Economic evaluation in chronic pain: a systematic review and de novo flexible economic model.

There is unmet need in patients suffering from chronic pain, yet innovation may be impeded by the difficulty of justifying economic value in a field beset by data limitations and methodological variability. A systematic review was conducted to identify and summarise the key areas of variability and limitations in modelling approaches in the economic evaluation of treatments for chronic pain. The results of the literature review were then used to support the development of a fully flexible open-source economic model structure, designed to test structural and data assumptions and act as a reference for future modelling practice. The key model design themes identified from the systematic review included: time horizon; titration and stabilisation; number of treatment lines; choice/ordering of treatment; and the impact of parameter uncertainty (given reliance on expert opinion). Exploratory analyses using the model to compare a hypothetical novel therapy versus morphine as first-line treatments showed cost-effectiveness results to be sensitive to structural and data assumptions. Assumptions about the treatment pathway and choice of time horizon were key model drivers. Our results suggest structural model design and data assumptions may have driven previous cost-effectiveness results and ultimately decisions based on economic value. We therefore conclude that it is vital that future economic models in chronic pain are designed to be fully transparent and hope our open-source code is useful in order to aspire to a common approach to modelling pain that includes robust sensitivity analyses to test structural and parameter uncertainty.

Hospital cost of Clostridium difficile infection including the contribution of recurrences in French acute-care hospitals.

BACKGROUND: The impact of Clostridium difficile infection (CDI) on healthcare costs is significant due to the extra costs of associated inpatient care. However, the specific contribution of recurrences has rarely been studied. AIM: The aim of this study was to estimate the hospital costs of CDI and the fraction attributable to recurrences in French acute-care hospitals. METHODS: A retrospective study was performed for 2011 on a sample of 12 large acute-care hospitals. CDI costs were estimated from both hospital and public insurance perspectives. For each stay, CDI additional costs were estimated by comparison to controls without CDI extracted from the national DRG (diagnosis-related group) database and matched on DRG, age and sex. When CDI was the primary diagnosis, the full cost of stay was used. FINDINGS: A total of 1067 bacteriological cases of CDI were identified corresponding to 979 stays involving 906 different patients. Recurrence(s) were identified in 118 (12%) of these stays with 51.7% of them having occurred within the same stay as the index episode. Their mean length of stay was 63.8 days compared to 25.1 days for stays with an index case only. The mean extra cost per stay with CDI was estimated at €9,575 (median: €7,514). The extra cost of CDI in public acute-care hospitals was extrapolated to €163.1 million at the national level, of which 12.5% was attributable to recurrences. CONCLUSION: The economic burden of CDI is substantial and directly impacts healthcare systems in France.

Physical fitness assessment in multiple sclerosis patients: a controlled study.

There is growing evidence to show the effectiveness of physical exercise for multiple sclerosis (MS) patients. Aim of this study was to evaluate aerobic capacity, strength, balance, and the rate of perceived exertion (RPE) after exercise, in ambulatory patients with mild MS and matched control healthy participants. Seventeen MS patients aged 48.09 ± 10.0 years, with mild MS disability (Expanded Disability Status Scale: EDSS 1.5 to 4.5) and 10 healthy sedentary age matched (41.9 ± 11.2 years) subjects volunteered for the study. MS patients underwent medical examination with resting electrocardiogram, arterial blood pressure, EDSS, and Modified Fatigue Impact Scale-MFIS. Both groups also underwent physical assessment with the Berg Balance Scale(,) test (Berg), Six Minutes Walking Test (6MWT), maximal isometric voluntary contraction (MIVC) of forearm, lower limb, shoulder strength test, and the Borg 10-point scale test. The one-way ANOVA showed significant differences for MFIS (F1.19=9.420; p<0.01), Berg (F1.19=13.125; p<0.01), handgrip MIVC (F1.19=4.567; p<0.05), lower limbs MIVC (F1.19=7.429; p<0.01), and 6MWT (F1.19=28.061; p<0.01) between groups. EDSS, Berg test and Borg scores explained 80% of 6MWT variation. Mild grade EDSS patients exhibited impaired balance, muscle strength, and low self pace-6MWT scores, whereas RPE response after the exercise was similar to that of sedentary individuals. Both groups showed similar global physiological adjustments to exercise.

