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1.
J Vasc Interv Radiol ; 31(8): 1221-1232, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32674872

RESUMO

PURPOSE: To evaluate the cost effectiveness of incorporating cryoablation in the treatment regimens for uncomplicated bone metastases using radiation therapy (RT) in single-fraction RT (SFRT) or multiple-fraction RT (MFRT) regimens. MATERIALS AND METHODS: A Markov model was constructed using 1-month cycles over a lifetime horizon to compare the cost effectiveness of multiple strategies, including RT followed by RT (RT-RT) for recurrent pain, RT followed by cryoablation (RT-ablation), and cryoablation followed by RT (ablation-RT). RT-RT consisted of 8 Gy in 1 fraction/8 Gy in 1 fraction (SFRT-SFRT) and 30 Gy in 10 fractions/20 Gy in 5 fractions (MFRT-MFRT). Probabilities and utilities were extracted from a search of the medical literature. Costs were calculated from a payer perspective using 2017 Medicare reimbursement in an outpatient setting. Incremental cost effectiveness ratios (ICERs) were calculated using strategies evaluated for willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). To account for model uncertainty, one-way and probabilistic sensitivity analyses were performed. RESULTS: In the base case analysis, SFRT-ablation was cost effective relative to SFRT-SFRT at $96,387/QALY. MFRT-ablation was cost effective relative to MFRT-MFRT at $85,576/QALY. Ablation-SFRT and ablation-MFRT were not cost effective with ICERs >$100,000/QALY. In one-way sensitivity analyses, results were highly sensitive to variation in multiple model parameters, including median survival (base: 9 months), with SFRT-SFRT favored at median survival ≤8.7 months. Probabilistic sensitivity analysis examining SFRT-based regimens showed that SFRT-ablation was preferred in 36.9% of simulations at WTP of $100,000/QALY. CONCLUSIONS: Cryoablation is a potentially cost-effective alternative to reirradiation with RT for recurrent of pain following RT; however, no strategy incorporating initial cryoablation was cost effective.


Assuntos
Neoplasias Ósseas/terapia , Criocirurgia/economia , Custos de Cuidados de Saúde , Cuidados Paliativos/economia , Cirurgia Assistida por Computador/economia , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/secundário , Redução de Custos , Análise Custo-Benefício , Criocirurgia/efeitos adversos , Fracionamento da Dose de Radiação , Humanos , Cadeias de Markov , Modelos Econômicos , Anos de Vida Ajustados por Qualidade de Vida , Radioterapia/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Retratamento/economia , Cirurgia Assistida por Computador/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
2.
J Cardiovasc Electrophysiol ; 29(2): 284-290, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29071765

RESUMO

INTRODUCTION: Although noninferiority of cryoballoon ablation (CBA) and radiofrequency catheter ablation for antral pulmonary vein isolation (APVI) has been reported in patients with paroxysmal atrial fibrillation (PAF), it is not clear whether contact force sensing (CF-RFA) and CBA with the second-generation catheter have similar procedural costs and long-term outcomes. The objective of this study is to compare the long-term efficacy and cost implications of CBA and CF-RFA in patients with PAF. METHODS AND RESULTS: A first APVI was performed in 146 consecutive patients (age: 63 ± 10 years, men: 95 [65%], left atrial diameter: 42 ± 6 mm) with PAF using CBA (71) or CF-RFA (75). Clinical outcomes and procedural costs were compared. The mean procedure time was significantly shorter with CBA than with CF-RFA (98 ± 39 vs. 158 ± 47 minutes, P < 0.0001). Despite a higher equipment cost in the CBA than the CF-RFA group, the total procedure cost was similar between the two groups (P = 0.26), primarily driven by a shorter procedure duration that resulted in a lower anesthesia cost. At 25 ± 5 months after a single ablation procedure, 51 patients (72%) in the CBA, and 55 patients (73%) in the CF-RFA groups remained free from atrial arrhythmias without antiarrhythmic drug therapy (P = 0.84). CONCLUSIONS: The procedure duration was approximately 60 minutes shorter with CBA than CF-RFA. The procedural costs were similar with both approaches. At 2 years after a single procedure, CBA and CF-RFA have similar single-procedure efficacies of 72-73%.


