results were consistent when adopting multiple imputation methods. CONCLUSIONS AND RELEVANCE: The addition of a comprehensive CT scan of the abdomen/pelvis for the screening of occult cancer in patients with unprovoked VTE is not cost effective, as it is both more costly and not more effective in detecting occult cancer.

Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes.

BACKGROUND: Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage. METHODS: A 2-group effectiveness study was completed comparing patients who received the 'Ottawa Model' for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups. RESULTS: The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001). CONCLUSIONS: Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.

Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada.

INTRODUCTION: Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD). METHODS: We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained. RESULTS: From the hospital payer's perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses. DISCUSSION: The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking.

Estimating quality of life in acute venous thrombosis.

IMPORTANCE: Future funding for new treatments in venous thromboembolism will be guided by cost-utility analyses. There is little available information on the utility of acute venous thromboembolism, limiting the validity of economic analyses. OBJECTIVE: To measure the quality of life in the health states relating to thromboembolism cost-utility analyses. DESIGN: A prospective cohort study. SETTING: A single-center, university-affiliated thrombosis clinic. PARTICIPANTS: Two hundred sixteen thrombosis clinic patients with a history of lower limb deep vein thrombosis (DVT) or pulmonary embolism (PE). EXPOSURES: Participants consented to take a standard gamble interview. Each participant rated the quality of life in acute DVT, acute PE, and bleeding complication health states. MAIN OUTCOMES AND MEASURES: The standard gamble measured quality of life (utility value) for acute DVT, acute PE, major intracranial bleeding event, minor intracranial bleeding event, and gastrointestinal bleeding event. RESULTS: Two hundred fifteen responses were included in the analysis. Twenty-six percent had experienced both PE and DVT; 54%, DVT alone; and 20%, PE alone. Forty-two percent had experienced more than 1 episode of thrombosis, and 23% had had cancer-associated thrombosis. We found the median utility for acute DVT was 0.81 (interquartile range [IQR], 0.55-0.94); acute PE, 0.75 (IQR, 0.45-0.91); major intracranial bleeding event, 0.15 (IQR, 0.00-0.65); minor intracranial bleeding event, 0.75 (IQR, 0.55-0.92); and gastrointestinal bleeding event, 0.65 (IQR, 0.15-0.86). The median length of symptoms for DVT or PE was 1 week (IQR, <1-3 weeks). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest published study on utilities in which the participants had personal experience of venous thromboembolism. We present unique information for economic analyses but have also identified future challenges for research in this area. Our summary results differ from those previously published, and we found wide variation in individual responses.

Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses.

BACKGROUND: We lack comprehensive information about the extent of out-of-pocket costs after diagnosis of early breast cancer and their effects on the family's financial situation. METHODS: This longitudinal study assessed out-of-pocket costs and wage losses during the first year after diagnosis of early breast cancer among Canadian women and spouses. Out-of-pocket costs for treatments and follow-up, consultations with other practitioners, home help, clothing, and natural health products were estimated, with information collected from telephone interviews. Generalized linear models were used to identify women at risk of having higher costs and the effects of out-of-pocket costs on perceptions of the family's financial situation. RESULTS: Overall, 829 women (participation, 86.2%) and 391 spouses participated. Women's median net out-of-pocket costs during the year after diagnosis were $1002 (2003 Canadian dollars; mean = $1365; SD = $1238), and 74.4% of these costs resulted from treatments and follow-up. Spouses' median costs were $111 (mean = $234; SD = $320), or 9% of couples' total expenses. In multivariable analyses, the percentage of women with out-of-pocket costs of $1773 or more (upper quartile) was statistically significantly associated with higher education, working at diagnosis, living more than 50 km from the hospital where surgery was performed, and having two and three different types of adjuvant treatment (all 2-sided P values ≤ .01). However, when considered simultaneously with wage losses, out-of-pocket costs were not associated with perceived deterioration in the family's financial situation; rather, wage losses were the driving factor. CONCLUSIONS: Overall, out-of-pocket costs from breast cancer for the year after diagnosis are probably not unmanageable for most women. However, some women were at higher risk of experiencing financial burden resulting from these costs.

