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1.
BMC Health Serv Res ; 19(1): 690, 2019 10 12.
Artigo em Inglês | MEDLINE | ID: mdl-31606031

RESUMO

BACKGROUND: In Asia, over 50% of patients with symptoms of tuberculosis (TB) access health care from private providers. These patients are usually not notified to the National TB Control Programs, which contributes to low notification rates in many countries. METHODS: From January 1, 2011 to December 31, 2012, Karachi's Indus Hospital - a private sector partner to the National TB Programme - engaged 80 private family clinics in its catchment area in active case finding using health worker incentives to increase notification of TB disease. The costs incurred were estimated from the perspective of patients, health facility and the program providing TB services. A Markov decision tree model was developed to calculate the cost-effectiveness of the active case finding as compared to case detection through the routine passive TB centers. Pakistan has a large private health sector, which can be mobilized for TB screening using an incentivized active case finding strategy. Currently, TB screening is largely performed in specialist public TB centers through passive case finding. Active and passive case finding strategies are assumed to operate independently from each other. RESULTS: The incentive-based active case finding program costed USD 223 per patient treated. In contrast, the center based non-incentive arm was 23.4% cheaper, costing USD 171 per patient treated. Cost-effectiveness analysis showed that the incentive-based active case finding program was more effective and less expensive per DALY averted when compared to the baseline passive case finding as it averts an additional 0.01966 DALYs and saved 15.74 US$ per patient treated. CONCLUSION: Both screening strategies appear to be cost-effective in an urban Pakistan context. Incentive driven active case findings of TB in the private sector costs less and averts more DALYs per health seeker than passive case finding, when both alternatives are compared to a common baseline situation of no screening.


Assuntos
Setor Privado/economia , Tuberculose/prevenção & controle , Adolescente , Adulto , Análise Custo-Benefício , Árvores de Decisões , Notificação de Doenças/economia , Notificação de Doenças/normas , Diagnóstico Precoce , Feminino , Humanos , Masculino , Programas de Rastreamento/economia , Motivação , Paquistão , Tuberculose/economia , Conduta Expectante/economia , Adulto Jovem
3.
World J Gastroenterol ; 25(18): 2217-2228, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31143072

RESUMO

BACKGROUND: Patients with pancreatic cystic neoplasms (PCN), without surgical indication at the time of diagnosis according to current guidelines, require lifetime image-based surveillance follow-up. In these patients, the current European evidenced-based guidelines advise magnetic resonance imaging (MRI) scanning every 6 mo in the first year, then annually for the next five years, without reference to any role for trans-abdominal ultrasound (US). In this study, we report on our clinical experience of a follow-up strategy of image-based surveillance with US, and restricted use of MRI every two years and for urgent evaluation whenever suspicious changes are detected by US. AIM: To report the results and cost-efficacy of a US-based surveillance follow-up for known PCNs, with restricted use of MRI. METHODS: We retrospectively evaluated the records of all the patients treated in our institution with non-surgical PCN who received follow-up abdominal US and restricted MRI from the time of diagnosis, between January 2012 and January 2017. After US diagnosis and MRI confirmation, all patients underwent US surveillance every 6 mo for the first year, and then annually. A MRI scan was routinely performed every 2 years, or at any stage for all suspicious US findings. In this communication, we reported the clinical results of this alternative follow-up, and the results of a comparative cost-analysis between our surveillance protocol (abdominal US and restricted MRI) and the same patient cohort that has been followed-up in strict accordance with the European guidelines recommended for an exclusive MRI-based surveillance protocol. RESULTS: In the 5-year period, 200 patients entered the prescribed US-restricted MRI surveillance follow-up. Mean follow-up period was 25.1 ± 18.2 mo. Surgery was required in two patients (1%) because of the appearance of suspicious features at imaging (with complete concordance between the US scan and the on-demand MRI). During the follow-up, US revealed changes in PCN appearance in 28 patients (14%). These comprised main pancreatic duct dilatation (n = 1), increased size of the main cyst (n = 14) and increased number of PNC (n = 13). In all of these patients, MRI confirmed US findings, without adding more information. The bi-annual MRI identified evolution of the lesions not identified by US in only 11 patients with intraductal papillary mucinous neoplasms (5.5%), largely consisting of an increased number of very small PCN (P = 0.14). The overall mean cost of surveillance, based on a theoretical use of the European evidenced-based exclusive MRI surveillance in the same group of patients, would have been 1158.9 ± 798.6 € per patient, in contrast with a significantly lower cost of 366.4 ± 348.7 € (P < 0.0001) incurred by the US-restricted MRI surveillance used at our institution. CONCLUSION: In patients with non-surgical PCN at the time of diagnosis, US surveillance could be a safe complementary approach to MRI, delaying and reducing the numbers of second level examinations and therefore reducing the costs.


