Cost-effectiveness of Palivizumab for Respiratory Syncytial Virus: A Systematic Review.

CONTEXT: Palivizumab prophylaxis is used as passive immunization for respiratory syncytial virus (RSV). However, because of its high cost, the value of this intervention is unclear. OBJECTIVE: To systematically review the cost-effectiveness of palivizumab prophylaxis compared with no prophylaxis in infants <24 months of age. DATA SOURCES: Medline, Embase, and Cochrane Library up to August 2018. STUDY SELECTION: Two reviewers independently screened results to include economic evaluations conducted between 2000 and 2018 from Organization for Economic Cooperation and Development countries. DATA EXTRACTION: Two reviewers independently extracted outcomes. Quality appraisal was completed by using the Joanna Briggs Institute checklist. Costs were adjusted to 2017 US dollars. RESULTS: We identified 28 economic evaluations (20 cost-utility analyses and 8 cost-effectiveness analyses); most were from the United States (n = 6) and Canada (n = 5). Study quality was high; 23 studies met >80% of the Joanna Briggs Institute criteria. Palivizumab prophylaxis ranged from a dominant strategy to having an incremental cost-effectiveness ratio of $2 526 203 per quality-adjusted life-year (QALY) depending on study perspective and targeted population. From the payer perspective, the incremental cost-effectiveness ratio for preterm infants (29-35 weeks' gestational age) was between $5188 and $791 265 per QALY, with 90% of estimates <$50 000 per QALY. Influential parameters were RSV hospitalization reduction rates, palivizumab cost, and discount rate. LIMITATIONS: Model design heterogeneity, model parameters, and study settings were barriers to definitive conclusions on palivizumab's economic value. CONCLUSIONS: Palivizumab as RSV prophylaxis was considered cost-effective in prematurely born infants, infants with lung complications, and infants from remote communities.

Outcomes for the First Year of Ontario's Birth Center Demonstration Project.

INTRODUCTION: In 2014, Ontario opened 2 stand-alone midwifery-led birth centers. Using mixed methods, we evaluated the first year of operations for quality and safety, client experience, and integration into the maternity care community. This article reports on our study of safety and quality of care. METHODS: This descriptive evaluation focused on women admitted to a birth center at the beginning of labor. For context, we matched this cohort (on a 1:4 basis) with similar low-risk midwifery clients giving birth in a hospital. Data sources included Ontario's Better Outcomes Registry and Network (BORN) Information System, the Canadian Institute for Health Information, Ontario census data, and birth center records. RESULTS: Of 495 women admitted to a birth center, 87.9% experienced a spontaneous vaginal birth, regardless of the eventual location of birth, and 7.7% had a cesarean birth. The transport rate to a hospital was 26.3%. When compared with midwifery clients with a planned hospital birth, rates of intervention (epidural analgesia, labor augmentation, assisted vaginal birth, and cesarean birth) were significantly lower in the planned birth center group, even when controlled for previous cesarean birth and body mass index. Markers of potential morbidity were identified in about 10% of birth center births; however, there were no short-term health impacts up to discharge from midwifery care at 6 weeks postpartum. Care was low in intervention and safe (minimal negative outcomes and transport rates comparable to the literature). DISCUSSION: In the first year of operation, care was consistent with national guidelines, and morbidity and mortality rates and intervention rates were low for women with low-risk pregnancies seeking a low-intervention approach for labor and birth. Further evaluation to confirm these findings is required as the number of births grows.

Assessment and management of older prisoners.

People over 60 make up the fastest growing age group in prison, but their specialist health and social needs may be difficult to accommodate on general wings. The author discusses the development of an assessment she has devised for prisoners aged over 65 at Jurby Prison on the Isle of Man to gather information on physical, social and mental health needs. Agreed plans of care covering continence, mental health, mobility, nutrition, sensory impairment and communication difficulties are also explored.

Therapeutic strategies, including a high surgical ligation rate, for patent ductus arteriosus closure in extremely premature infants in a North American centre.

OBJECTIVE: To document the rate of surgical ligation of a patent ductus arteriosus (PDA) in extremely premature infants who had received more than one course of indomethacin. Outcomes were compared among three subgroups (ligation, further indomethacin and no further treatment) of infants who received at least one course of indomethacin, and between two subgroups (one course of indomethacin and more than one course) among infants who underwent ligation. STUDY DESIGN: A retrospective chart review of all 23 weeks+0 days to 26 weeks+6 days' gestational age infants with a PDA born between 1994 and 2005 was performed. Secondary outcomes were compared among the subgroups. RESULTS: The final study population consisted of 196 extremely premature infants with a PDA. The rate of surgical ligation in the 88 infants who received more than one course of indomethacin was 64%. The ligation subgroup, in comparison with the no further treatment subgroup, spent a greater median time on mechanical ventilation (39 versus 29 days, P<0.001) and in hospital (115 versus 92 days P=0.002), while trending toward lower mortality (18% versus 40%, P=0.07). The PDA closed following the first course of indomethacin in only 20% of infants. CONCLUSIONS: A majority of extremely premature infants receiving more than one course of indomethacin underwent surgical ligation. Repeated indomethacin courses were generally well tolerated, but were mostly unsuccessful. Ligation appears to have potential risks and benefits. A randomized trial should be performed after studies define a hemodynamically significant PDA that will result in morbidity and/or mortality unless treated.

