Potential health economic impact of intravenous iron supplementation to erythropoiesis-stimulating agent treatment in patients with cancer- or chemotherapy-induced anemia.

BACKGROUND: Intravenous (i.v.) iron supplementation significantly improves the response to erythropoiesis-stimulating agent (ESA)-based therapies in patients with cancer- or chemotherapy-induced anemia. The economic implications of adding i.v. iron to ESA treatment are less well investigated. Published randomized controlled trials do not provide sufficient data for a comprehensive cost-effectiveness analysis. METHODS: Preliminary cost calculations from the Swiss health care system perspective based on a meta-analysis and published results of eight randomized controlled trials without correction for decreased ESA need provide a conservative cost-effectiveness estimate. RESULTS: The additional total cost of i.v. iron supplementation ranged from EUR 417 to EUR 901 per patient depending on the evaluated iron-carbohydrate complex. Considering a 24% absolute increase in the proportion of ESA responders, the incremental cost-effectiveness ratios per additional responder are EUR 1,704-3,686. In routine practice, better values may be achieved due to ESA dose savings. CONCLUSION: Supplementation of ESAs with i.v. iron appears to be an economically viable treatment option in anemic cancer patients. Additional research on ESA dose savings and cost-effectiveness is required.

Trastuzumab beyond progression: a cost-utility analysis.

BACKGROUND: The continuation of trastuzumab beyond progression in combination with capecitabine as secondary chemotherapy for HER2-positive metastatic breast cancer (MBC) prolongs progression-free survival without a substantial increase in toxicity. PATIENTS AND METHODS: A Markov cohort simulation was used to follow the clinical course of typical patients with MBC. Information on response rates and major adverse effects was derived, and transition probabilities were estimated, based on the results of the Breast International Group 03-05 clinical trial. Direct costs were assessed from the perspective of the Swiss health care system. RESULTS: The addition of trastuzumab to capecitabine is estimated to cost on average an additional of €33,980 and to yield a gain of 0.35 quality-adjusted life years (QALYs), resulting in an incremental cost-effectiveness ratio of €98,329/QALYs gained. Probabilistic sensitivity analysis showed that the willingness-to-pay threshold of €60,000/QALY was reached in 12% of cases. CONCLUSION: The addition of trastuzumab to capecitabine in MBC patients is more expensive than what is typically regarded as cost-effective but falls within the value ranges found for established regimens in the treatment of MBC.

Cost-effectiveness of antihypertensive treatment in patients 80 years of age or older in Switzerland: an analysis of the HYVET study from a Swiss perspective.

This analysis shows the economic benefit of antihypertensive treatment in patients 80 years of age or older from the perspective of the Swiss healthcare system. The cost-effectiveness analysis of antihypertensive treatment in the elderly was carried out applying the results of the Hypertension in the Very Elderly Trial study to the Swiss healthcare system. The analysis shows that hypertension treatment provides, compared with placebo, an additional life expectancy of 0.0457 years per patient, over a follow-up period of 2 years. The medication cost was covered by the reduction of costs related to the treatment of strokes, myocardial infarctions and heart failure: the total cost per patient in the active group resulted in a dominant strategy of savings compared with the placebo group. Sensitivity analysis yielded a stable estimate after varying the costs of medication, stroke, myocardial infarction, heart failure and life expectancy, confirming the robustness of these results. Moreover, considering that antihypertensive treatment also positively affects the incidence of dementia, those net benefits might even be underestimated.

[Evolution of influenza vaccination coverage in France from 2001 to 2006]. / Evolution du taux de couverture vaccinale contre la grippe en France : de 2001 à 2006.

INTRODUCTION: The increased risk of a new influenza pandemic has raised awareness of the need for high influenza vaccination rates. OBJECTIVES: This study aims at assessing trends in influenza vaccination coverage from 2001 to 2006 in France, at understanding the drivers and barriers, and to identify vaccination intentions for 2006/2007. METHODS: We conducted a mail-based household survey on 9,835 persons representative of the population from age 15. Essentially, the same questionnaire was used in all seasons. RESULTS: The influenza vaccination coverage rate slightly increased, reaching 24.2% in 2005/2006 (70.1% in patients over 65). In the last two seasons the fact that the vaccination was provided for free was the most frequent reason for getting vaccinated. Older age, considering influenza as a serious disease and recommendations from the family doctor or nurse were also important drivers for vaccination. Only 2% of those vaccinated in 2005/2006 indicated the threat of avian influenza as a reason. The reasons for non-vaccination among persons never vaccinated before were feeling too young for vaccination, never having considered vaccination before and absence of recommendation by the family doctor. Among those who were previously vaccinated but not in the current season, the reasons for not being vaccinated were not finding vaccination necessary, forgetfulness and having influenza-like illness despite vaccination. CONCLUSION: Stable vaccination rates were observed from 2001 to 2006. France is well on its way to reach the international vaccination goal set by the WHO (75% in the elderly population), but continuously effort is needed for others.

