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1.
Clin Infect Dis ; 70(8): 1628-1635, 2020 04 10.
Artigo em Inglês | MEDLINE | ID: mdl-31165855

RESUMO

BACKGROUND: Severe adverse events after treatment with ivermectin in individuals with high levels of Loa loa microfilariae in the blood preclude onchocerciasis elimination through community-directed treatment with ivermectin (CDTI) in Central Africa. We measured the cost of a community-based pilot using a test-and-not-treat (TaNT) strategy in the Soa health district in Cameroon. METHODS: Based on actual expenditures, we empirically estimated the economic cost of the Soa TaNT campaign, including financial costs and opportunity costs that will likely be borne by control programs and stakeholders in the future. In addition to the empirical analyses, we estimated base-case, less intensive, and more intensive resource use scenarios to explore how costs might differ if TaNT were implemented programmatically. RESULTS: The total costs of US$283 938 divided by total population, people tested, and people treated with 42% coverage were US$4.0, US$9.2, and US$9.5, respectively. In programmatic implementation, these costs (base-case estimates with less and more intensive scenarios) could be US$2.2 ($1.9-$3.6), US$5.2 ($4.5-$8.3), and US$5.4 ($4.6-$8.6), respectively. CONCLUSIONS: TaNT clearly provides a safe strategy for large-scale ivermectin treatment and overcomes a major obstacle to the elimination of onchocerciasis in areas coendemic for Loa loa. Although it is more expensive than standard CDTI, costs vary depending on the setting, the implementation choices made by the institutions involved, and the community participation rate. Research on the required duration of TaNT is needed to improve the affordability assessment, and more experience is needed to understand how to implement TaNT optimally.


Assuntos
Loíase , Oncocercose , Animais , Camarões/epidemiologia , Custos e Análise de Custo , Humanos , Ivermectina/uso terapêutico , Loa , Loíase/tratamento farmacológico , Loíase/epidemiologia , Loíase/prevenção & controle , Oncocercose/tratamento farmacológico , Oncocercose/epidemiologia , Oncocercose/prevenção & controle
2.
Stroke ; 50(11): 3220-3227, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31637975

RESUMO

Background and Purpose- In the United Kingdom, mechanical thrombectomy (MT) for acute ischemic stroke patients assessed beyond 6 hours from symptom onset will be commissioned up to 12 hours provided that advanced imaging (AdvImg) demonstrates salvageable brain tissue. While the accuracy of AdvImg differs across technologies, evidence is limited regarding the proportion of patients who would benefit from late MT. We compared the cost-effectiveness of 2 care pathways: (1) MT within and beyond 6 hours based on AdvImg selection versus (2) MT only within 6 hours based on conventional imaging selection. The impact of varying AdvImg accuracy and prior probability for acute ischemic stroke patients to benefit from late MT was assessed. Methods- A decision tree and a Markov trace were developed. A hypothetical United Kingdom cohort of suspected stroke patients aged 71 years with first event was modeled. Costs, health outcomes, and probabilities were obtained from the literature. Outcomes included costs, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Probabilistic sensitivity analyses were performed. Various scenarios with prior probabilities of 10%, 20%, and 30%, respectively, for acute ischemic stroke patients to benefit from late MT, and with perfect accuracy, 80% sensitivity, and 70% specificity of AdvImg were studied. Results- Incremental cost-effectiveness ratios resulting from our deterministic analyses varied from $8199 (£6164) to $49 515 (£37 229) per QALY gained. AdvImg accuracy impacted the incremental cost-effectiveness ratio only when its specificity decreased. Over lifetime horizons, all scenarios including late MT improved QALYs and LYs. Depending on the scenario, the probabilistic sensitivity analyses showed probabilities varying between 46% and 93% for the late MT pathway to be cost-effective at a willingness to pay threshold of $39 900 (£30 000) per QALY. Conclusions- Late MT based on AdvImg selection may be good value for money. However, additional data regarding the implementation of AdvImg and prior probability to benefit from late MT are needed before its cost-effectiveness can be fully assessed.


Assuntos
Isquemia Encefálica/economia , Trombólise Mecânica/economia , Modelos Econômicos , Acidente Vascular Cerebral/economia , Idoso , Isquemia Encefálica/terapia , Custos e Análise de Custo , Feminino , Humanos , Masculino , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Reino Unido
3.
N Engl J Med ; 369(24): 2304-12, 2013 Dec 12.
Artigo em Inglês | MEDLINE | ID: mdl-24251360