Assuntos
Fibrilação Atrial/economia , Fibrilação Atrial/cirurgia , Ablação por Cateter/economia , Criocirurgia/economia , Custos Hospitalares , Veias Pulmonares/cirurgia , Potenciais de Ação , Idoso , Anestesia/economia , Antiarrítmicos/economia , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Custos de Medicamentos , Técnicas Eletrofisiológicas Cardíacas/economia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Intervalo Livre de Progressão , Veias Pulmonares/fisiopatologia , Recidiva , Reoperação/economia , Estudos Retrospectivos , Fatores de Tempo
3.
Ophthalmology ; 121(1): 318-326, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23953099

RESUMO

PURPOSE: To provide insight into the preoperative factors that affect outcome after pneumatic retinopexy (PR) for treatment of primary rhegmatogenous retinal detachment repair. Additionally, we sought to analyze the cost of rhegmatogenous retinal detachment repair in the United States to determine potential cost savings with pneumatic retinopexy. DESIGN: Single-center, retrospective, observational consecutive case series and third party payer-perspective comparative cost analysis. PARTICIPANTS: We included 141 eyes undergoing pneumatic retinopexy for the treatment of primary rhegmatogenous retinal detachment. METHODS: Preoperative characteristics, anatomic outcomes, and best-available visual acuity were collected. Anatomic and visual outcomes were analyzed based on the presence of selected preoperative factors. The primary cohort was divided into 2 groups based on preoperative characteristics: (1) traditional pneumatic retinopexy and (2) nontraditional pneumatic retinopexy. Comparative cost analyses were performed between pneumatic retinopexy, scleral buckling, and vitrectomy. MAIN OUTCOME MEASURES: Anatomic and visual outcomes at 6 months. RESULTS: Overall anatomic success was 78.7% and visual acuity improved significantly (logarithm of the minimum angle of resolution [logMAR] 0.48-0.25; P <0.005). A 97.6% final anatomic success rate was achieved. Anatomic outcomes were similar between traditional versus nontraditional (84.1% vs 74.4%; P = 0.16), phakic versus pseudophakic (79.1% vs 78.0%; P = 0.88), and macula-on versus macula-off (77.9% vs 81.1%; P = 0.68) groups. Anatomic failure was predicted by the presence of an inferior retinal break (P <0.005) or visible vitreous traction on a retinal break (P = 0.04). Visual outcomes were similar between each of the traditional versus nontraditional (logMAR 0.21 vs 0.27; P >0.05) and phakic versus pseudophakic groups (logMAR 0.23 vs 0.28; P >0.05). Visual outcomes were better in macula-on detachments compared with those in which the macula was detached (logMAR 0.18 vs 0.42; P <0.005). Annual health care cost savings in the United States ranging from $6 to $30 million are theoretically possible by increasing pneumatic retinopexy utilization from the current rate of 15% to 20%-35%. CONCLUSIONS: Pneumatic retinopexy is an effective treatment modality for primary rhegmatogenous retinal detachment. Anatomic and visual outcomes are similar for traditional and nontraditional preoperative inclusion criteria, as well as phakic and pseudophakic eyes. Inferior breaks and visible vitreous traction on a tear predicted failure. Increased utilization of pneumatic retinopexy would achieve significant cost savings while maintaining outcomes.


Assuntos
Redução de Custos/economia , Criocirurgia/economia , Descolamento Retiniano/economia , Descolamento Retiniano/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Local , Custos e Análise de Custo , Tamponamento Interno , Feminino , Fluorocarbonos/administração & dosagem , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Recurvamento da Esclera/economia , Hexafluoreto de Enxofre/administração & dosagem , Resultado do Tratamento , Estados Unidos , Acuidade Visual , Vitrectomia/economia
4.
Am Fam Physician ; 86(12): 1118-24, 2012 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-23316984

RESUMO

Cutaneous cryosurgery refers to localized application of freezing temperatures to achieve destruction of skin lesions. It can be used to treat a broad range of benign and premalignant skin conditions, and certain malignant skin conditions, with high cure rates. Cellular destruction is accomplished by delivery of the cryogen via dipstick, probe, or spray techniques. It is widely used in primary care because of its safety, effectiveness, low cost, ease of use, good cosmetic results, and lack of need for anesthesia. Cryosurgery is as effective as alternative therapies for most cases of molluscum contagiosum, dermatofibromas, keloids, and plantar or genital warts. It is a more effective cure for common warts than salicylic acid or observation. Cryosurgery is generally the treatment of choice for actinic keratosis. Contraindications to cryosurgery include cryofibrinogenemia, cryoglobulinemia, Raynaud disease, agammaglobulinemia, and multiple myeloma. Complications from cryosurgery include hypopigmentation and alopecia, and can be avoided by limiting freeze times to less than 30 seconds. Referral to a dermatologist should be considered in cases of diagnostic uncertainty or for treatment of skin cancer, which requires larger amounts of tissue destruction, resulting in higher complication rates.