Assuntos
Assistência ao Convalescente/métodos , Análise Custo-Benefício , Neoplasias Pancreáticas/diagnóstico por imagem , Conduta Expectante/métodos , Assistência ao Convalescente/economia , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Humanos , Imagem por Ressonância Magnética/efeitos adversos , Imagem por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Ultrassonografia/efeitos adversos , Ultrassonografia/economia , Conduta Expectante/economia
4.
J Gynecol Oncol ; 30(3): e37, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30887758

RESUMO

OBJECTIVE: The purpose of this study was to assess the incidence rate of cervical intraepithelial neoplasia (CIN) and cervical cancer, and their costs according to age. METHODS: We collected data on annual incidence and medical costs of CIN and cervical cancer from 2010 until the end of 2014 from the Health Insurance Review and Assessment (HIRA) service. The CIN was classified into CIN3 (high-grade) requiring conization and CIN1/2 (low-grade) requiring observation. RESULTS: Incidence rates of CIN3 and cervical cancer are reducing over time, whereas CIN1/2 is increasing significantly (p for trend: <0.001). The peak ages of incidence were 25-29, 30-34, and 70-74 years old for CIN1/2, CIN3, and cervical cancer, respectively. The crude incidence of CIN1/2 increased by approximately 30% in 2014 compared to 5 years ago and demonstrated an increasing trend in all age groups. The CIN3 showed a significantly increasing trend in the age group of 30-39 years old, the cervical cancer was significantly reduced in all ages, except the 35-39 years old. The treatment for cervical cancer costs $3,342 per year, whereas the treatment for CIN3 and CIN1/2 cost $467 and $83, respectively. CONCLUSION: The crude incidence rate of cervical cancer is currently decreasing among Korean women, but the incidence rates and medical costs of CIN and cervical cancer are increasing in women in their 30s in Korea. These findings suggest that different strategies by age will be required for prevention of cervical cancer in Korea.


Assuntos
Neoplasia Intraepitelial Cervical/economia , Neoplasia Intraepitelial Cervical/epidemiologia , Custos de Cuidados de Saúde , Neoplasias do Colo do Útero/economia , Neoplasias do Colo do Útero/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia/economia , Biópsia/estatística & dados numéricos , Neoplasia Intraepitelial Cervical/terapia , Conização/economia , Conização/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Incidência , Pessoa de Meia-Idade , Gradação de Tumores , República da Coreia/epidemiologia , Neoplasias do Colo do Útero/terapia , Conduta Expectante/economia , Conduta Expectante/estatística & dados numéricos , Adulto Jovem
5.
Urology ; 127: 107-112, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30790649

RESUMO

OBJECTIVE: To determine the most cost-effective approach to the management of distal ureteral stones in children given the potential for recurrent renal colic during a trial of passage versus potential stent discomfort and complications of ureteroscopy. METHODS: We developed a decision tree to project costs and clinical outcomes associated with observation, medical explusive therapy (MET), and ureteroscopy for the management of an index patient with a 4-mm-distal ureteral stone. We determined which strategy would be least costly and offer the most pain-free days within 30days of diagnosis. We performed a one-way sensitivity analysis on the probability of successful stone passage with MET. We obtained probabilities from the literature and costs from the 2016 Pediatric Health Information System Database. RESULTS: Ureteroscopy was the costliest strategy but maximized the number of pain-free days within 30days of diagnosis ($5282/29 pain-free days). MET was less costly than ureteroscopy but also less effective ($615/21.8 pain-free days). Observation cost more than MET and was also less effective ($2139/15.5 pain-free days). The one-way sensitivity analysis on the probability of successful stone passage with MET demonstrated that ureteroscopy always has the highest net monetary benefits value and is therefore the recommended strategy given a fixed willingness-to-pay. DISCUSSION: Using a rigorous decision-science approach, we found that ureteroscopy is the recommended strategy in children with small distal ureteral stones. Although it costs more than MET, it resulted in more pain-free days in the first 30days following diagnosis given the faster resolution of the stone episode.