RESUMO

BACKGROUND: Observational evidence suggests that the use of a genotype-guided dosing algorithm may increase the effectiveness and safety of acenocoumarol and phenprocoumon therapy. METHODS: We conducted two single-blind, randomized trials comparing a genotype-guided dosing algorithm that included clinical variables and genotyping for CYP2C9 and VKORC1 with a dosing algorithm that included only clinical variables, for the initiation of acenocoumarol or phenprocoumon treatment in patients with atrial fibrillation or venous thromboembolism. The primary outcome was the percentage of time in the target range for the international normalized ratio (INR; target range, 2.0 to 3.0) in the 12-week period after the initiation of therapy. Owing to low enrollment, the two trials were combined for analysis. The primary outcome was assessed in patients who remained in the trial for at least 10 weeks. RESULTS: A total of 548 patients were enrolled (273 patients in the genotype-guided group and 275 in the control group). The follow-up was at least 10 weeks for 239 patients in the genotype-guided group and 245 in the control group. The percentage of time in the therapeutic INR range was 61.6% for patients receiving genotype-guided dosing and 60.2% for those receiving clinically guided dosing (P=0.52). There were no significant differences between the two groups for several secondary outcomes. The percentage of time in the therapeutic range during the first 4 weeks after the initiation of treatment in the two groups was 52.8% and 47.5% (P=0.02), respectively. There were no significant differences with respect to the incidence of bleeding or thromboembolic events. CONCLUSIONS: Genotype-guided dosing of acenocoumarol or phenprocoumon did not improve the percentage of time in the therapeutic INR range during the 12 weeks after the initiation of therapy. (Funded by the European Commission Seventh Framework Programme and others; EU-PACT ClinicalTrials.gov numbers, NCT01119261 and NCT01119274.).


Assuntos
Acenocumarol/administração & dosagem , Algoritmos , Anticoagulantes/administração & dosagem , Hidrocarboneto de Aril Hidroxilases/genética , Genótipo , Femprocumona/administração & dosagem , Vitamina K Epóxido Redutases/genética , Idoso , Citocromo P-450 CYP2C9 , Feminino , Seguimentos , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Farmacogenética , Método Simples-Cego , Tromboembolia/induzido quimicamente , Falha de Tratamento
4.
J Vasc Surg ; 63(3): 827-38.e2, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26916588

RESUMO

BACKGROUND: Patients with a large unruptured abdominal aortic aneurysm with a diameter >5.0 cm are treated with open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Because many studies have assessed the cost-effectiveness of these treatments with conflicting results, this systematic review examined published cost-effectiveness analyses of elective EVAR vs OSR in patients with abdominal aortic aneurysm. METHODS: A systematic search strategy using three databases was conducted to find all relevant studies. Characteristics extracted from these studies included study characteristics (eg, age of the population), input parameters (eg, costs of the EVAR procedure), general results, and sensitivity analyses. The quality of each study was assessed using the Drummond checklist. RESULTS: The search identified 1141 potentially relevant studies, of which 13 studies met inclusion criteria. Most studies found that EVAR was more expensive and more effective than OSR. However, most studies concluded that the health gained from EVAR did not offset the higher total costs, leading to an unacceptably high incremental cost-effectiveness ratio. EVAR was considered more cost-effective in patient groups with a high surgical risk. The quality of most studies was judged as reasonably good. CONCLUSIONS: Overall, published cost-effectiveness analyses of EVAR do not provide a clear answer about whether elective EVAR is a cost-effective solution because the incremental cost-effectiveness ratio varies considerably among the studies. This answer can best be provided through a cost-effectiveness analysis of EVAR that incorporates more recent technologic advances and the improved experience that clinicians have with EVAR.


Assuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/economia , Custos Hospitalares , Procedimentos Cirúrgicos Vasculares/economia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico , Redução de Custos , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
5.
Int J Technol Assess Health Care ; 32(1-2): 46-53, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27002226

RESUMO

OBJECTIVES: There is little specific guidance on performing an early cost-effectiveness analysis (CEA) of medical tests. We developed a framework with general steps and applied it to two cases. METHODS: Step 1 is to narrow down the scope of analysis by defining the test's application, target population, outcome measures, and investigating current test strategies and test strategies if the new test were available. Step 2 is to collect evidence on the current test strategy. Step 3 is to develop a conceptual model of the current and new test strategies. Step 4 is to conduct the early-CEA by evaluating the potential (cost-)effectiveness of the new test in clinical practice. Step 5 involves a decision about the further development of the test. RESULTS: The first case illustrated the impact of varying the test performance on the headroom (maximum possible price) of an add-on test for patients with an intermediate-risk of having rheumatoid arthritis. Analyses showed that the headroom is particularly dependent on test performance. The second case estimated the minimum performance of a confirmatory imaging test to predict individual stroke risk. Different combinations of sensitivity and specificity were found to be cost-effective; if these combinations are attainable, the medical test developer can feel more confident about the value of further development of the test. CONCLUSIONS: A well-designed early-CEA methodology can improve the ability to develop (cost-)effective medical tests in an efficient manner. Early-CEAs should continuously integrate insights and evidence that arise through feedback, which may convince developers to return to earlier steps.