Cost-effectiveness of trastuzumab in the adjuvant treatment of early breast cancer: a model-based analysis of the HERA and FinHer trial.

BACKGROUND: Routine adjuvant administration of trastuzumab (T) has been implemented in most centers, but its economic impact has not yet been well examined. METHODS: A Markov model was constructed based on clinical data of the Herceptin Adjuvant (HERA) and the Finland Herceptin (FinHer) trials. Costs from the perspective of a Swiss health care provider were calculated based on resource use. RESULTS: On the basis of HERA data, our model yielded an overall survival rate of 71.8% for the T group versus 62.8% for the control group [risk ratio (RR) = 0.87) after 10 years and 62.9% versus 52.7% (RR = 0.84) after 15 years. Cost-effectiveness resulted in 40505 Euros (EUR) per life years gained (LYG) after 10 years and 19673 EUR per LYG after 15 years. For the FinHer regimen, overall survival after 10 and 15 years resulted in 81.8% versus 66.1% (RR = 0.81) and 73.6% versus 57.0% (RR = 0.77). Costs of 8497 EUR per patient could be saved after 10 years and 9256 EUR after 15 years compared with the control group. CONCLUSION: In a long-term perspective, adjuvant T based on the HERA regimen can be considered cost-effective. The regimen used in the FinHer trial is even cost saving, but estimations are based on a single small trial.

Pharmacoeconomics of anticoagulation therapy for stroke prevention in atrial fibrillation: a review.

INTRODUCTION: Atrial fibrillation (AF) increases the risk of ischemic stroke 5-fold and may not only be responsible for as many as 15% of all strokes that occur but also for larger and more disabling strokes than those attributable to other causes which increase the associated costs of care. Anticoagulation with warfarin in the target INR of 2.5 is a major clinical challenge in real-life practice, given that the complex relationship between warfarin dosage and response is readily altered by a variety of factors such as concurrent medications, illnesses, genetic influences, and dietary/lifestyle changes. Consequently, INR values are out of the target range approximately half of the time in real-life studies compared to clinical trial setting. Current anticoagulation therapies are less likely to be cost-effective in routine clinical practice and need improvement. The aim of this review is to discuss the pharmacoeconomic consequences of this management strategy by analysing the optimal treatment option within specific age and risk groups, confirming current guidelines for a health economic perspective and considering the economic impact on health care policy. METHODS: An electronic search of the Medline/PubMed database from 1966 to 2005 was performed to identify articles dealing with all pharmacoeconomic aspects of stroke prevention in atrial fibrillation. The following search terms were used: 'atrial fibrillation', 'stroke', 'cost', 'warfarin'. RESULTS: Treatment with warfarin is cost-effective (versus aspirin or no therapy) in patients with AF at moderate-to-high risk of stroke. The cost-effectiveness of anticoagulation therapy is driven by the achieved risk reduction rather than the potential benefits estimated from clinical trials. Failure to maintain optimal anticoagulation places patients at risk of complications, the management of which is a significant cost driver. CONCLUSION: Improvement could be achieved by optimising physicians and patient's knowledge driven through prevention campaigns by health care policy.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

[Cost-effectiveness of atorvastatin for the prevention of coronary disease. An analysis of the ASCOT study]. / Kosteneffektivität von Atorvastatin zur Prävention der koronaren Herzkrankheit. Eine Analyse der ASCOT Studie.