OBJECTIF: Étayer le taux de ligatures chirurgicales de persistances du canal artériel (PCA) chez des grands prématurés qui avaient reçu plus d'une série de traitement à l'indométhacine. Les chercheurs ont comparé les issues entre les trois sous-groupes (ligature, nouvelle série de traitement à l'indométhacine et aucun traitement supplémentaire) et les nourrissons qui avaient reçu au moins une série de traitement à l'indométhacine, ainsi qu'entre deux sous-groupes (une série de traitement à l'indométhacine et plus d'une dose) et les nourrissons qui avaient eu une ligature. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de tous les nourrissons de 23+0 à 26+6 semaines d'âge gestationnel ayant une PCA, qui étaient nés entre 1994 et 2005. Ils ont comparé les issues secondaires entre les sous-groupes. RÉSULTATS: La population finale à l'étude se composait de 196grands prématurés ayant une PCA. Le taux de ligatures chirurgicales chez les 88 nourrissons qui avaient reçu plus d'une série de traitement à l'indométhacine s'élevait à 64 %. Le sous-groupe ligaturé, par rapport au sous-groupe n'ayant pas reçu de traitement supplémentaire, présentait une durée médiane plus élevée sous ventilation mécanique (39 jours par rapport à 29, P<0,001) et d'hospitalisation (115 jours par rapport à 92, P=0,002), tout en manifestant une tendance vers une mortalité moins élevée (18 % par rapport à 40 %, P=0,07). La PCA s'est fermée après la première dose d'indométhacine chez seulement 20% des nourrissons. CONCLUSIONS: La majorité des grands prématurés qui avaient reçu plus d'une série de traitement à l'indométhacine ont subi une ligature chirurgicale. Les nouvelles séries de traitement à l'indométhacine étaient généralement bien tolérées, mais la plupart étaient sans effet sur la PCA. La ligature semble s'associer à des risques et bienfaits potentiels. Il faudrait procéder à un essai aléatoire après que des études auront défini une PCA significative sur le plan hémodynamique qui s'associe à une morbidité ou une mortalité à moins d'être traitée.

(Correcting) misdiagnoses of asthma: a cost effectiveness analysis.

BACKGROUND: The prevalence of physician-diagnosed-asthma has risen over the past three decades and misdiagnosis of asthma is potentially common. OBJECTIVE: to determine whether a secondary-screening-program to establish a correct diagnosis of asthma in those who report a physician diagnosis of asthma is cost effective. METHOD: Randomly selected physician-diagnosed-asthmatic subjects from 8 Canadian cities were studied with an extensive diagnostic algorithm to rule-in, or rule-out, a correct diagnosis of asthma. Subjects in whom the diagnosis of asthma was excluded were followed up for 6-months and data on asthma medications and heath care utilization was obtained. Economic analysis was performed to estimate the incremental lifetime costs associated with secondary screening of previously diagnosed asthmatic subjects. Analysis was from the perspective of the Canadian healthcare system and is reported in Canadian dollars. RESULTS: Of 540 randomly selected patients with physician diagnosed asthma 150 (28%; 95%CI 19-37%) did not have asthma when objectively studied. 71% of these misdiagnosed patients were on some asthma medications. Incorporating the incremental cost of secondary-screening for the diagnosis of asthma, we found that the average cost savings per 100 individuals screened was $35,141 (95%CI $4,588-$69,278). CONCLUSION: Cost savings primarily resulted from lifetime costs of medication use averted in those who had been misdiagnosed.

Depressive symptoms are associated with medication use and lower health-related quality of life in overweight women with binge eating disorder.

BACKGROUND: Depression is a most burdensome illness, with personal and societal costs surpassing those of any other illness. Furthermore, depression affects women at a much higher rate than men. The most prevalent eating disorder among adult women is binge eating disorder (BED). Depression and obesity are common in women with BED, most of whom seek treatment later in life. Depression, obesity, and age are associated with greater health care use and lower health-related quality of life (HRQOL). Hence, for women with BED estimating the effects of depression can be confounded by both age and body mass index (BMI). The current study examined the relationships between depression, HRQOL, and health care utilization among treatment seeking women with BED. METHODS: Participants (n = 105) completed the Structured Clinical Interview for DSM-IV, a health care utilization and cost survey, the Personality Assessment Inventory depression scale, and the EQ-5D to measure HRQOL. FINDINGS: On average, participants were severely obese with a mean BMI of 38.20 (SD = 6.80); 67.27% had a lifetime history of depression. Participants had higher health care costs and lower HRQOL than published age- and gender-matched norms. After controlling for age and BMI, depressive symptoms were significantly related to greater medication use (excluding antidepressants), and lower HRQOL. CONCLUSION: Results suggest that targeting depressive symptoms may reduce the economic and personal burden of BED for women.

Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis.

OBJECTIVE: Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis. METHODS: An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping. RESULTS: The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919-1325) for the combination therapy, $1210 (95% CI: 1004-1441) for no active treatment, $1322 (95% CI: 1093-1571) for epinephrine alone, and $1360 (95% CI: 1124-1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11-13) for the combination therapy, 12.7 days (95% CI: 12-13) for no active treatment, 13.0 days (95% CI: 12-14) for epinephrine alone, and 12.6 days (95% CI: 12-13) for dexamethasone alone. CONCLUSION: Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.