Assuntos
Análise Custo-Benefício/organização & administração , Técnicas e Procedimentos Diagnósticos/economia , Avaliação da Tecnologia Biomédica/organização & administração , Artrite Reumatoide/diagnóstico , Tomada de Decisões , Humanos , Modelos Econométricos , Recidiva , Sensibilidade e Especificidade , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo
6.
Eur J Haematol ; 93(3): 198-206, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24673368

RESUMO

OBJECTIVES: The purpose of this study was to assess the impact of acute myeloid leukemia (AML) and its treatment on health-related quality of life (HRQOL) by comparing the HRQOL of AML survivors with the HRQOL in the general population. METHODS: Two HRQOL questionnaires (EQ-5D and QLQ-C30) were sent to patients diagnosed with AML between 1999 and 2011 at a single academic hospital and still alive in 2012. HRQOL in AML survivors was compared with general population reference values. Multivariate analysis was used to identify factors associated with HRQOL in AML survivors. RESULTS: Questionnaires were returned by 92 of the 103 patients (89%). AML survivors reported significantly worse functioning, more fatigue, pain, dyspnea, appetite loss, and financial difficulties and lower EQ-VAS scores than the general population (P < 0.05). Impaired HRQOL in AML survivors was mainly found in survivors without a paid job. Other factors associated with a poor HRQOL were allogeneic hematopoietic stem cell transplantation and the absence of social support. CONCLUSION: This single-center study showed that the HRQOL in AML survivors is worse than the HRQOL in the general population. HRQOL in these patients can be improved by adequately treating and preventing fatigue, pain, dyspnea, and appetite loss.


Assuntos
Leucemia Mieloide Aguda/psicologia , Qualidade de Vida/psicologia , Sobreviventes/psicologia , Adulto , Idoso , Dispneia/fisiopatologia , Dispneia/psicologia , Emprego/economia , Emprego/psicologia , Fadiga/fisiopatologia , Fadiga/psicologia , Feminino , Transplante de Células-Tronco Hematopoéticas/psicologia , Humanos , Renda , Leucemia Mieloide Aguda/patologia , Leucemia Mieloide Aguda/terapia , Masculino , Pessoa de Meia-Idade , Dor/fisiopatologia , Dor/psicologia , Isolamento Social/psicologia , Inquéritos e Questionários
7.
Br J Clin Pharmacol ; 77(4): 626-41, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23919835

RESUMO

Coumarin derivatives, such as warfarin, acenocoumarol and phenprocoumon are frequently prescribed oral anticoagulants to treat and prevent thromboembolism. Because there is a large inter-individual and intra-individual variability in dose-response and a small therapeutic window, treatment with coumarin derivatives is challenging. Certain polymorphisms in CYP2C9 and VKORC1 are associated with lower dose requirements and a higher risk of bleeding. In this review we describe the use of different coumarin derivatives, pharmacokinetic characteristics of these drugs and differences amongst the coumarins. We also describe the current clinical challenges and the role of pharmacogenetic factors. These genetic factors are used to develop dosing algorithms and can be used to predict the right coumarin dose. The effectiveness of this new dosing strategy is currently being investigated in clinical trials.


Assuntos
Acenocumarol/administração & dosagem , Algoritmos , Anticoagulantes/administração & dosagem , Cálculos da Dosagem de Medicamento , Farmacogenética , Femprocumona/administração & dosagem , Varfarina/administração & dosagem , Acenocumarol/farmacocinética , Anticoagulantes/farmacocinética , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Citocromo P-450 CYP2C9/genética , Genótipo , Humanos , Farmacogenética/economia , Femprocumona/farmacocinética , Vitamina K Epóxido Redutases/genética , Varfarina/farmacocinética
8.
Value Health ; 17(2): 245-53, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24636383

RESUMO

INTRODUCTION: Dutch policy regulations require outcomes research for the assessment of appropriate drug use and cost-effectiveness after 4 years of temporary reimbursement. We investigated whether outcomes research reduced policymaker uncertainty regarding the question whether the costs are worth public funding. METHODS: Our cohort study included 139 patients with relapsed/refractory multiple myeloma who were treated outside of a clinical study; 72 received bortezomib and 67 did not receive bortezomib. Detailed data were retrospectively collected from medical records in 38% of Dutch hospitals. RESULTS: All patients received second-line treatment; 65%, 40%, and 14%, received three, four, or five or more lines of therapy. Neither a specific treatment sequence nor an appropriate comparator could be identified because of large variation in regimes. Kaplan-Meier curves showed an increased overall survival (mean [median] 29.5 [33.2] vs. 28.0 [21.6] months) for patients treated with bortezomib (Wilcoxon P = 0.01). Total mean costs were €81,626 (range €17,793-€229,783) and €52,760 (range €748-€179,571) for patients receiving bortezomib and patients not receiving bortezomib, respectively. Patients treated with bortezomib, however, were not comparable to other patients despite attempts to correct for confounding. Therefore, it was impossible to develop a feasible model to obtain a valid incremental cost-effectiveness estimate. CONCLUSIONS: It was possible to develop evidence on bortezomib's use, effects, and costs in everyday practice. Much uncertainty, however, remained regarding its cost-effectiveness. Policymakers should carefully consider whether outcomes research sufficiently decreases uncertainty or whether other options (e.g., finance- and/or outcomes-based risk-sharing arrangements) are more appropriate to ensure sufficient value for money of expensive drugs.