BACKGROUND: Increasing health service expenditure, on the one hand, and the politically declared objective of stability of statutory contributions and restriction of public funds, on the other hand, have been central points in the political and social discussion for several years. PATIENTS AND METHODS: Cost-effectiveness of Atorvastatin in primary prevention was analysed by applying the results of the Anglo Scandinavian Cardiac Outcomes Trial (ASCOT study) to the German health system. Costs and effectiveness were subject to an extensive sensitivity analysis. RESULTS: The cost-effectiveness of Atorvastatin treatment in Germany is approximately 10,102 Euro (95% CI: 9109; 12,881) per life-year gained. Taking 2004 price reductions into consideration, these values are reduced to 7311 Euro [95% CI: 5197; 10,091) per life-year gained. The robustness of this result was substantiated through extensive sensitivity analyses. CONCLUSION: The administration of the lipid lowering compound Atorvastatin in hypertensive patients with additional coronary heart disease risk factors in Germany is cost-effective.

Comparison of resource utilization and long-term quality-of-life outcomes between laparoscopic and conventional colorectal surgery.

BACKGROUND: The outcomes of laparosopic and conventional colorectal surgery, with special reference to costs of treatment and patients' quality of life, were compared. METHODS: A partly retrospective cohort study was designed to assess the use of resources, and a follow-up interview was undertaken to evaluate patients' quality of life after both to define laparoscopic (LAP) and conventional (CON) surgery. RESULTS: The length of hospital stay was significantly lower in the LAP group (median, 11 days; interquartile range [IQR], 9-15) than in the CON group (median, 16 days; IQR, 13-23; p < 0.0001), which is reflected in lower costs of hospitalization calculated for the three most frequent surgical interventions. Statistically significant improvements were noted between the median scores in the domains of physical functioning (LAP 85 vs CON 68; p < 0.05) and vitality (LAP 85 vs CON 69; p < 0.05). CONCLUSION: Laparoscopy is a promising alternative for the treatment of patients with colorectal diseases, offering lower costs and a better quality of life in the long term.

Cost-effectiveness studies in ovarian cancer.

Ovarian cancer is the fifth leading cause of cancer-related deaths. The costs associated with this cancer impact both on the affected individual and on the health system. Screening is currently unproven as a strategy for improving outcomes for women with ovarian cancer. Randomized controlled trials, however, are underway, estimating any impact of screening with ultrasound and CA125 on ovarian cancer mortality. Paclitaxel and carboplatin combination, the standard first-line chemotherapy regimen for ovarian cancer, has not been compared with cisplatin and cyclophosphamide regarding the cost-effectiveness and cost-utility, but for paclitaxel and cisplatin, numerous studies have addressed these issues. The estimated incremental costs resulting from these studies fall well within the generally accepted range for new therapies. Although acquisition costs of new chemotherapy drugs exceed those of older drugs, the impact of costly drugs on total costs may be cost saving due to less costs related to supportive and palliative care. The most important costs for the patient, the pain and suffering associated with ovarian cancer and its treatment, are hard to quantify. Nevertheless, patients' quality of life must be considered when making a clinical decision to treat this disease. A review of available cost-effectiveness studies is presented and discussed.

[Costs and cost-effectiveness of Eptifibatide in the treatment of coronary ischemic syndromes. An analysis based on the PURSUIT study]. / Kosten und Kosteneffektivität von Eptifibatid in der Behandlung des akuten Koronarsyndroms. Eine Analyse auf Basis der PURSUIT-Studie.

AIMS: We analyzed whether using Eptifibatide plus heparin compared to heparin alone in patients with acute coronary ischemic syndromes is cost saving and/or cost-effective from the perspective of German hospitals. Our analysis is based on the clinical results of the PURSUIT study. MATERIALS AND METHODS: We conducted an incremental cost-consequence and cost-effectiveness analysis from the perspective of the admitting hospital. Costs refer to the initial hospitalization following the event. Incremental drug costs are based on a 72 hour infusion of Eptifibatide. Additional costs are analyzed as resulting from the management of complicating myocardial infarctions, including incremental days on the general ward or intensive care unit as well as necessary revascularization procedures. All costs are expressed in EURO (EUR). The estimated costs of managing ischemic complications are based on typical patterns seen in German hospitals. Our estimation of the life-years saved by using Eptifibatide is based on the DEALE method. All calculations are standardized to a hypothetical cohort of 100 treated patients. RESULTS: There are 0.064 saved life-years per patient. Cost-effectiveness of Eptifibatide is EUR 14,464 per life-year saved. CONCLUSION: Eptifibatide is cost-effective compared to other therapies in the treatment of acute coronary ischemic syndromes. The additional costs of using this substance should be reimbursed to the hospitals.

Determinants of costs and resource utilization associated with open heart surgery.

