Economic evaluation of school-based caries preventive programs: A systematic review.

OBJECTIVE: Assess interventions and health outcomes in studies giving data on economic evaluation (EE) of school-based caries prevention. BASIC RESEARCH DESIGN: Systematic review. Both partial EE that included cost description, cost-outcome description, cost analysis and full EE that included both cost and outcome of at least 2 interventions were included. Quality assessment used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. RESULTS: An electronic search of 6 databases identified 558 titles and abstracts. Paper eligibility screening identified 32 full papers which met the inclusion criteria. Most were conducted in the United States and cost effectiveness analysis was the most common type of EE. Nine were model-based studies and 17 derived their data from single studies. Sealants were most frequently evaluated followed by fluoride mouthrinse. Many CHEERS criteria were not met in the included studies. The following were found to be cost-effective: school-based, under general supervision, longer duration of program and targeting high caries risk groups. CONCLUSIONS: The deficiencies in the existing studies warrant more investigations of the economic aspects of school-based activities interventions to prevent caries.

Comparing the cost-effectiveness of linezolid to trimethoprim/sulfamethoxazole plus rifampicin for the treatment of methicillin-resistant Staphylococcus aureus infection: a healthcare system perspective.

OBJECTIVE: Few industry-independent studies have been conducted to compare the relative costs and benefits of drugs to treat methicillin-resistant Staphylococcus aureus (MRSA) infection. We performed a stochastic cost-effectiveness analysis comparing two treatment strategies-linezolid versus trimethoprim-sulfamethoxazole plus rifampicin-for the treatment of MRSA infection. METHODS: We used cost and effectiveness data from a previously conducted clinical trial, complementing with other data from published literature, to compare the two regimens from a healthcare system perspective. Effectiveness was expressed in terms of quality-adjusted life-years (QALYs). Several sensitivity analyses were performed using Monte Carlo simulation, to measure the effect of potential parameter changes on the base-case model results, including potential differences related to type of infection and drug toxicity. RESULTS: Treatment of MRSA infection with trimethoprim-sulfamethoxazole plus rifampicin and linezolid were found to cost on average €146 and €2536, and lead to a gain of 0.916 and 0.881 QALYs, respectively. Treatment with trimethoprim-sulfamethoxazole plus rifampicin was found to be more cost-effective than linezolid in the base case and remained dominant over linezolid in most alternative scenarios, including different types of MRSA infection and potential disadvantages in terms of toxicity. With a willingness-to-pay threshold of €0, €50 000 and €200 000 per QALY gained, trimethoprim-sulfamethoxazole plus rifampicin was dominant in 100%, 96% and 85% of model iterations. A 95% discount on the current purchasing price of linezolid would be needed when it goes off-patent for it to represent better value for money compared with trimethoprim-sulfamethoxazole plus rifampicin. CONCLUSIONS: Combined treatment of trimethoprim-sulfamethoxazole plus rifampicin is more cost-effective than linezolid in the treatment of MRSA infection.

Multistate modelling to estimate the excess length of stay associated with meticillin-resistant Staphylococcus aureus colonisation and infection in surgical patients.

Currently available evidence on the excess length of stay (LOS) associated with nosocomial infections is limited by methodology, including time-dependent bias. To determine the excess LOS associated with nosocomial meticillin-resistant Staphylococcus aureus (MRSA) infection and colonisation, 797 MRSA-colonised, 167 MRSA-infected and 13,640 MRSA-negative surgical patients were included in a multistate model. The occurrence of MRSA infection or colonisation was the time-dependent exposure, and discharge or death was the study endpoint. The excess LOS was extracted by computing the Aalen-Johansen estimator of the matrix of transition probabilities. Multivariate Cox regression analysis was used to assess the independent effect of MRSA on excess LOS. MRSA infection prolonged LOS by 14.5 [95% confidence interval (CI): 7.8, 21.3] days compared to uninfected patients, and by 5.9 (95% CI: 0.1, 11.7) days compared to patients only colonised by MRSA. The hazard of discharge was reduced by nosocomial MRSA infection both with respect to MRSA-free patients and MRSA carriers [adjusted hazard ratio (HR): 0.69; 95% CI: 0.59, 0.81; and HR: 0.79; 95% CI: 0.65, 0.95, respectively]. MRSA carriage alone did not decrease the hazard of discharge after adjustment for confounding (HR: 1.00; 95% CI: 0.93, 1.07). Multistate modelling is a promising statistical method to evaluate the health-economic impact of nosocomial antibiotic-resistant infections.

Estimating the impact of healthcare-associated infections on length of stay and costs.

