Pasireotide for the Prevention of Pancreatic Fistula Following Pancreaticoduodenectomy: A Cost-effectiveness Analysis.

OBJECTIVE: To determine the cost-effectiveness of perioperative administration of pasireotide for reduction of pancreatic fistula (PF). SUMMARY: PF is a major complication following pancreaticoduodenectomy (PD), associated with significant morbidity and healthcare-related costs. Pasireotide is a novel multireceptor ligand somatostatin analogue, which has been demonstrated to reduce the incidence of PF following pancreas resection; however, the drug cost is significant. This study sought to estimate the cost-effectiveness of routine administration of pasireotide to patients undergoing PD, compared with no intervention from the perspective of the hospital system. METHODS: A decision-analytic model was developed to compare costs for perioperative administration of pasireotide versus no pasireotide. The model was populated using an institutional database containing all PDs performed 2002 to 2012 at a single institution, including data regarding clinically significant PF (International Study Group on Pancreatic Fistula Grade B or C) and hospital-related inpatient costs for 90 days following PD, converted to 2014 $USD. Relative risk of PF associated with pasireotide was estimated from the published literature. Deterministic and probabilistic sensitivity analyses were performed to test robustness of the model. RESULTS: Mean institutional cost of index admissions was $67,417 and $31,950 for patients with and without PF, respectively. Pasireotide was the dominant strategy, associated with savings of $1685, and a mean reduction of 1.5 days length of stay. Univariate sensitivity analyses demonstrated cost-savings down to a PF rate of 5.6%, up to a relative risk of PF of 0.775, and up to a drug cost of $2817. Probabilistic sensitivity analysis showed 79% of simulations were cost saving. CONCLUSIONS: Pasireotide appears to be a cost-saving treatment following PD across a wide variation of clinical and cost scenarios.

A decision model and cost analysis of intra-operative cell salvage during hepatic resection.

BACKGROUND: Intraoperative cell salvage (ICS) can reduce allogeneic transfusions but with notable direct costs. This study assessed whether routine use of ICS is cost minimizing in hepatectomy and defines a subpopulation of patients where ICS is most cost minimizing based on patient transfusion risk. METHODS: A decision model from a health systems perspective was developed to examine adoption and non-adoption of ICS use for hepatectomy. A prospectively maintained database of hepatectomy patients provided data to populate the model. Probabilistic sensitivity analysis was used to determine the probability of ICS being cost-minimizing at specified transfusion risks. One-way sensitivity analysis was used to identify factors most relevant to institutions considering adoption of ICS for hepatectomies. RESULTS: In the base case analysis (transfusion risk of 28.8%) the probability that routine utilization of ICS is cost-minimizing is 64%. The probability that ICS is cost-minimizing exceeds 50% if the patient transfusion risk exceeds 25%. The model was most sensitive to patient transfusion risk, variation in costs of allogeneic blood, and number of appropriate cases the device could be used for. CONCLUSIONS: ICS is cost-minimizing for routine use in liver resection, particularly when used for patients with a risk of transfusion of 25% or greater.

Rural-urban disparities in incidence and outcomes of neuroendocrine tumors: A population-based analysis of 6271 cases.

BACKGROUND: Despite their rising incidence, neuroendocrine tumors (NETs) remain a poorly understood disease. Living in a rural area (RA) affects the incidence and outcomes of other types of cancer. This study compared the incidence and outcomes of NETs for patients in RAs and patients in urban areas (UAs). METHODS: A population-based cohort study of patients with NETs in Ontario, Canada from 1994 to 2011 was conducted. An RA was defined as any community with a population < 10,000 and outside the commuting zone of a metropolitan area. Incidence, advanced stage at presentation, distant recurrence-free survival (dRFS), and overall survival (OS) were compared between patients who lived in RAs and patients who lived in UAs with univariate and multivariate regression analyses. RESULTS: The cohort included 6271 patients diagnosed with NETs, of whom 13.5% (n = 846) resided in RAs. The incidence of NETs was higher in RAs at 3.01 per 100,000 per year versus UAs at 2.82 per 100,000 per year (relative rate, 1.10; P = .04). RA living was not associated with an advanced stage at presentation (odds ratio, 1.15; 95% confidence interval, 0.96-1.38). Patients who lived in RAs had worse 10-year dRFS (62.8% vs 65.9%, P = .03) and OS (44.6% vs 48.8%, P = .004). RAs were independently associated with decreased OS (hazard ratio, 1.16; 95% confidence interval, 1.04-1.30). CONCLUSIONS: Patients are more commonly diagnosed with NETs in RAs, but they do not present at more advanced stages in comparison with patients diagnosed in UAs. Patients living in RAs experience worse cancer recurrence and OS, and this is possibly related to variations in socioeconomic status, rural environmental factors, and access to specialized health care.

