Malleable Transplant Criteria: At What Cost?

An 18-year-old male who had been diagnosed at age 7 with a rare, progressive liver disease was referred to the transplant center and received a transplant, even though he did not meet the center's criteria for a patient with hepatopulmonary syndrome (HPS). Complications required relisting the patient urgently, but he eventually fully recovered; total hospital charges for his treatment exceeded $5 million. Reflection upon the case resulted in analysis of two ethical questions: primarily, clinician obligation to balance the provision of actuarially fair health care to society against the healing of a single patient; secondarily, the effects of malleable transplant criteria on trust in the patient selection process. We affirmed that physicians should not be principally responsible for justifying financial investment to society or for upholding beneficence beyond the individual physician and patient relationship in order to contain costs. We concluded, however, that such instances, when combined with manipulation of transplant center criteria, pose a potential threat to public trust. We therefore suggested that transplant centers maintain independent ethics committees to review such cases.

High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six Cases.

OBJECTIVES: To discuss the dilemma of adequate decision making in patients with intravenous drug abuse and recurrent valve prosthesis infections or in patients with positive HIV or hepatitis C status. Ethical, social, and economic considerations, not only in terms of technical feasibility but also in terms of unpromising results and aspects of resources, are discussed. Thoughts are presented about the legitimation of cardiac surgery centers refusing to perform surgery in high-risk patients with HIV or hepatitis C infections. METHODS: Presentation of six cases for discussion. Three patients were addicted to intravenous drugs and had recurrent prosthetic valve endocarditis, and the other three patients had either paravalvular leakage of a mitral valve prosthesis or acute aortic dissection or coronary artery disease. Five of these patients suffered from HIV/AIDS and infective hepatitis C. Four of these patients were refused by other centers due to high risk or a lack of capacity. RESULTS: All six patients were operated during 2013. Mortality was 17%. CONCLUSION: Decision making in noncompliant drug addicts with recurrent prosthesis infection and in HIV-positive patients leads beyond surgical challenges to ethical and economic considerations.

Análisis del Impacto Presupuestario del tratamiento mediante quimiohipertermia neoadyuvante en el cáncer vesical no músculo invasivo / Analysis of Budgetary Impact of moderate and high risk non muscle-invasive bladder cancer by means of neoadjuvant hyperthermia chemotherapy compared to the standard adjuvant treatment with BCG

OBJETIVO: Estudiar la relación de coste-efectividad e impacto presupuestario de una pauta de quimiohipertermia (QHT) neoadyuvante en pacientes con cáncer vesical no musculo invasivo (NMI) comparándolo con un tratamiento estándar de BCG y aplicando valores de recidiva y progresión basadas en tablas de riesgo internacionalmente aceptadas. MÉTODOS: Para ello, se diseñó un modelo desde la perspectiva de un sistema público de salud tras un seguimiento de 3 años para comparar los costes de aplicar quimiohipertermia neoadyuvante a los pacientes del ensayo clínico (8 instilaciones semanales de 80 mg Mitomicina C recirculando a 43 ºC durante 1 hora previas a la realización de una resección transuretral del tumor vesical) con los costes de tratar a 15 pacientes con el mismo perfil de riesgo con el tratamiento estándar adyuvante de BCG (grupo control). Se incluyeron los costes reales disponibles correspondientes a fármacos y desechables y los publicados relativos a la resección transuretral (RTU) de vejiga, biopsia fría y riesgo de recidiva tumoral. Se descartaron del modelo los costes de pruebas diagnósticas y de seguimiento por no variar entre ambos grupos. RESULTADOS: El modelo construido con datos de costes reales y publicados establece una diferencia favorable para el tratamiento neoadyuvante con quimiohipertermia en términos de coste a 3 años con un ahorro mínimo global de 10.300€ y de 687€ por paciente, todo ello con una mejora de la efectividad del tratamiento. Estos valores pueden pasar a 25.960€ de ahorro mínimo y 1.731€ de ahorro por paciente, si se asume un cambio de protocolo después de la neoadyuvancia que utilice la biopsia fría para comprobar el resultado. De los 15 pacientes pretratados con quimiohipertermia, 11 de riesgo alto y 4 de riesgo medio, 9 han respondido de forma completa (ausencia de tumor residual) y 6 de forma parcial (reducción del tumor). El número de recurrencias esperadas se ha reducido de 8 a 2 y de progresiones de 3 a 0. CONCLUSIONES: El tratamiento neoadyuvante con quimiohipertermia constituye una estrategia terapéutica coste-efectiva

OBJECTIVES: To study the relationship between cost-effectiveness and budgetary impact the application of a neoadjuvant chemo-hyperthermia treatment on 15 patients with NMI multi-recurrent bladder cancer and/or whose risk of recurrence and progression is medium-high, compared with the standard neoadjuvant BCG treatment, has had on the Hospital Comarcal de Monforte de Lemos (Lugo). METHODS: A model was designed from an SNS perspective with a temporary horizon of three years to compare the costs of applying neoadjuvant chemohyperthermia on the patients of the clinical test (8 instillations weekly of 80 mg Mitomycin C recirculating at 43° C for an hour prior to carrying out a transurethral resection of the bladder tumor) with the costs of treating 15 patients with the same risk profile with the standard adjuvant treatment of BCG (control group). The effective available costs corresponding to drugs, disposables and those relative to TURBT, cold biopsy and tumor relapse were included. The costs of diagnostic tests and followup were discarded from the model because they did not vary between groups. RESULTS: The model built with effective and published cost data establishes a favourable difference in favour of the neoadjuvant treatment with chemo hyperthermia in terms of 3 year costs with a minimum global savings of 10,300€ and 687€ per patient, together with an improvement in the effectiveness of the treatment. These values could reach a minimum savings of 25,960€ and 1,731€ per patient, if a change in protocol is made after the neoadjuvant treatment, which uses the cold biopsy to check the results. Of the 15 patients pre-treated with chemo-hyperthermia, 11 high-risk and 4 medium-risk, 9 have responded completely (absence of residual tumor) and 6 partially (shrinking of the tumor). The number of expected relapses has been reduced from 8 to 2 and progression from 3 to 0. CONCLUSIONS: The neoadjuvant treatment with chemo hyperthermia constitutes a cost-effective therapeutic strategy

Palivizumab: a debate about funding.

A clinician and the chair of the hospital drug committee debate the merits of the use of palivizumab as prophylaxis against respiratory syncytial virus infection for a preterm baby with oxygen-dependent, chronic lung disease and discuss the issue of public funding of palivizumab. An ethicist comments on ethical aspects of the debate about cost-effectiveness.