AIMS: This study sought to determine the patient- and the therapy-related determinants of in-hospital costs for patients undergoing heart surgery at the University Hospital in Zurich. METHODS AND RESULTS: We performed a retrospective analysis of all adult cardiac surgical patients from the canton St. Gallen who were covered by a fixed fee arrangement (29,500 Swiss francs (19,470 Euro)) and referred to our institution during 1998. A total of 201 patients (143 (71%) male) with basic insurance were hospitalized in 1998 under the fixed fee arrangement. The mean age of the patients was 61.4 years (95% confidence intervals (CI): 60; 63). With the help of univariate analysis, the following pre-operative characteristics were found to be significantly associated with cost: age (P<0.001), pre-operative cardiac diagnosis (coronary vs valvular heart disease) (P<0.001) and EuroSCORE (P<0.0001). A significant correlation was also found between intra-operative variables and costs (P<0.0001) as well as between postoperative variables and costs (P<0.0001). A linear regression model based on EuroSCORE, operation time and postoperative infection status is able to predict costs for patients (all P -values <0.0001, except for P<0.05 for operation time, R(2)=0.565). CONCLUSIONS: These results suggest that both pre-operative (patient related) and intra-operative (therapy- and patient-related) variables are predictors of costs in cardiac surgical patients.

[Cost effectiveness of clopidogrel in secondary cardiovascular prevention: a cost-effectiveness analysis based on the Caprie Study]. / Die Wirtschaftlichkeit von Clopidogrel in der kardiovaskulären Sekundärprävention: eine Kosten-Effektivitäts-Analyse auf der Grundlage der Caprie-Studie.

As a result of medical progress each year numerous new therapies are introduced to the medical community, and each of them must prove its usefulness in two arenas. Firstly, does the new therapy improve outcomes relative to conventional therapy? If this test is passed, the second question is: are the improved outcomes worth the extra costs? Controlled clinical trials answer the first question and economic analysis, the second. The CARPIE-Study has proven, that Clopidogrel, a new antiplatelet drug, was superior in secondary prevention of cardiovascular events to aspirin. On the basis of this study we conducted a cost-effectiveness analysis from the perspective of Swiss third party payers. The following costs were included in the analysis: treatment costs of aspirin and clopidogrel, myocardial infarction, ischaemic stroke and primary non-fatal intracranial haemorrhage. For the calculation of the years of life gained the DEALE-method was applied. The net costs of treating 1000 patients, i.e. incremental drug costs less savings of treatment costs, are Fr. 1.5 Mio. The intervention with Clopidogrel lead to an additional gain of 63 life years in compared to aspirin. At additional yearly cost of Fr. 722.--per patient the analysis yield a cost-effectiveness of CHF 24,164 (nominal) Fr. 22,837 (discounted) per additional year of live saved. The results suggest that the cost-effectiveness of Clopidogrel in secondary prevention lie well within the range of other preventive cardiovascular interventions. Therefore, from an economic perspective the use of Clopidogrel in secondary prevention of major cardiovascular events in patients with atherosclerotic vascular disease is justifiable.

The estimated economic burden of genital herpes in the United States. An analysis using two costing approaches.

BACKGROUND: Only limited data exist on the costs of genital herpes (GH) in the USA. We estimated the economic burden of GH in the USA using two different costing approaches. METHODS: The first approach was a cross-sectional survey of a sample of primary and secondary care physicians, analyzing health care resource utilization. The second approach was based on the analysis of a large administrative claims data set. Both approaches were used to generate the number of patients with symptomatic GH seeking medical treatment, the average medical expenditures and estimated national costs. Costs were valued from a societal and a third party payer's perspective in 1996 US dollars. RESULTS: In the cross-sectional study, based on an estimated 3.1 million symptomatic episodes per year in the USA, the annual direct medical costs were estimated at a maximum of $984 million. Of these costs, 49.7% were caused by drug expenditures, 47.7% by outpatient medical care and 2.6% by hospital costs. Indirect costs accounted for further $214 million. The analysis of 1,565 GH cases from the claims database yielded a minimum national estimate of $283 million direct medical costs. CONCLUSIONS: GH appears to be an important public health problem from the health economic point of view. The observed difference in direct medical costs may be explained with the influence of compliance to treatment and possible undersampling of subpopulations in the claims data set. The present study demonstrates the validity of using different approaches in estimating the economic burden of a specific disease to the health care system.

Medical-economical aspects of high sensitivity C-reactive protein assay for the prediction of coronary heart disease. An analysis in Germany and Italy.