Comparing multiple competing interventions in the absence of randomized trials using clinical risk-benefit analysis.

BACKGROUND: To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery. METHODS: Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding. RESULTS: The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement. CONCLUSIONS: Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance.

Evaluating survivorship care plans: results of a randomized, clinical trial of patients with breast cancer.

PURPOSE: An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes. PATIENTS AND METHODS: Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures. RESULTS: Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005). CONCLUSION: The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer.

Out-of-pocket costs for accessing adjuvant radiotherapy among Canadian women with breast cancer.

PURPOSE: Patients with breast cancer incur out-of-pocket costs when they receive adjuvant radiation. These treatments are administered in dedicated centers on a daily basis over 4 to 5 weeks. We assessed the extent of out-of-pocket costs to access radiotherapy and identified women at risk of experiencing higher costs. PATIENTS AND METHODS: This prospective study was conducted among 800 women from eight Quebec hospitals (participation, 86%), of whom 693 women received adjuvant radiotherapy. Costs to access treatment (transportation, parking, lodging, and meals) were estimated on the basis of information collected by telephone interviews. Generalized linear models were used to identify women at risk of having higher costs. RESULTS: Mean and median total costs (including financial aid received) to access radiotherapy were 445 Canadian dollars (Can$; standard deviation, Can$407) and Can$311, respectively. Women who lived at home but far from the radiotherapy center had the highest risk of experiencing weekly costs of at least Can$122 (highest quartile; prevalence ratio [PR], 5.8; 95% CI, 4.7 to 7.1) followed by women who lived away from home and farther from the center (PR, 4.5; 95% CI, 3.4 to 6.0) and by women who lived away from home and closer to the center (PR, 2.14; 95% CI, 1.3 to 3.5). When women stayed at a cancer lodge during treatment, costs were reduced by 80%. CONCLUSION: Considered in and of themselves, out-of-pocket costs for access to radiotherapy appeared relatively modest. Financial assistance initiatives for women who lived away from home during treatments contributed to a substantial reduction of access costs. These efforts should be maintained, but financial assistance should also target patients with cancer who live at home during treatments but have to travel relatively long distances on a daily basis.

(Correcting) misdiagnoses of asthma: a cost effectiveness analysis.

BACKGROUND: The prevalence of physician-diagnosed-asthma has risen over the past three decades and misdiagnosis of asthma is potentially common. OBJECTIVE: to determine whether a secondary-screening-program to establish a correct diagnosis of asthma in those who report a physician diagnosis of asthma is cost effective. METHOD: Randomly selected physician-diagnosed-asthmatic subjects from 8 Canadian cities were studied with an extensive diagnostic algorithm to rule-in, or rule-out, a correct diagnosis of asthma. Subjects in whom the diagnosis of asthma was excluded were followed up for 6-months and data on asthma medications and heath care utilization was obtained. Economic analysis was performed to estimate the incremental lifetime costs associated with secondary screening of previously diagnosed asthmatic subjects. Analysis was from the perspective of the Canadian healthcare system and is reported in Canadian dollars. RESULTS: Of 540 randomly selected patients with physician diagnosed asthma 150 (28%; 95%CI 19-37%) did not have asthma when objectively studied. 71% of these misdiagnosed patients were on some asthma medications. Incorporating the incremental cost of secondary-screening for the diagnosis of asthma, we found that the average cost savings per 100 individuals screened was $35,141 (95%CI $4,588-$69,278). CONCLUSION: Cost savings primarily resulted from lifetime costs of medication use averted in those who had been misdiagnosed.

Validity of information obtained from a method for estimating cancer costs from the perspective of patients and caregivers.