Assuntos
Antineoplásicos/uso terapêutico , Ácidos Borônicos/uso terapêutico , Mieloma Múltiplo/tratamento farmacológico , Avaliação de Resultados em Cuidados de Saúde , Formulação de Políticas , Pirazinas/uso terapêutico , Adulto , Idoso , Antineoplásicos/economia , Ácidos Borônicos/economia , Bortezomib , Estudos de Coortes , Análise Custo-Benefício , Estudos de Viabilidade , Seguimentos , Política de Saúde , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/economia , Países Baixos , Pirazinas/economia , Mecanismo de Reembolso , Estudos Retrospectivos , Estatísticas não Paramétricas , Taxa de Sobrevida , Incerteza
9.
Eur J Public Health ; 23(3): 447-52, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22542542

RESUMO

BACKGROUND: Evidence suggests a higher prevalence of type 2 diabetes (T2D) in The Netherlands than in England, although generalized obesity prevalence is substantially lower in The Netherlands. Metabolic syndrome (MS) is more strongly associated with the risk of progression to T2D than generalized obesity. Therefore examining MS may help to better understand the differences in T2D between the two countries. We assessed whether the Dutch and English differences in T2D prevalence reflect similar differences in MS in Whites, South-Asian Indians and African-Caribbeans living in these two countries. METHODS: Secondary analyses of population-based studies of 3010 participants aged 35-60 years. Metabolic syndrome was defined according to the International Diabetes Federation criteria. Prevalence ratios (PRs) were estimated using regression models. RESULTS: In general, the Dutch ethnic groups had a higher prevalence of MS than their English counterparts. Adjusted PRs were 1.37[95% confidence interval (CI)1.03-1.82] and 1.52 (1.06-2.19) in White-Dutch men and women compared to White-English men and women; 2.20 (1.14-4.26) and 1.46 (0.96-2.24) in Dutch-African-Caribbean men and women compared to English-African-Caribbean men and women and 0.97 (0.74-1.27) and 1.42 (1.00-2.03) in Dutch-Indian men and women compared with their English-Indian peers, respectively. Similar patterns were also observed for some MS components, e.g. raised fasting glucose in men and central obesity in women. CONCLUSION: The comparatively high prevalence of MS among Dutch ethnic groups may contribute to their high prevalence of T2D. The high levels of some MS components, e.g. raised fasting glucose in men and central obesity in women add to the high prevalence of MS in Dutch ethnic groups.


Assuntos
Doenças Cardiovasculares/etnologia , Comparação Transcultural , Diabetes Mellitus Tipo 2/etnologia , Etnicidade/estatística & dados numéricos , Síndrome Metabólica/etnologia , Adulto , África/etnologia , Antropometria , População Negra/psicologia , População Negra/estatística & dados numéricos , Glicemia/análise , Doenças Cardiovasculares/diagnóstico , Estudos Transversais , Diabetes Mellitus Tipo 2/diagnóstico , Inglaterra/epidemiologia , Etnicidade/psicologia , Feminino , Inquéritos Epidemiológicos , Humanos , Hipertensão/diagnóstico , Hipertensão/etnologia , Índia/etnologia , Estilo de Vida/etnologia , Lipídeos/sangue , Masculino , Síndrome Metabólica/complicações , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Obesidade/complicações , Obesidade/epidemiologia , Vigilância da População , Análise de Regressão , Fatores de Risco , Fatores Socioeconômicos , População Branca/psicologia , População Branca/estatística & dados numéricos
10.
Acta Oncol ; 51(1): 57-64, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22122695