Management of focal epilepsy in adults treated with polytherapy in France: the direct cost of drug resistance (ESPERA study).

PURPOSE: To estimate the direct costs associated with the current management of focal epilepsy in adults treated with a combination of antiepileptic drugs (AEDs) in France and the supplementary costs of drug resistant epilepsy as defined by the International League Against Epilepsy (ILAE) in 2009. METHODS: ESPERA was a multicentre, observational, cross-sectional study conducted in France in 2010. A random sample of neurologists, including specialists in epilepsy, prospectively enrolled adults with focal epilepsy treated with a combination of AEDs. Investigators classified their patients according to the 2009 ILAE criteria for drug resistance and this classification was then reviewed by two experts. All items of healthcare resource use associated with epilepsy over the previous year were documented retrospectively and valued from a societal perspective. RESULTS: Seventy-one neurologists enrolled 405 patients. After experts' review, 70.6% of patients were classified with drug-resistant epilepsy, 22.4% with drug-responsive epilepsy and 7% with undefined epilepsy. The mean annual epilepsy-related direct costs per patient were €4485±€4313 in patients with drug-resistant epilepsy compared to €1926±€1795 in patients with drug-responsive epilepsy. In these two groups, costs of AEDs were estimated at €2603 and €1544, respectively. Patients with drug-resistant epilepsy were more often hospitalised (mean annual cost: €1270 vs. €97) and underwent more additional tests (mean annual cost: €194 vs. €53). CONCLUSION: The direct cost of focal epilepsy in adults on AED combinations was estimated at €3850/patient/year. Drug resistance, as defined by the 2009 ILAE criteria, resulted in significant extra costs which varied with seizure frequency.

Management of relapsed or refractory multiple myeloma in French hospitals and estimation of associated direct costs: a multi-centre retrospective cohort study.

WHAT IS KNOWN AND BACKGROUND: For relapsed or refractory multiple myeloma (RRMM), a series of novel agents (thalidomide, bortezomib and lenalidomide) has emerged during the latest decade, but their use in routine clinical practice is not well documented as well as the cost of RRMM. OBJECTIVE: Our aim is to review the therapeutic management of such patients in France and to estimate the associated costs. METHODS: A retrospective cohort study, based on chart reviews, was conducted in French Haematology Departments over the period 2004-2007 and the associated direct costs estimated. RESULTS: One hundred and two patients with a relapse after first-line therapy were selected from five centres. The average follow-up from diagnosis or the date of first relapse to death or to the latest news was respectively 56.25 and 23.53 months. Novel agents were used in 73% of all cases, and in all cases of first relapse. Thalidomide and bortezomib were respectively the most frequently used second-line (57%) and third-line treatments (44%). The average number of lines of treatment received per patient as from first relapse was 2.75 (min 1; max 8) and the mean direct cost per month was estimated at 3130 € after the first relapse. This cost was represented in greater part by the cost of chemotherapy drugs (66%). WHAT IS NEW AND CONCLUSION: The use of novel agents such as thalidomide, bortezomib and lenalidomide for RRMM is highly prevalent in France from the first relapse. The associated medical cost is substantial mainly due to the cost of the new agents.

In-patient care costs of patients with bipolar I disorder: a comparison between two European centers.