PURPOSE: We describe a method we developed for estimating cancer costs from the perspective of patients and caregivers and evidence supporting validity of estimates obtained. METHODS: To increase validity, interview questions were anchored to treatments; costs were divided into their components; most questions focused on facts; and the research team combined responses into cost estimates. Evidence for validity comes from a prospective study of breast cancer costs using this method. RESULTS: Estimates obtained using interview responses were similar to those from independent sources. Women reported being reimbursed $205 on average for prosthesis (government reimbursement =$200); paying $15.48 per night at cancer lodge (average rate =$17.52); receiving government illness insurance for 14.6 weeks at 53% of usual salary (governmental program covers 15 weeks at 55%). A priori hypotheses about relations of costs with other characteristics were also confirmed. For example, patients' weekly travel costs increased as a function of distance from the radiotherapy center, with patients living <25, 25-49 and ≥50 km away spending $54, $141 and $240, respectively (P<.0001); and the proportion of annual salary lost was 37% for self-employed workers compared to 18% for employees (P<.0001). CONCLUSIONS: Evidence to date supports the validity of estimates obtained using this method.

Wage losses in the year after breast cancer: extent and determinants among Canadian women.

BACKGROUND: Wage losses after breast cancer may result in considerable financial burden. Their assessment is made more urgent because more women now participate in the workforce and because breast cancer is managed using multiple treatment modalities that could lead to long work absences. We evaluated wage losses, their determinants, and the associations between wage losses and changes for the worse in the family's financial situation among Canadian women over the first 12 months after diagnosis of early breast cancer. METHODS: We conducted a prospective cohort study among women with breast cancer from eight hospitals throughout the province of Quebec. Information that permitted the calculation of wage losses and information on potential determinants of wage losses were collected by three pretested telephone interviews conducted over the year following the start of treatment. Information on medical characteristics was obtained from medical records. The main outcome was the proportion of annual wages lost because of breast cancer. Multivariable analysis of variance using the general linear model was used to identify personal, medical, and employment characteristics associated with the proportion of wages lost. All statistical tests were two-sided. RESULTS: Among 962 eligible breast cancer patients, 800 completed all three interviews. Of these, 459 had a paying job during the month before diagnosis. On average, these working women lost 27% of their projected usual annual wages (median = 19%) after compensation received had been taken into account. Multivariable analysis showed that a higher percentage of lost wages was statistically significantly associated with a lower level of education (P(trend) = .0018), living 50 km or more from the hospital where surgery was performed (P = .070), lower social support (P = .012), having invasive disease (P = .086), receipt of chemotherapy (P < .001), self-employment (P < .001), shorter tenure in the job (P(trend) < .001), and part-time work (P < .001). CONCLUSION: Wage losses and their effects on financial situation constitute an important adverse consequence of breast cancer in Canada.

Surveillance mammography following the treatment of primary breast cancer with breast reconstruction: a systematic review.

BACKGROUND: Both the prevalence of breast cancer and the number of breast cancer patients seeking breast reconstruction are increasing, highlighting the importance for evidence to direct the clinician in the follow-up of these patients. Current practice guidelines recommend surveillance mammography of the contralateral breast in all breast cancer patients, and of the ipsilateral breast in women treated with breast-conserving surgery. However, there are no guidelines specifically addressing the role of surveillance mammography for women who have undergone mastectomy and breast reconstruction. METHODS: A systematic review was conducted to identify studies specifically addressing the issue of surveillance mammography among women with breast reconstruction following treatment for primary breast cancer. RESULTS: This systematic review identified eight articles, consisting of case reports and case series, that address the issue of surveillance mammography of the ipsilateral breast in women with breast reconstruction. The articles demonstrated that certain local recurrences are able to be detected by surveillance mammography. CONCLUSION: This study has demonstrated the paucity of evidence and highlighted the need for further research to evaluate this issue.

Cost-effectiveness of irbesartan 300 mg given early versus late in patients with hypertension and a history of type 2 diabetes and renal disease: a Canadian perspective.