Assuntos
Litotripsia/economia , Stents/economia , Cálculos Ureterais/terapia , Ureteroscopia/economia , Conduta Expectante/economia , Análise de Variância , Criança , Pré-Escolar , Análise Custo-Benefício , Bases de Dados Factuais , Árvores de Decisões , Feminino , Humanos , Litotripsia/métodos , Masculino , Medição de Risco , Índice de Gravidade de Doença , Cálculos Ureterais/diagnóstico , Ureteroscopia/métodos
6.
AJR Am J Roentgenol ; 212(4): 830-838, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30779659

RESUMO

OBJECTIVE: The objective of our study was to evaluate the cost-effectiveness of active surveillance (AS) versus nephron-sparing surgery (NSS) in patients with a Bosniak IIF or III renal cyst. MATERIALS AND METHODS: Markov models were developed to estimate life expectancy and lifetime costs for 60-year-old patients with a Bosniak IIF or III renal cyst (the reference cases) managed by AS versus NSS. The models incorporated the malignancy rates, reclassification rates during follow-up, treatment effectiveness, complications and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify management preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold, using data from studies in the literature and the 2015 Medicare Physician Fee Schedule. The effects of key parameters were addressed in a multiway sensitivity analysis. RESULTS: The prevalence of malignancy for Bosniak IIF and III renal cysts was 26% (25/96) and 52% (542/1046). Under base case assumptions for Bosniak IIF cysts, the incremental cost-effectiveness ratio of NSS relative to AS was $731,309 per QALY for women, exceeding the assumed societal willingness-to-pay threshold, and AS outperformed NSS for both life expectancy and cost for men. For Bosniak III cysts, AS yielded greater life expectancy (24.8 and 19.4 more days) and lower lifetime costs (cost difference of $12,128 and $11,901) than NSS for men and women, indicating dominance of AS over NSS. Superiority of AS held true in sensitivity analyses for men 46 years old or older and women 57 years old or older even when all parameters were set to favor NSS. CONCLUSION: AS is more cost-effective than NSS for patients with a Bosniak IIF or III renal cyst.


Assuntos
Doenças Renais Císticas/cirurgia , Nefrectomia/economia , Conduta Expectante/economia , Análise Custo-Benefício , Feminino , Humanos , Doenças Renais Císticas/patologia , Expectativa de Vida , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Anos de Vida Ajustados por Qualidade de Vida
7.
Am J Obstet Gynecol ; 220(6): 590.e1-590.e10, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30768934

RESUMO

BACKGROUND: A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes. OBJECTIVE: We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States. STUDY DESIGN: A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years. RESULTS: In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time. CONCLUSION: In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.


Assuntos
Cesárea/economia , Macrossomia Fetal/economia , Hipertensão Induzida pela Gravidez/economia , Trabalho de Parto Induzido/economia , Paralisia do Plexo Braquial Neonatal/economia , Natimorto/economia , Adulto , Cesárea/estatística & dados numéricos , Análise Custo-Benefício , Parto Obstétrico/economia , Parto Obstétrico/métodos , Feminino , Macrossomia Fetal/epidemiologia , Custos de Cuidados de Saúde , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Trabalho de Parto Induzido/métodos , Paralisia do Plexo Braquial Neonatal/epidemiologia , Paridade , Morte Perinatal , Gravidez , Anos de Vida Ajustados por Qualidade de Vida , Natimorto/epidemiologia , Conduta Expectante/economia
8.
Ann Surg ; 269(2): 358-366, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29194083

RESUMO

OBJECTIVE: To compare long-term clinical and economic outcomes associated with 3 management strategies for reducible ventral hernia: repair at diagnosis (open or laparoscopic) and watchful waiting. BACKGROUND: There is variability in ventral hernia management. Recent data suggest watchful waiting is safe; however, long-term clinical and economic outcomes for different management strategies remain unknown. METHODS: We built a state-transition microsimulation model to forecast outcomes for individuals with reducible ventral hernia, simulating a cohort of 1 million individuals for each strategy. We derived cohort characteristics (mean age 58 years, 63% female), hospital costs, and perioperative mortality from the Nationwide Inpatient Sample (2003-2011), and additional probabilities, costs, and utilities from the literature. Outcomes included prevalence of any repair, emergent repair, and recurrence; lifetime costs; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratios. We performed stochastic and probabilistic sensitivity analyses to identify parameter thresholds that affect optimal management, using a willingness-to-pay threshold of $50,000/QALY. RESULTS: With watchful waiting, 39% ultimately required repair (14% emergent) and 24% recurred. Seventy per cent recurred with repair at diagnosis. Laparoscopic repair at diagnosis was cost-effective compared with open repair at diagnosis (incremental cost-effectiveness ratio $27,700/QALY). The choice of operative strategy (open vs laparoscopic) was sensitive to cost and postoperative quality of life. When perioperative mortality exceeded 5.2% or yearly recurrence exceeded 19.2%, watchful waiting became preferred. CONCLUSIONS: Ventral hernia repair at diagnosis is very cost-effective. The choice between open and laparoscopic repair depends on surgical costs and postoperative quality of life. In patients with high risk of perioperative mortality or recurrence, watchful waiting is preferred.