BACKGROUND: Bipolar disorder (BPD) is a disabling disease with high morbidity rates. An international (Spain, France) comparative study about hospitalizations and in-patient care costs associated with BPD I was performed. Centers were included if they had access to a database of computerized patient charts exhaustively covering a defined catchment area. METHODS: Economic evaluation was performed by multiplying the average cumulated annual length of stay (LOS) of hospitalized bipolar patients by a full cost per day of hospitalization in each center to obtain the corresponding annual costs. RESULTS: Hospitalization rates per annum and per 100,000 individuals (general population aged 15+) were similar between France (43.6) and Spain (43.1). There were only slight differences in relation to length of stay (LOS) per patient hospitalized with 18.1 days in Spain and 20.4 days in France. The overall estimated annual hospitalization costs were in the same order of magnitude after adjustment to an adult population of 100,000: euro 232,000 (Spain) and euro 226,500 (France). Mixed episodes had the longest LOS followed by depressive episodes, while manic episodes had the shortest ones. Mania was the most costly disorder representing 53.7% of annual BPD in-patient care costs. CONCLUSIONS: BPD I care requires large resources and frequent hospitalizations, especially during manic episodes. Depressive and mixed episodes require longer hospital stays than manic episodes. Out-patient costs should now be evaluated.

Spinal curvature: comparison of frontal measurements with the Spinal Mouse and radiographic assessment.

AIM: The Spinal Mouse is an external non-invasive device which measures the spinal shape and mobility of the spine in several planes. The aim of the present study was to evaluate the reliability and the validity of the Spinal Mouse to assess frontal standing measurements of the spine in a sample of young healthy volunteers. METHODS: Twenty-six young volunteers of both sex took part in the study. Angle data of vertebral inclination of each subject in frontal view were measured by Spinal Mouse and standard radiography for vertebral segments from T1-T2 down to L5-S1. RESULTS: Repetition of the measurements by Spinal Mouse performed by two examiners in different days resulted in no significant difference for the parameter examined, as well as measurements performed by the two examiners in the same day (P<0.05). The ICC values showed no correlation between the two devices in the following pairs of vertebrae: T2-T3, T4-T5, T5-T6, T7-T8, T8-T9, T9-T10, T11-T12, T12-L1, L1-L2, L3-L4, L4-L5. CONCLUSION: The Spinal Mouse results, concerning the standing frontal curvature of the spine, even if reliable, were poor when compared with the standard radiography.

[Methodological aspects of economic evaluation in pediatrics: illustration by RSV infection prophylaxis in the French setting]. / Aspects méthodologiques de l'évaluation économique du médicament en pédiatrie : exemple de la prophylaxie de l'infection à VRS en France.

The methodological approach of the economic evaluation of drugs in pediatrics is illustrated by the case study of the prophylaxis for RSV infections using palivizumab in the French setting. The indications for the reimbursement of this treatment have been restricted to premature children with bronchopulmonary dysplasia (BPD) or hemodynamically significant congenital-heart disease. A model was developed primarily using the results of the pivotal clinical studies on palivizumab. Unit costs were estimated (2006 values) in both societal and payer's perspectives. An assumption was made and discussed on the benefits of the prophylaxis on mortality. Based on the different data available and the estimated costs and benefits, different cost-effectiveness ratios (CERs) were estimated from both the society's and payer's points of view. A discount rate of 3% was applied to benefit. The CER obtained in the most unfavorable case is considered acceptable for the innovative-medical technologies in the French-healthcare system. Some of the parameters used by the model will be illustrated from the EPIPAGE study data from 2 of the 9 regions involved in this study: this evaluation suggests that the children not having an RSV infection during their 1st year of life will continue to require significantly fewer hospitalizations in the following years. These additional evaluations also suggest that the model overestimates the costs of the treatment with regard to the true medical situation. This could be explained by the model not using the children's exact weight or the real number of injections because the children had been discharged from the maternity ward based on their date of birth and the epidemic period. In spite of these factors, RSV prophylaxis using palivizumab in premature children with BPD or hemodynamically significant congenital-heart disease can be considered cost-effective in France.

Estimation of direct unit costs associated with non-vertebral osteoporotic fractures in five European countries.