RESUMO

BACKGROUND: Little is known about how well guidelines about adjuvant chemotherapy in colon cancer are followed in daily practice. We evaluated the current guideline, which is based on the MOSAIC trial, by examining implementation, treatment patterns and disease-free survival. MATERIAL AND METHODS: We analysed a population-based cohort of 391 patients treated with adjuvant chemotherapy for stage III colon cancer in 2005-2006. Data were gathered from the Dutch Cancer Registry and medical records of 19 hospitals. Patients were classified according to whether or not they fulfilled MOSAIC trial eligibility criteria. RESULTS: The administered regimens were: fluorouracil-leucovorin (17 patients), capecitabine (93), fluorouracil-leucovorin plus oxaliplatin (145), and capecitabine plus oxaliplatin (136). After its inclusion in national guidelines, oxaliplatin was prescribed in 16 hospitals within six months. Patients receiving oxaliplatin were younger and had less comorbidity than other patients. Dose schedules corresponded well with guidelines. Two-year disease-free survival probability of oxaliplatin patients meeting MOSAIC eligibility criteria was 78.4% (95% CI 72.5-84.3), which was comparable to MOSAIC trial results. CONCLUSION: Guidelines for adjuvant chemotherapy in stage III colon cancer are generally well followed in daily practice. However, uncertainty remains regarding the optimal treatment of elderly patients and patients with comorbidities, which underscores the need for practical clinical trials including these patients.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias do Colo/tratamento farmacológico , Fidelidade a Diretrizes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Capecitabina , Quimioterapia Adjuvante , Estudos de Coortes , Neoplasias do Colo/patologia , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Intervalo Livre de Doença , Feminino , Fluoruracila/administração & dosagem , Fluoruracila/análogos & derivados , Humanos , Leucovorina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Países Baixos , Compostos Organoplatínicos/administração & dosagem , Oxaliplatina , Sistema de Registros , Resultado do Tratamento , Adulto Jovem
11.
Arch Public Health ; 79(1): 39, 2021 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-33743785

RESUMO

BACKGROUND: Inconsistent use of generic and disease-specific health-related quality of life (HRQOL) instruments in multiple sclerosis (MS) studies limits cross-country comparability. The objectives: 1) investigate real-world HRQOL of MS patients using both generic and disease-specific HRQOL instruments in the Netherlands, France, the United Kingdom, Spain, Germany and Italy; 2) compare HRQOL among these countries; 3) determine factors associated with HRQOL. METHODS: A cross-sectional, observational online web-based survey amongst MS patients was conducted in June-October 2019. Patient demographics, clinical characteristics, and two HRQOL instruments: the generic EuroQOL (EQ-5D-5L) and disease-related Multiple Sclerosis Quality of Life (MSQOL)-54, an extension of the generic Short Form-36 (SF-36) was collected. Health utility scores were calculated using country-specific value sets. Mean differences in HRQOL were analysed and predictors of HRQOL were explored in regression analyses. RESULTS: In total 182 patients were included (the Netherlands: n = 88; France: n = 58; the United Kingdom: n = 15; Spain: n = 10; living elsewhere: n = 11). Mean MSQOL-54 physical and mental composite scores (42.5, SD:17.2; 58.3, SD:21.5) were lower, whereas the SF-36 physical and mental composite scores (46.8, SD:22.6; 53.1, SD:22.5) were higher than reported in previous clinical trials. The mean EQ-5D utility was 0.65 (SD:0.26). Cross-country differences in HRQOL were found. A common predictor of HRQOL was disability status and primary progressive MS. CONCLUSIONS: The effects of MS on HRQOL in real-world patients may be underestimated. Combined use of generic and disease-specific HRQOL instruments enhance the understanding of the health needs of MS patients. Consequent use of the same instruments in clinical trials and observational studies improves cross-country comparability of HRQOL.

12.
J Eval Clin Pract ; 26(5): 1457-1466, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31994256

RESUMO

RATIONALE, AIMS, AND OBJECTIVES: While different imaging and treatment options are available in acute coronary syndrome (ACS) care, there is a lack of data regarding their use across Europe. We examined the diagnostic and treatment strategies in patients with known or suspected ACS as reported by physicians and identified variations in responses across European countries and geographical areas. METHOD: A web-based clinician survey focusing on ACS imaging and revascularization treatments was circulated through email distribution lists and websites of European professional societies in the field of cardiology. We collected information on respondents' clinical setting and specialty. Reported percentages of patients receiving imaging or treatment modalities and percentages of clinicians reporting to use modalities in a range of clinical scenarios were analyzed. Statistical comparisons were performed. RESULTS: In total, 69 responses were received (Sweden [n = 20], United Kingdom [n = 16], Northern/Western Europe [n = 17], Southern Europe [n = 9], and Central Europe [n = 7]). Considerable variations between geographical areas were seen in terms of reported diagnostic modalities and treatment strategies. For example, when presented with the scenario of a theoretical 45-year-old smoking female with a suspected ACS, 56% of UK clinicians reported to use coronary computed tomography angiography, compared to only 10% of Swedish clinicians (P = .002). Large variations were observed regarding the reported use of fractional flow reserve by physicians for non-culprit lesions during invasive management of myocardial infarction patients (44% in Sweden, 31% in the United Kingdom, and 30% in Northern/Western Europe vs non-use in Central and Southern Europe). CONCLUSIONS: In this survey, respondents reported different diagnostic and treatment strategies in ACS care. These variations seem to have geographic components. Larger studies or real world data are needed to verify these observations and investigate their causes. More research is needed to compare the quality and efficiency of ACS care across countries and explore pathways for improvement.