BACKGROUND: Elevated plasma concentrations of C-reactive protein (CRP) are associated with increased cardiovascular risk. We studied the cost-effectiveness of CRP determination in primary and secondary prevention settings in two European countries: Germany and Italy. METHODS: Using a decision analytic model we evaluated the costs and consequences of testing or not testing using a high sensitivity (hs)-CRP assay. In a primary prevention model we analyzed a hypothetical cohort of 300000 apparently healthy men divided into three age groups (35-44, 45-54 and 55-64 years). Individuals with CRP levels > 3 mg/l were administered either aspirin or statins according to lipid levels. The cohort was followed for 5 years. In the secondary prevention model hs-CRP testing was evaluated in a cohort of 10000 patients with total cholesterol levels < 4.52 mmol/l and a history of myocardial infarction or unstable angina. The two strategies tested were: 1) administer pravastatin only to those with high CRP values, and 2) treat all patients. The analysis was performed from the societal perspective. Event rates were obtained from epidemiological studies and clinical trials. RESULTS: In the primary prevention model, strategies including testing showed, for men aged 45 years and older, cost-effectiveness ratios between each life year saved (LYS) and cost savings in Germany equal to 10217euro and between each LYS and savings in Italy equal to 16950euro In the age group 35-44 years, therapy with aspirin showed cost-effectiveness ratios of 5318euro and 11203euro per LYS in Germany and in Italy respectively. The widespread use of statins showed an unfavorable cost-effectiveness profile: 44630euro per LYS in Germany and 36270euro per LYS in Italy. In the secondary prevention model, hs-testing for CRP can reduce the cost-effectiveness of pravastatin from 16400 to 6830euro per quality adjusted life year gained. Sensitivity analysis performed on the variables test price and costs of cardiovascular events resulted in minimal changes of the cost-effectiveness ratios. CONCLUSIONS: Both in the primary and the secondary prevention settings, hs-testing for CRP can better target individuals at higher risk, thus improving outcomes and resulting in a more cost-effective strategy.

Medical economic considerations of supportive cancer care.

In an era of increasing cost containment in health care, it has become extremely important to allocate resources as efficiently as possible. This implies that formal health economic considerations are taken into account. One of increasing importance is the field of economic appraisal, which allows to quantify the value for money of medical interventions. This research is extremely useful in the field of supportive care of cancer patients. Economic considerations, social, political and ethical issues will also have to be addressed. The sum of these activities will enable us to make better choices in health care and ensure that sufficient resources are allocated to supportive cancer treatment. Cancer patients have physical, social, spiritual and emotional needs. They may suffer from severe physical symptoms, from social isolation, spiritual abandonment, and emotions such as sadness and anxiety, or feelings of deception, helplessness, anger and guilt. In some of them, the disease is rapidly progressing and ultimately they die. Their demanding care evokes intense feelings in health care providers, all the more since these incurable patients represent a challenge, which could be condensed under the heading "the challenge of medical omnipotence". The complexity of the matter, the interdisciplinary approach and the emergence of an increasingly cost conscience health care environment put supportive cancer care in a difficult realm.

[Cost effectiveness of pravastatin in secondary coronary prevention in patients with myocardial infarct or unstable angina in Germany. An analysis on the basis of the LIPID trial]. / Kosteneffektivität von Pravastatin in der koronaren Sekundärprävention bei Patienten mit Myokardinfarkt oder instabiler Angina pectoris in Deutschland. Eine Analyse auf der Grundlage der LIPID-Studie.

Secondary coronary prevention with lipid lowering drugs has become a major issue in health policy formulation due to the large upfront investment in drug therapy. The recently completed LIPID trial with pravastatin in secondary prevention immediately raise the question whether pravastatin might be cost-effective in Germany. We conducted a cost-effectiveness analysis from the perspective of third party payers. The following costs were included in the analysis: daily treatment costs of pravastatin, non-fatal myocardial infarction, coronary bypass operations and stroke. Life years gained were obtained by applying the declining exponential approximation of life expectancy. All calculations were standardized to 1,000 treated patients. The net costs of treating 1,000 patients (i.e. drug costs minus the costs of sequelae and interventions) are DM 8.4 Mio. In addition, a total of 405 life years may be saved through treatment. The corresponding cost-effectiveness of pravastatin treatment is DM 20,674,-(DM 17,314,-, discounted by 3% p.a.).