The objective of this study was to estimate the unit costs of non-vertebral osteoporotic fractures in five European countries based on the results of the SOTI and TROPOS clinical trials in postmenopausal osteoporotic women. The information recorded in the Case Report Forms was used. The perspective of third party payers was adopted. Hip fracture unit cost was the highest. The ranges of costs among countries was narrow for hip from 8,346 euros (Italy) to 9,907euros (France), but wider for other fractures: 890 euros (Spain) to 2,022 euros (Italy) for wrist, 1,167euros (Spain) to 3,268 euros (Italy) for pelvis, 837euros (Spain) to 2,116 euros (Italy) for sternum/clavicle, 565 euros (Spain) to 908 euros (France) for rib, 1,518 euros (Spain) to 3,651 euros (Belgium) for humerus, 1,805 euros (Spain) to 3,521 euros (Italy) for leg. The costs of those fractures should be considered when estimating the cost of osteoporosis.

[Assessment of human papillomavirus testing on liquid-based Cyto-screen system for women with atypical squamous cells of undetermined significance. Effect of age]. / Evaluation du test de détection des papillomavirus humains en milieu liquide Cyto-screen après diagnostic d'atypies des cellules malpighiennes de signification indéterminée. Effet de l'âge.

OBJECTIVE: Analyse the performance of human papillomavirus testing with hybrid capture II on liquid-based CYTO-screen system for women diagnosed with atypical squamous cells of undetermined significance according to the age. PATIENTS AND METHODS: Were included all women diagnosed with atypical squamous cells of undetermined significance for whom human papillomavirus testing was performed and cytological and histological procedures were available over a follow-up period of 6 to 18 months. RESULTS: Human papillomavirus testing was performed in 3,047 patients, and results were compared to cytological and histological follow-up diagnosis in 1,880 cases (61.7%). The sensitivity for diagnosing cervical intraepithelial neoplasia was 93.3% in women less than 30 of age and 89.7% in women more than 30 of age. Specificity was 44.9% in women less than 30 of age and 64.4% in women more than 30 of age. Likelihood ratios confirmed these results as they show a low discriminatory power in case of positive result specifically in women less than 30 of age but an excellent performance in case of negative result. DISCUSSION AND CONCLUSION: The use of human papillomavirus testing after a diagnosis of atypical squamous cells of undetermined significance with the residual material of Cyto-screen system is a possible triage procedure to identify patients needing a colposcopy. Its specificity is better for women over 30.

[An epidemiological model of genital herpes for assessment of potential impact of therapy and prophylaxis: application to France]. / Un modèle épidémiologique de l'herpès génital pour l'évaluation des interventions thérapeutiques et prophylactiques.

OBJECTIVES: This study was performed to quantify the development of the number of cases of genital herpes and to assess the impact of different treatment strategies in France. METHOD: A model for the natural history of herpes simplex virus genital infection is presented and applied to the French population. The model encompasses infection by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), first episodes, recurrences, viral shedding and the effect of treatment on infected individuals. RESULTS: In the Year 2000, 270,000 individuals would have suffered from genital herpes in France. A total annual cumulated number of 1.5 million episodes of recurrence and 23 million days of viral shedding were estimated. Seventy percent of viral shedding occurred in sub-clinical seropositive individuals. The expected number of attributable neonatal deaths remained very low. Systematic treatment of clinical episodes might reduce the number of days with lesions (- 27 p. 100), and is also effective on viral shedding (symptomatic: - 50 p. 100). Continuous treatment of the most severe patients (>or=6 recurrences per Year) might reduce viral shedding slightly more (- 85 p. 100). Antiviral treatment might have a major impact on the quality of life of these patients but would only slightly curb the number of new infections. DISCUSSION: This model tries to integrate the various data currently available at international level on the epidemiology of genital herpes. However, many aspects are still not well documented and remain uncertain. It is therefore necessary to define various assumptions in order to simulate the natural history of the disease in a population. The lack of French data especially on the HSV-1 and HSV-2 seroprevalence profiles reinforces these uncertainties. Our results should hence be considered as exploratory. However, this modeling approach is the only possible way to integrate the multiple parameters describing the pathology and predicting of the public health impact of different interventions. This model is an open tool which may be modified when new data become available.