Assuntos
Síndrome Coronariana Aguda , Reserva Fracionada de Fluxo Miocárdico , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/terapia , Europa (Continente) , Feminino , Humanos , Pessoa de Meia-Idade , Inquéritos e Questionários , Suécia
13.
Pharmacogenomics ; 19(3): 213-226, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29334316

RESUMO

Biomarkers associated with prognosis in multiple myeloma (MM) can be used to stratify patients into risk categories. An attractive alternative to uniform treatment (UT), risk-stratified treatment (RST) is proposed where high-risk patients receive bortezomib-based regimens while standard-risk patients receive alternative less costly regimens. An early Markov-type decision analytic model evaluated the potential therapeutic and economic value of different RST strategies compared with UT in MM patients in key European countries. Results suggest RST strategies were both cheaper and more effective than UT across all countries, with the molecular marker-only strategy RST-SKY92 producing maximum health gains (0.031-0.039 QALYs). The conclusions remained consistent in the univariate sensitivity analyses. These findings should encourage stakeholders to support the adoption of RST approaches in MM.


Assuntos
Antineoplásicos/economia , Bortezomib/economia , Custos de Cuidados de Saúde , Modelos Econômicos , Mieloma Múltiplo/tratamento farmacológico , Mieloma Múltiplo/economia , Antineoplásicos/uso terapêutico , Biomarcadores Tumorais/análise , Biomarcadores Tumorais/economia , Bortezomib/uso terapêutico , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Europa (Continente) , Humanos , Estimativa de Kaplan-Meier , Cadeias de Markov , Mieloma Múltiplo/mortalidade , Anos de Vida Ajustados por Qualidade de Vida
14.
PLoS Negl Trop Dis ; 12(3): e0006250, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29534061

RESUMO

BACKGROUND: The control or elimination of neglected tropical diseases (NTDs) has targets defined by the WHO for 2020, reinforced by the 2012 London Declaration. We estimated the economic impact to individuals of meeting these targets for human African trypanosomiasis, leprosy, visceral leishmaniasis and Chagas disease, NTDs controlled or eliminated by innovative and intensified disease management (IDM). METHODS: A systematic literature review identified information on productivity loss and out-of-pocket payments (OPPs) related to these NTDs, which were combined with projections of the number of people suffering from each NTD, country and year for 2011-2020 and 2021-2030. The ideal scenario in which the WHO's 2020 targets are met was compared with a counterfactual scenario that assumed the situation of 1990 stayed unaltered. Economic benefit equaled the difference between the two scenarios. Values are reported in 2005 US$, purchasing power parity-adjusted, discounted at 3% per annum from 2010. Probabilistic sensitivity analyses were used to quantify the degree of uncertainty around the base-case impact estimate. RESULTS: The total global productivity gained for the four IDM-NTDs was I$ 23.1 (I$ 15.9 -I$ 34.0) billion in 2011-2020 and I$ 35.9 (I$ 25.0 -I$ 51.9) billion in 2021-2030 (2.5th and 97.5th percentiles in brackets), corresponding to US$ 10.7 billion (US$ 7.4 -US$ 15.7) and US$ 16.6 billion (US$ 11.6 -US$ 24.0). Reduction in OPPs was I$ 14 billion (US$ 6.7 billion) and I$ 18 billion (US$ 10.4 billion) for the same periods. CONCLUSIONS: We faced important limitations to our work, such as finding no OPPs for leprosy. We had to combine limited data from various sources, heterogeneous background, and of variable quality. Nevertheless, based on conservative assumptions and subsequent uncertainty analyses, we estimate that the benefits of achieving the targets are considerable. Under plausible scenarios, the economic benefits far exceed the necessary investments by endemic country governments and their development partners. Given the higher frequency of NTDs among the poorest households, these investments represent good value for money in the effort to improve well-being, distribute the world's prosperity more equitably and reduce inequity.


Assuntos
Erradicação de Doenças/economia , Saúde Global/estatística & dados numéricos , Doenças Negligenciadas/economia , Doenças Negligenciadas/epidemiologia , Doenças Negligenciadas/prevenção & controle , Gerenciamento Clínico , Saúde Global/economia , Gastos em Saúde , Humanos , Pobreza , Literatura de Revisão como Assunto
16.
Indian J Med Res ; 125(3): 203-16, 2007 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-17496351