BACKGROUND: The Irbesartan in Reduction of Microalbuminuria trial and the Irbesartan in Diabetic Nephropathy Trial found that irbesartan is renoprotective in patients having hypertension with type 2 diabetes. OBJECTIVE: The objective of this study was to assess whether treatment with irbesartan is cost-effective in Canada relative to conventional care in this patient population and whether it is more cost-effective to treat patients early rather than later in the development of renal disease from the perspective of the Canadian health and social care system. METHODS: The analysis compared 3 alternative strategies for the management of hypertension in patients with type 2 diabetes and early renal disease: (1) conventional hypertensive treatment excluding the use of angiotensin II receptor antagonists (AIIRAs); (2) the early addition of irbesartan (an AIIRA) to conventional treatment; and (3) the late addition of irbesartan to conventional treatment. A Markov model was used to simulate the progression of renal disease (microalbuminuria to death) in hypertensive patients with type 2 diabetes over a 25-year time horizon. Transition probabilities were derived from the 2 randomized controlled trials. A cost-effectiveness analysis was conducted with outcome measured in life-years gained (LYGs). RESULTS: The early addition of irbesartan during microalbuminuria was cost-saving and more effective than both delaying irbesartan treatment until advanced overt nephropathy (AON) (0.45 LYG, Can $54,100 saved) and conventional antihypertensive use (0.62 LYG, $68,400 saved). This was due to the increased drug costs associated with the use of irbesartan being offset by savings arising from delays in the development of overt nephropathy and the subsequent delay to end-stage renal disease (ESRD). Sensitivity analyses confirmed the robustness of the study results. CONCLUSIONS: The early use of irbesartan for patients with hypertension and type 2 diabetes who have yet to develop overt nephropathy is both more effective and less costly than delaying irbesartan treatment until AON and conventional antihypertensive use. Analysis suggests that the earlier irbesartan is added to conventional antihypertensive treatment, the greater the delays in the onset of ESRD and the overall savings in health care resource utilization from the perspective of the Canadian health and social care system.

Signet-ring cell carcinoma of the urinary bladder mimicking retroperitoneal fibrosis.

We present the case of a 77-year-old white woman with a past medical history of transitional cell carcinoma of the urinary bladder that presented with symptoms of acute renal failure and duodenal obstruction and posed a diagnostic dilemma. Initially, she presented with bilateral ureteral strictures and eventually required bilateral nephrostomy tubes. Later, the patient developed intractable nausea and vomiting secondary to a duodenal stricture. The finding of a "stranding appearance" on computed tomography imaging of the retroperitoneal space raised the suspicion of retroperitoneal fibrosis. Subsequent endoscopic placement of metal stents to relieve the duodenal obstruction failed to relieve her symptoms. The patient's poor general condition precluded an exploratory laparotomy. The patient expired shortly thereafter and an autopsy was performed. The autopsy results revealed full wall thickness signet-ring cell carcinoma of the urinary bladder with extensive metastasis to the retroperitoneum.

Impact of program duration and contact frequency on efficacy and cost of cardiac rehabilitation: results of a randomized trial.

BACKGROUND: Secondary prevention through cardiac rehabilitation (CR) has been recommended for most patients with coronary artery disease (CAD). Although generally reimbursed for 3 months, to date, optimal CR program duration and frequency of patient contact has yet to be identified. This study compared standard (33 sessions for 3 months) versus distributed (33 sessions for 12 months) CR for effects on exercise variables, risk factors, health-related quality of life (HRQL), depressive symptoms, and direct costs to the cardiac health care system. METHODS: We randomly assigned 392 patients to either standard CR (n = 196) or distributed CR (n = 196). Outcomes were cardiorespiratory fitness, daily physical activity, coronary risk factors, generic and heart disease HRQL, and depressive symptoms, measured 12 and 24 months after program intake. Secondary outcomes included these variables measured after 3 months. Costs to the cardiac health care system were determined 2 years after program initiation. RESULTS: Both groups showed improvements over time in cardiorespiratory fitness, daily physical activity, low-density lipoprotein cholesterol, generic and heart disease HRQL, and depressive symptoms. Over time, blood pressure and body mass index values worsened. Smoking status, high-density lipoprotein cholesterol, and triglyceride levels remained unchanged. There were no clinically meaningful or statistically significant between group differences for outcomes at 12 or 24 months. The costs of the programs to the cardiac health care system were not different. CONCLUSIONS: From a clinical standpoint, this study indicates that both standard and distributed program formats serve patients with CAD equally well over the longer term. Programs could use either program delivery model (standard or distributed) depending on patient or program needs. Costs to the cardiac health care system are similar.