Donepezil for the treatment of mild to moderate Alzheimer's disease in France: the economic implications.

In the present study, the socioeconomic impact of the use of the acetylcholinesterase inhibitor donepezil in patients with mild to moderate Alzheimer's disease (AD) living in France was examined. A model was created to extrapolate over a 3-year period the results from placebo-controlled trials together with epidemiological and prevalence data. Costs considered in the model were net societal costs associated with paid and unpaid assistance, general medical consumption and institutional care. The model suggested that delays in cognitive decline and functional dependence due to treatment reduced the time spent in institutional care and the burden on caregivers. Over a 3-year period, total net costs of caring for untreated patients with an initial Mini-Mental State Examination score ranging from 10 to 26 were EUR 53,206 compared with EUR 42,720 for a patient treated with donepezil--an annual cost saving of approximately EUR 3,500 per patient. Cost savings were mainly due to savings in unpaid caregiver time, which, apart from patient institutionalization, represented the most costly component of total care in this study but had no direct budgetary impact. Overall, these data suggest that donepezil is a cost-effective treatment for mild to moderately impaired AD patients living in France.

[Bipolar I disorder in France: prevalence of manic episodes and hospitalisation-related costs]. / Le trouble bipolaire I en France: prévalence des épisodes maniaques et coût des hospitalisations pour ce motif.

Bipolar disorder is a chronic, highly disabling illness. However, few studies have evaluated the economic impact of this illness. The objective of this study was to estimate: 1) the annual number of manic episodes in patients with bipolar I disorder, and 2) the costs of hospitalisations related to manic episodes in France. We only included data on bipolar I disorder, as there is greater consensus and better documentation for this subgroup of patients with bipolar disorder. The prevalence of manic episodes was estimated using published epidemiological data. A computerised literature search was performed using the traditional scientific and medical databases. Additional epidemiological references were identified from published studies and textbooks. For hospitalisation data, we used the statistics of the Medical Information Department of a large psychiatric hospital in Paris for the year 1999. We estimated the annual number of manic episodes in France based on: 1) the lifetime prevalence of bipolar I disorder, 2) the average cycle duration, 3) the proportion of rapid cycling patients, and 4) the proportion of depressive vs. manic episodes for patients with bipolar I disorder. In order to estimate the prevalence of bipolar I disorder, we conducted a random effects meta-analysis using published international data. Results of the meta-analysis, which was based on a total of 62 736 patients, showed the lifetime prevalence of bipolar I disorder to be 0.82% [95% CI: 0.42, 1.21]. Applied to the adult population in France, this prevalence implies that the number of persons who have ever experienced a bipolar I -disorder is approximately 390,000 [95% CI: 200,000, 575,000]. Few studies provide information on the duration of cycles in patients with bipolar I disorder. Available estimates suggest the cycle duration to be approximately 12 months. Regarding the proportion of rapid cyclers, data from the meta-analysis by Tondo et al. show that 18% of patients with bipolar disorder experience at least four episodes of mood disorder per year. Finally, based on findings provided by cohort studies, the number of depressive episodes appears to be roughly equal to the number of manic episodes during the course of bipolar disorder. A rapid cycling rate of 18% and a cycle duration of 12 months imply that, on average, among 100 bipolar patients, 18 will have a 3-month cycle duration and 82 a 14-month cycle duration. Given an equal proportion of manic and depressive episodes, the annual number of manic episodes would then be 68 for a cohort of 100 bipolar patients (0.68 episode per patient per year). Applying this figure to the estimate of the total number of patients with bipolar I disorder in France suggests that the annual number of manic episodes in France is 265,000 [95% CI: 136,000, 391,000]. Based on data from a psychiatric hospital in Paris, the proportion of manic episodes that require hospitalisation was estimated to be around 63% with an average length of stay of 32.4 days. Hence the annual number of hospitalisations for manic episodes in France is estimated to be 167 000 [95% CI: 86 000, 246 000] and the hospitalisation-related costs 1,3 billion euros approximately. Our review of literature highlights the lack of medical and economic data at the national level on the frequency and hospitalisation-related costs of manic episodes in patients with bipolar I disorder in France. Given the lifetime prevalence of bipolar I disorder which may be as high as 3% among adults, further studies are required in order to provide representative national data and to allow economic evaluations of costs related to bipolar disorder in France.