Assuntos
Criocirurgia/métodos , Dermatopatias/cirurgia , Condiloma Acuminado/cirurgia , Criocirurgia/efeitos adversos , Criocirurgia/economia , Criocirurgia/instrumentação , Histiocitoma Fibroso Benigno/cirurgia , Humanos , Queloide/cirurgia , Ceratose Actínica/cirurgia , Molusco Contagioso/cirurgia , Guias de Prática Clínica como Assunto , Dermatopatias/patologia , Neoplasias Cutâneas/cirurgia , Resultado do Tratamento , Estados Unidos , Verrugas/cirurgia , Cicatrização
5.
Ann Acad Med Singap ; 31(4): 502-8, 2002 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12161888

RESUMO

INTRODUCTION: A retrospective study in the referral centre for sexually transmitted infections (STIs) in Singapore to describe the epidemiology and treatment outcome of patients with anogenital warts. SUBJECTS AND METHODS: We reviewed the case records of 301 patients with anogenital warts who were seen over a 1-year period (1999). We also attempted to interview every patient by telephone to find out if they had any clinical recurrences for which treatment was sought elsewhere. RESULTS: There were 255 males and 46 females with a mean age of 34 years. Two hundred and nineteen (72.8%) presented with symptoms lasting 12 weeks or less. In males, warts occurred most frequently in the preputial cavity (52.5%) and on the penile shaft (40.8%). In females, they occurred most frequently on the external genitalia (91.3%). Two hundred and thirty-five males were treated with cryotherapy and 69% (95% CI, 62.6% to 74.8%) achieved clinical resolution after a mean of 6 treatment cycles. Seven males were treated with podophyllin 0.25% in ethanol and 71% (95% CI, 29.0% to 96.3%) were clinically cured after a mean of 4 treatment cycles. Thirty-nine females were treated with cryotherapy and 67% (95% CI, 49.8% to 80.9%) achieved clinical cure after a mean of 4 treatment cycles. Of the 290 patients treated at the centre, 212 (73%; 95% CI, 67.3% to 77.8%) patients (184 males, 28 females) achieved clinical cure after a mean of 7 weeks (range, 1 to 34 weeks); 90% (95% CI, 86.0% to 93.2%) of them by 15 weeks. Seven-two patients defaulted follow-up and 6 responded partially to treatment. Of the 212 patients who achieved clinical cure, 195 were interviewed by telephone, on an average, 17.7 months after clinical resolution. Thirty-seven (19%; 95% CI, 13.7% to 25.2%), all males, relapsed clinically after a mean of 100 days (range, 5 to 329 days); 90% (95% CI, 84.6% to 93.6%) relapsed by 228 days. CONCLUSIONS: Podophyllin 0.25% in ethanol was the most cost-effective treatment for males. One in 5 patients had a recurrence of their warts and most had their recurrence within 8 months of initial resolution.


Assuntos
Condiloma Acuminado/epidemiologia , Condiloma Acuminado/terapia , Doenças dos Genitais Femininos/epidemiologia , Doenças dos Genitais Femininos/terapia , Doenças dos Genitais Masculinos/epidemiologia , Doenças dos Genitais Masculinos/terapia , Adolescente , Adulto , Idoso , Aminoquinolinas/economia , Aminoquinolinas/uso terapêutico , Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Condiloma Acuminado/economia , Análise Custo-Benefício/economia , Criocirurgia/economia , Feminino , Doenças dos Genitais Femininos/economia , Doenças dos Genitais Masculinos/economia , Humanos , Imiquimode , Ceratolíticos/economia , Ceratolíticos/uso terapêutico , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Podofilina/economia , Podofilina/uso terapêutico , Recidiva , Estudos Retrospectivos , Singapura/epidemiologia
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