Cost effectiveness of Elidel in the management of patients with atopic dermatitis in Canada.

BACKGROUND: With increasing pressure on health care resources, it is necessary to demonstrate that new treatments are both effective and cost effective. OBJECTIVE: The purpose of this study was to assess the cost effectiveness of pimecrolimus (Elidel) compared to usual therapy in the treatment of both adults and children with atopic eczema in Canada. METHODS: Analysis was performed using a decision model which estimated the incremental cost per quality adjusted life year (QALY) gained from both a societal and health care perspective. RESULTS: For children, Elidel leads an incremental cost per QALY of 38,000 dollars from a societal perspective. For adults, the incremental cost per QALY was 35,000 dollars. CONCLUSION: Elidel will lead to an overall increase in costs but with an improvement in clinical outcomes. The cost effectiveness ratios for Elidel were consistently below 50,000 dollars per QALY gained. Given previous funding decisions in Canada, Elidel may be considered a cost-effective use of health care resources.

Impact of particulate air pollution on quality-adjusted life expectancy in Canada.

Air pollution and premature death are important public health concerns. Analyses have repeatedly demonstrated that airborne particles are associated with increased mortality and estimates have been used to forecast the impact on life expectancy. In this analysis, we draw upon data from the American Cancer Society (ACS) cohort and literature on utility-based measures of quality of life in relation to health status to more fully quantify the effects of air pollution on mortality in terms of quality-adjusted life expectancy. The analysis was conducted within a decision analytic model using Monte Carlo simulation techniques. Outcomes were estimated based on projections of the Canadian population. A one-unit reduction in sulfate air pollution would yield a mean annual increase in Quality-Adjusted Life Years (QALYs) of 20,960, with gains being greater for individuals with lower educational status and for males compared to females. This suggests that the impact of reductions in sulfate air pollution on quality-adjusted life expectancy is substantial. Interpretation of the results is unclear. However, the potential gains in QALYs from reduced air pollutants can be contrasted to the costs of policies to bring about such reductions. Based on a tentative threshold for the value of health benefits, analysis suggests that an investment in Canada of over 1 billion dollars per annum would be an efficient use of resources if it could be demonstrated that this would reduce sulfate concentrations in ambient air by 1 microg/m(3). Further analysis can assess the efficiency of targeting such initiatives to communities that are most likely to benefit.

Which cancer clinical trials should be considered for economic evaluation? Selection criteria from the National Cancer Institute of Canada's Working Group on Economic Analysis.

Rising health care costs, expensive new health care technologies and increasing patient expectations are placing huge pressures on the publicly funded health care system in Canada. As a result, policy makers need information on the cost and cost-effectiveness of new therapies in addition to their clinical benefits. In response to this need, the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) established a Working Group on Economic Analysis (WGEA) to provide advice on the economic evaluation of new cancer therapies. This article describes the WGEA's recommendations on which trials should be considered for concurrent analysis of economic, as well as related issues, such as the number of patients required for an economic analysis within a prospective clinical trial and the selection of participating centres. The recommendations in this document are meant to be pragmatic, as the WGEA recognizes that both the research funds and human resource capacity for this type of research in Canada are limited. These recommendations are currently guiding priority setting with regard to trials for economic evaluation in NCIC trials. Examples of how these recommendations have been applied to actual trials are presented.