A simulation model for evaluating the medical and economic outcomes of screening strategies for colorectal cancer.

Mathematical models have been shown to be useful in predicting the cost-effectiveness of cancer screening programmes. We designed a computer macro-simulation model aimed at predicting the cost-effectiveness of alternative colorectal cancer screening strategies. This model was built to determine the cost-effectiveness of a biennial screening programme using the Hemoccult test in Burgundy (France). It was validated with data from the Danish randomized study. Estimates of our model showed an extremely close concordance with observed results in the Danish study. The observed mortality reduction was 18.0% and the estimated mortality reduction was 18.4%. Preliminary data from the Burgundy study predict a 14.6% colorectal cancer mortality reduction after 10 years. Sensitivity analyses were performed with different assumptions regarding the participation rates and the lead-time. This model can serve to assess the cost-effectiveness of a variety of screening modalities.

Cost of care for inpatients with community-acquired intra-abdominal infections.

Few studies have assessed the actual costs associated with failure of initial empiric antibiotic therapy administered to patients with community-acquired intra-abdominal infections. The goals of this study were (i) to determine the frequency of unsuccessful initial empiric therapy in a real-world setting and (ii) to determine the associated impact on medical costs. Thus, a retrospective chart review was performed at four acute-care university hospitals in France. A total of 292 patients hospitalized for community-acquired intra-abdominal infection were included. The mean age of the cohort was 51 years, and 42% of the patients were female. The most commonly administered empiric regimens were intravenous amoxicillin/clavulanate alone (69 patients) or in combination with other antibiotics ( n=87) and piperacillin/tazobactam alone ( n=24) or in combination ( n=48). Other regimens included broad-spectrum penicillin, cephalosporins, and fluoroquinolones administered alone or in combination ( n=64). Empiric therapy was successful in 189 (65%) patients and unsuccessful in 103 (35%). Among the 292 patients with community-acquired infection, 15 died of the infection, 8 required reoperation and 80 required second-line antibiotic therapy. Patients with unsuccessful initial empiric therapy had significantly more parenteral antibiotic days (10.3 vs. 7.6 days) and a longer length of stay (16.2 vs. 12.8 days) compared to those with successful initial empiric therapy. A better selection of initial empiric antibiotic therapy may significantly influence the medical costs associated with patients who are hospitalized with community-acquired intra-abdominal infections.

[Management, cost and mortality of a cohort of patients with advanced heart failure (the EPICAL study)]. / Prise en charge et coût de l'insuffisance cardiaque sévère dans l'étude EPICAL en Lorraine.

The objectives of this study are to describe the management, outcomes and costs of patients with severe chronic heart failure (CHF) and to identify the associated socio-demographic and clinical determinants. In 1994, the EPICAL study enrolled in a French region a representative cohort of 358 patients presenting for the first time with severe CHF (NYHA class III or IV) requiring hospitalization. The mean annual cost per patient was 125 652 FF, 92.6 per cent of which was associated with in-patient care including the index hospitalization. Ten per cent of patients contributed 33 per cent of the total cumulative costs. The rate of readmission was very high (20 per cent per month of follow-up) and appeared as a major cost driver. Three variables were identified in a multivariate logistic regression as the main contributors to cost: the presence of co-morbidity, renal insufficiency and marital status (living alone versus with spouse). These findings confirmed the major clinical and economic interest of any intervention that could lower the rate of readmissions in this group of patients.

Cost effectiveness of emedastine versus levocabastine in the treatment of allergic conjunctivitis in 7 European countries.