RESUMO

BACKGROUND & OBJECTIVE: An ideal instrument for the assessment of health related quality of life (HRQOL) in patients with diabetes mellitus type I (T1DM) should incorporate the benefits of both generic and disease-specific instruments. The objective of this study was to investigate the responsiveness and the ability to provide information about diabetes-specific associations with HRQOL, of two generic instruments, in comparison with two diabetes-specific instruments, in patients with T1DM. METHODS: In a Dutch cohort of 234 patients with T1DM we longitudinally assessed HRQOL using both generic and diabetes-specific instruments. We investigated the responsiveness, the associations with diabetes-specific variables and the identification of specific patients by the instruments used. RESULTS: The generic RAND-36 was able to detect statistically significant and clinically relevant changes in HRQOL over time. Moreover, the RAND-36 was associated with (changes in) diabetes-specific variables. The generic and diabetes-specific instruments partly identified different patients with lowest HRQOL. INTERPRETATION & CONCLUSION: The RAND-36 was highly responsive to changes in HRQOL in patients with T1DM and revealed diabetes-specific associations with HRQOL. A low correlation between the generic and diabetes-specific instruments and partly different identification of patients with lower HRQOL support the complementary use of these instruments in patients with T1DM.


Assuntos
Diabetes Mellitus Tipo 1/fisiopatologia , Nível de Saúde , Qualidade de Vida , Adulto , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 1/psicologia , Feminino , Humanos , Hipoglicemia/prevenção & controle , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Inquéritos e Questionários
17.
PLoS Negl Trop Dis ; 11(1): e0005289, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-28103243

RESUMO

BACKGROUND: Lymphatic filariasis (LF), onchocerciasis, schistosomiasis, soil-transmitted helminths (STH) and trachoma represent the five most prevalent neglected tropical diseases (NTDs). They can be controlled or eliminated by means of safe and cost-effective interventions delivered through programs of Mass Drug Administration (MDA)-also named Preventive Chemotherapy (PCT). The WHO defined targets for NTD control/elimination by 2020, reinforced by the 2012 London Declaration, which, if achieved, would result in dramatic health gains. We estimated the potential economic benefit of achieving these targets, focusing specifically on productivity and out-of-pocket payments. METHODS: Productivity loss was calculated by combining disease frequency with productivity loss from the disease, from the perspective of affected individuals. Productivity gain was calculated by deducting the total loss expected in the target achievement scenario from the loss in a counterfactual scenario where it was assumed the pre-intervention situation in 1990 regarding NTDs would continue unabated until 2030. Economic benefits from out-of-pocket payments (OPPs) were calculated similarly. Benefits are reported in 2005 US$ (purchasing power parity-adjusted and discounted at 3% per annum from 2010). Sensitivity analyses were used to assess the influence of changes in input parameters. RESULTS: The economic benefit from productivity gain was estimated to be I$251 billion in 2011-2020 and I$313 billion in 2021-2030, considerably greater than the total OPPs averted of I$0.72 billion and I$0.96 billion in the same periods. The net benefit is expected to be US$ 27.4 and US$ 42.8 for every dollar invested during the same periods. Impact varies between NTDs and regions, since it is determined by disease prevalence and extent of disease-related productivity loss. CONCLUSION: Achieving the PCT-NTD targets for 2020 will yield significant economic benefits to affected individuals. Despite large uncertainty, these benefits far exceed the investment required by governments and their development partners within all reasonable scenarios. Given the concentration of the NTDs among the poorest households, these investments represent good value for money in efforts to share the world's prosperity and reduce inequity.


Assuntos
Quimioprevenção/economia , Helmintíase/prevenção & controle , Doenças Negligenciadas/economia , Doenças Negligenciadas/prevenção & controle , Anti-Helmínticos/administração & dosagem , Anti-Helmínticos/economia , Análise Custo-Benefício , Helmintíase/tratamento farmacológico , Helmintíase/economia , Humanos , Doenças Negligenciadas/tratamento farmacológico , Fatores Socioeconômicos , Medicina Tropical/economia
18.
Appl Health Econ Health Policy ; 14(1): 67-75, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25917685

RESUMO

BACKGROUND AND OBJECTIVE: The cost-effectiveness of clinical interventions is often assessed using current care as the comparator, with national guidelines as a proxy. However, this comparison is inadequate when clinical practice differs from guidelines, or when clinical practice differs between hospitals. We examined the degree of variation in the way patients with a recent transient ischemic attack (TIA) or minor ischemic stroke are assessed and used the results to illustrate the importance of investigating possible clinical practice variation, and the need to perform hospital-level cost-effectiveness analyses (CEAs) when variation exists. METHODS: Semi-structured interviews were conducted with 16 vascular neurologists in hospitals throughout the Netherlands. Questions were asked about the use of initial and confirmatory diagnostic imaging tests to assess carotid stenosis in patients with a recent TIA or minor ischemic stroke, criteria to perform confirmatory tests, and criteria for treatment. We also performed hospital-level CEAs to illustrate the consequences of the observed diagnostic strategies in which the diagnostic test costs, sensitivity and specified were varied according to the local hospital conditions. RESULTS: 56 % (9/16) of the emergency units and 63 % (10/16) of the outpatient clinics use the initial and confirmatory diagnostic tests to assess carotid stenosis in accordance with the national guidelines. Of the hospitals studied, only one uses the recommended criteria for use of a confirmatory test, 38 % (6/16) follow the guidelines for treatment. The most cost-effective diagnostic test strategy differs between hospitals. CONCLUSIONS: If important practice variation exists, hospital-level CEAs should be performed. These CEAs should include an assessment of the feasibility and costs of switching to a different strategy.