Healthcare-associated infections (HAIs) unquestionably have substantial effects on morbidity and mortality. However, quantifying the exact economic burden attributable to HAIs still remains a challenging issue. Inaccurate estimations may arise from two major sources of bias. First, factors other than infection may affect patients' length of stay (LOS) and healthcare utilization. Second, HAI is a time-varying exposure, as the infection can impact on LOS and costs only after the infection has started. The most frequent mistake in previously published evidence is the introduction of time-dependent information as time-fixed, on the assumption that the impact of such exposure on the outcome was already present on admission. Longitudinal and multistate models avoid time-dependent bias and address the time-dependent complexity of the data. Appropriate statistical methods are important in analysis of excess costs and LOS associated with HAI, because informed decisions and policy developments may depend on them.

Cost-effectiveness of universal MRSA screening on admission to surgery.

Policy-makers have recommended universal screening to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Risk profiling of MRSA carriers and rapid PCR tests are now available, yet cost-effectiveness data are limited. The present study assessed the cost-effectiveness of universal PCR screening on admission to surgery. A decision analysis model from the hospital perspective compared costs and the probability of any MRSA infection across three strategies: (i) PCR screening; (ii) screening for risk factors (prior hospitalization or antibiotic use) combined with pre-emptive isolation and contact precautions pending chromogenic agar results; and (iii) no screening. Clinical data were taken from studies at a Swiss teaching hospital as well as from published literature. Costs were derived from hospital accounting systems. Compared to no screening, the PCR strategy resulted in higher costs (CHF 10503 vs. 10358) but a lower infection probability (0.0041 vs. 0.0088), producing a base-case incremental cost-effectiveness ratio of CHF 30784 per MRSA infection avoided. The risk factor strategy was more costly yet less effective than PCR, although, after varying epidemiologic inputs, the costs and effects of both screening strategies were similar. Sensitivity analyses suggested that on-admission prevalence of MRSA carriage predicts cost-effectiveness, alongside the probability of cross-transmission, and the costs of MRSA infection, screening and contact precautions. Although reducing the risk of MRSA infection, universal PCR screening is not strongly cost-effective at our centre. However, local epidemiology plays a critical role. Settings with a higher prevalence of MRSA colonization may find universal screening cost-effective and, in some cases, cost-saving.

Onset of symptom relief with rabeprazole: a community-based, open-label assessment of patients with erosive oesophagitis.

BACKGROUND: In numerous clinical trials, proton pump inhibitors have demonstrated potent acid suppression and healing of erosive oesophagitis, as well as successful symptom relief for the entire spectrum of gastro-oesophageal reflux disease. AIM: The 'Future of Acid Suppression Therapy' (FAST) trial evaluated, in actual clinical practice, the timing of symptom relief, changes in symptom severity, health-related quality of life and safety in endoscopically confirmed erosive gastro-oesophageal reflux disease treated with rabeprazole. METHODS: This open-label, multicentre study enrolled 2579 patients to receive rabeprazole treatment using 20 mg once daily for 8 weeks. Between two clinical visits (at enrollment and week 8), patients used an interactive voice response system to rate gastro-oesophageal reflux disease symptoms. Subgroup analyses of efficacy were conducted for gender, age, Hetzel-Dent grade, presence of Barrett's oesophagus and for patients reporting previously ineffective symptom relief with omeprazole or lansoprazole. RESULTS: On day 1, rabeprazole significantly decreased daytime and night-time heartburn severity, regurgitation and belching. Complete relief of daytime and night-time heartburn was achieved in 64.0% and 69.2% of symptomatic patients, respectively, on day 1, and in 81.1% and 85.7% of patients, respectively, on day 7. Patients with moderate or severe heartburn symptoms at baseline achieved an even greater degree of satisfactory symptom relief (none or mild) from day 1 onwards. The median time to satisfactory heartburn relief was 2 days. Subgroup analyses showed no consistent differences in efficacy compared to the overall population treated. Health-related quality of life in patients was significantly lower than that of the US general population and improved significantly after 8 weeks of rabeprazole therapy. Rabeprazole was well tolerated, with headache as the most common adverse event, reported by less than 2% of the study population. CONCLUSIONS: In this large, open-label trial, rabeprazole rapidly and effectively relieved gastro-oesophageal reflux disease symptoms in most patients with erosive oesophagitis. Substantial symptom relief was noted on day 1; improvement continued over the first week and at week 4. By week 8, the health-related quality of life had also improved vs. baseline.

Racial differences in access to high-quality cardiac surgeons.

OBJECTIVES: Racial differences in access to cardiac artery bypass graft (CABG) surgery are well documented. This study extends the literature by examining racial differences in access to high-quality cardiac surgeons. METHODS: The analyses included 11,296 CABG surgeries in New York State in 1996. Regression techniques were used to identify significant associations between a patient's race, health maintenance organization (HMO) enrollment, and the quality of the surgeon performing the surgery, measured by the surgeon's risk-adjusted mortality rate (RAMR). RESULTS: Non-Whites were more likely than Whites to have access to surgeons of higher RAMR, by 11.7% among HMO enrollees (1-tailed P < .1) and by 5.4% among fee-for-service enrollees (1-tailed P < .05). CONCLUSIONS: Even when racial minorities do gain access to CABG services, they are more likely that non-Whites to receive care from lower-quality providers.