OBJECTIVE: To assess the cost effectiveness of emedastine, a new antihistamine, versus levocabastine in the treatment of acute allergic conjunctivitis (AAC) in Belgium, France, Germany, The Netherlands, Norway, Portugal and Sweden. DESIGN AND SETTING: Randomised double-blind multicountry clinical trial followed by economic modelling from the treatment provider perspective. PATIENTS: A total of 221 patients (109 emedastine, 112 levocabastine) with AAC were included. METHODS: The clinical trial compared the efficacy and safety of emedastine 0.05% and levocabastine 0.05%, both twice daily, for 42 days, using ocular redness, itching, days without symptoms and clinical failure as outcome measures. The cost of first-line treatment failure, including visits, drugs and laboratory examinations, was established in each country from a panel of ophthalmologists and general practitioners. Full sensitivity analyses were conducted. RESULTS: From day 7 to 42, patients treated with emedastine had less itching (p < 0.001) and less redness (p < 0.001). The failure rate was 10% less (p < 0.02) with emedastine and patients treated with emedastine had an incremental 8.5 days (p < 0.01) without symptoms. Emedastine and levocabastine were equally well tolerated. In all European countries, the cost of failure was lower with emedastine. Emedastine was found to be economically dominant relative to levocabastine, i.e. more effective and less expensive, in Belgium, Germany, Portugal and Sweden; in France, The Netherlands and Norway the incremental cost was low (less than 1 euro per additional symptom-free day). CONCLUSION: Through a model based on a randomised clinical trial and cost estimates of treatment failure derived from practitioner interviews, emedastine is a cost-effective treatment of AAC.

[Can donor insemination be optimised?]. / Peut-on optimiser l'insémination avec donneur?

OBJECTIVE: To compare the different donor insemination technics. MATERIAL AND METHOD: Analysis of the published studies about donor insemination which value the effectiveness of Intra Cervical Insemination (ICID) and Intra Uterine Insemination (IUID), the interest of ovulation induction, the possible complications, and the cost-effectiveness ratio. RESULTS: The meta-analysis of the Cochrane data base (10 comparative studies IUID versus ICID, 2568 donor insemination cycles) lead to a pregnancy rate per cycle (PRC) 17.77% with IUID versus 7.68% with ICID. The odds ratio is 2.63 (CI from 1.85 to 3.73). With these PRC, the direct cost per evolutive pregnancy is 54,780 F with ICID and 25,675 F with IUID. CONCLUSION: If it is possible to propose ICID to patient with an excellent regularity of ovulation. IUID with ovulation induction by gonadotropins is today the gold standard, and more especially as the law restrict the number of donor inseminations. Indeed, the IUID is two or three times more effective than ICID, consume the half of sperm straws, use a semen of moderate quality, there is no complication provided that the cycle is cancelled if there is more than two mature follicles and the cost-effectiveness ratio is greatly in favour with IUID.

Economic analysis of adjuvant therapy with interferon alpha-2a in stage II malignant melanoma.

Using the trial demonstrating that interferonalpha-2a (IFNalpha-2a) is efficacious as adjuvant therapy in stage II melanoma, we evaluate its outcomes and economic consequences. Using rates observed in the 5-year trial and published figures, survival and Q-TWIST (Time Without Symptoms and Toxicity) were extrapolated to a 10-year and lifetime horizon. Cost analysis was performed using the trial's data, published literature and experts' opinions from the perspective of the French Sickness Funds. Patients in the IFNalpha-2a-group have an additional 0.26 years in life-expectancy over a 5-year time period (P=0.046), 0.67 years over a 10-year period and 2.59 years over a lifetime. Cost per life-year-gained was estimated at approximately 14400 after 5 years, 6635 after 10 years and 1716 over a lifetime. Assuming that there is an improvement in disease-free survival only, cost is 26147 per Q-TWIST. Cost-effectiveness of IFNalpha-2a in stage II melanoma compares favourably with estimates for widely used therapies in the oncological field.