Assuntos
Análise Custo-Benefício/métodos , Ataque Isquêmico Transitório/economia , Padrões de Prática Médica/economia , Acidente Vascular Cerebral/economia , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/economia , Fidelidade a Diretrizes/economia , Fidelidade a Diretrizes/estatística & dados numéricos , Custos de Cuidados de Saúde , Humanos , Entrevistas como Assunto , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Inquéritos e Questionários
19.
PLoS Negl Trop Dis ; 10(2): e0004397, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26890487

RESUMO

BACKGROUND: Neglected Tropical Diseases (NTDs) not only cause health and life expectancy loss, but can also lead to economic consequences including reduced ability to work. This article describes a systematic literature review of the effect on the economic productivity of individuals affected by one of the five worldwide most prevalent NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths (ascariasis, trichuriasis, and hookworm infection) and trachoma. These diseases are eligible to preventive chemotherapy (PCT). METHODOLOGY/PRINCIPAL FINDINGS: Eleven bibliographic databases were searched using different names of all NTDs and various keywords relating to productivity. Additional references were identified through reference lists from relevant papers. Of the 5316 unique publications found in the database searches, thirteen papers were identified for lymphatic filariasis, ten for onchocerciasis, eleven for schistosomiasis, six for soil-transmitted helminths and three for trachoma. Besides the scarcity in publications reporting the degree of productivity loss, this review revealed large variation in the estimated productivity loss related to these NTDs. CONCLUSIONS: It is clear that productivity is affected by NTDs, although the actual impact depends on the type and severity of the NTD as well as on the context where the disease occurs. The largest impact on productivity loss of individuals affected by one of these diseases seems to be due to blindness from onchocerciasis and severe schistosomiasis manifestations; productivity loss due to trachoma-related blindness has never been studied directly. However, productivity loss at an individual level might differ from productivity loss at a population level because of differences in the prevalence of NTDs. Variation in estimated productivity loss between and within diseases is caused by differences in research methods and setting. Publications should provide enough information to enable readers to assess the quality and relevance of the study for their purposes.


Assuntos
Doenças Negligenciadas/economia , Doenças Negligenciadas/prevenção & controle , Animais , Quimioprevenção , Humanos , Doenças Negligenciadas/tratamento farmacológico , Doenças Negligenciadas/epidemiologia , Medicina Tropical , Trabalho
20.
Urology ; 95: 121-7, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27179773

RESUMO

OBJECTIVE: To evaluate the effect of cytoreductive nephrectomy (CN) on overall survival (OS) in primary metastatic renal cell carcinoma (mRCC) patients treated with first-line sunitinib. PATIENTS AND METHODS: Patients with primary mRCC treated with first-line sunitinib were selected from a Dutch population-based registry. A propensity score was calculated reflecting the probability of a patient undergoing CN prior to sunitinib using a set of known covariates, such as the Memorial Sloan Kettering Cancer Center and International mRCC Database Consortium risk factors. After propensity score matching, differences in OS were analyzed using the Kaplan-Meier method and a multivariable Cox proportional hazards model was used to evaluate the effect of CN on OS. RESULTS: A total of 227 patients met the selection criteria; 74 patients (33%) underwent CN prior to sunitinib. In the matched population, the median OS of patients who underwent CN was 17.9 months compared to 8.8 months for patients treated with sunitinib only. Multivariable analysis showed that CN was an independent predictor of OS (hazard ratio 0.61, 95% confidence interval: 0.41-0.92). A subgroup analysis of patients with a time to targeted therapy of <1 year showed a median OS of 12.7 months for patients treated with CN compared to 8.0 months for patients treated with sunitinib only. The corresponding hazard ratio was 0.67 (95% confidence interval: 0.46-0.98). CONCLUSION: This study suggests that CN may be effective. However, the benefit was modest when correcting for time from diagnosis to sunitinib. One important limitation is the use of a registry (with retrospectively collected data), which made it impossible to correct for unmeasured characteristics that could be associated with treatment choices or survival.


Assuntos
Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/terapia , Indóis/uso terapêutico , Neoplasias Renais/mortalidade , Neoplasias Renais/terapia , Pirróis/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Carcinoma de Células Renais/secundário , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução , Feminino , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Sistema de Registros , Estudos Retrospectivos , Sunitinibe , Taxa de Sobrevida , Adulto Jovem
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