Staging laparoscopy in the management of gastric cancer: a population-based analysis.

BACKGROUND: Staging laparoscopy can detect radiographically occult peritoneal metastases and prevent futile laparotomy in patients with gastric adenocarcinoma. We sought to assess the use of staging laparoscopy for gastric adenocarcinoma in a cohort of older patients and to compare outcomes after laparoscopy alone with nontherapeutic laparotomy. STUDY DESIGN: Using Surveillance, Epidemiology and End Results (SEER) population-based cancer registry data linked with Medicare claims, we identified patients aged 65 or older diagnosed with gastric adenocarcinoma between 1998 and 2005. We defined staging laparoscopy as a laparoscopic procedure from 1 month before the date of diagnosis until death and futile laparotomy as a laparotomy in the absence of a therapeutic intervention. We examined trends in the use of staging laparoscopy and compared outcomes between patients who underwent staging laparoscopy alone and those who had a futile laparotomy. RESULTS: Of 11,759 patients with gastric adenocarcinoma, 6,388 (54.3%) had at least 1 surgical procedure. Staging laparoscopy was performed in 506 (7.9%) patients who had any surgery, and 151 (29.8%) of these patients did not have a subsequent therapeutic intervention. Patients who underwent staging laparoscopy alone had a significantly lower rate of in-hospital mortality (5.3% vs 13.1%, p < 0.001) and shorter length of hospitalization (2 vs 10 days, p < 0.001) than patients who had futile laparotomy. CONCLUSIONS: Our findings in this large, population-based cohort suggest that staging laparoscopy is used infrequently in the management of older patients with gastric adenocarcinoma. Increased use of staging laparoscopy could reduce the substantial morbidity and mortality associated with nontherapeutic laparotomy.

Arthroplasty versus internal fixation of femoral neck fractures: a clinical decision analysis.

BACKGROUND: The optimal surgical management of displaced femoral neck fractures in the elderly remains controversial. Treatment alternatives include arthroplasty and internal fixation. Options for arthroplasty include total hip arthroplasty and hemiarthroplasty, whereas options for internal fixation include multiple screws and sliding hip screws. We sought to compare arthroplasty and internal fixation alternatives and determine the key factors influencing final outcomes using a clinical decision analysis. MATERIALS AND METHODS: We constructed a decision analytic model representing potential outcomes after arthroplasty and internal fixation alternatives. Probabilities of events following each procedure were systematically derived from a literature review. Relative outcome preferences were estimated using health utility questionnaires with surgeons and lay persons. Sensitivity analyses determined threshold values that would alter the preferred decision. RESULTS: In the arthroplasty comparison, patients treated with total hip arthroplasty achieved higher expected utility values than patients treated with hemiarthroplasty (0.80 versus 0.74). In the internal fixation analysis, sliding hip screw fixation yielded higher expected utility values than multiple screws (0.76 versus 0.73). Overall, total hip arthroplasty achieved higher expected utility values than either approach to internal fixation. The superiority of arthroplasty over internal fixation was maintained over a wide range of probabilities and utilities. CONCLUSIONS: When outcomes and their values are considered in a systematic manner, arthroplasty results in better patient outcomes when compared to internal fixation in the management of displaced hip fractures in the elderly.

Treatment of displaced femoral neck fractures in the elderly: a cost-benefit analysis.

BACKGROUND: The optimal treatment for displaced femoral neck fractures in elderly patients is controversial. Compared with hemiarthroplasty (HA), internal fixation (IF) is associated with less operative trauma, bleeding, and possibly lower mortality at the expense of a higher reoperation rate and possibly increased cost. METHODS: We estimated the costs from a third party payer perspective after 1 year of 2 strategies (HA and IF) for the treatment of femoral neck fractures in patients over the age of 60 years. Using a decision board, we elicited patient preferences for the 2 operative approaches and calculated the net benefit using the willingness-to-pay technique. RESULTS: The 1-year projected cost of 1 IF was $18,100, and that of 1 HA was $15,843 (incremental cost of $2257 for each IF). Of 108 participants, 61 (56.5%) chose IF as the preferred treatment option and were willing to pay an average of $3.33 per month to have this option available if needed. In Ontario, the total incremental cost of performing IF in patients that choose it was $64,714,103, and the total societal benefit was $289,263,600, yielding a net benefit of $224,549,497. CONCLUSION: The benefits of IF over HA outweigh the incremental costs from the perspective of a third-party payer. IF should be available to patients that choose it.

The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia.

BACKGROUND: The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies. METHODS: We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis. RESULTS: From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed. CONCLUSIONS: Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.