Assuntos
Hérnia Ventral/economia , Hérnia Ventral/terapia , Herniorrafia/economia , Conduta Expectante/economia , Adulto , Idoso , Análise Custo-Benefício , Feminino , Hérnia Ventral/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
9.
Ann Allergy Asthma Immunol ; 122(1): 79-85, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30025910

RESUMO

BACKGROUND: Layperson food allergy management plans commonly stipulate that if epinephrine is used to immediately call 911 and seek care in the nearest medical facility for observation. OBJECTIVE: To evaluate the cost-effectiveness of this strategy, vs a watchful waiting approach before activating emergency medical services (EMS). METHODS: We performed a cost-effectiveness analysis using Markov modeling simulated over a 20-year horizon comparing activating EMS immediately after epinephrine use for allergic reactions to peanut vs a "wait and see" approach in which EMS was only activated if symptoms of the reaction did not promptly resolve after treatment. The base-case model assumed a 10-fold increased fatality risk with delayed EMS activation. RESULTS: The fatality risk associated with early EMS use was minimal, with a per-patient fatality rate over a 20-year horizon of 1.2 × 10-6, vs 1.9 × 10-6 for a wait and see approach. The incremental cost per life-year saved was $142,943,447 for early EMS vs wait and see, with the cost per death prevented reaching $1,349,335,651 as the simulation concluded. Cost of early EMS activation rose to $321,625,534 per life-year saved ($3,035,454,848 per death prevented) if a 5-fold increase in fatality risk was assumed, and was $12,997,173 per life-year saved ($122,689,936 per death prevented) if a 100-fold increase in fatality risk was assumed. CONCLUSION: Medical observation of a treated and promptly resolved peanut allergic reaction has minimal benefit and excessive costs. Immediately activating EMS after using epinephrine for a peanut allergic reaction in this context is not cost-effective.


Assuntos
Anafilaxia/economia , Análise Custo-Benefício/estatística & dados numéricos , Serviços Médicos de Emergência/economia , Epinefrina/uso terapêutico , Hipersensibilidade a Amendoim/tratamento farmacológico , Hipersensibilidade a Amendoim/economia , Conduta Expectante/economia , Antígenos de Plantas/imunologia , Arachis/imunologia , Humanos , Hipersensibilidade a Amendoim/mortalidade
10.
JAMA Oncol ; 5(1): 60-66, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30242397

RESUMO

Importance: Localized prostate cancer diagnosis and treatment among elderly men who are not likely to benefit represents a potential source of low-value health care services. Objective: To quantify the costs to the Medicare program associated with detection and treatment of prostate cancer among elderly men in the United States. Design, Setting, and Participants: This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age. Main Outcomes and Measures: Estimated costs to the Medicare program overall, and in each (mutually exclusive) category related to diagnosis and workup, treatment, follow-up, and morbidity management. Results: This nationwide, population-based, retrospective cohort study included 49 692 men with nonmetastatic prostate cancer from the SEER-Medicare database (all participants were 70 years or older; 25 981 [52.3%] were 76 years or older). The median per-patient cost within 3 years after prostate cancer diagnosis was $14 453 (interquartile range [IQR], $4887-$27 899). The majority of this cost was attributable to treatment costs (median, $10 558; IQR, $1990-$23 718). Patients with a Gleason score of 6 or lower who pursued initial conservative management (no treatment within 12 months of diagnosis) had a 3-year median total cost of $1914 per patient. The estimated total 3-year cost to the Medicare program associated with the annual detection of prostate cancer in men 70 years or older is approximately $1.2 billion. Increasing active surveillance use in those with Gleason score of 6 or lower could reduce this cost by $320 million. Conclusions and Relevance: There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.


Assuntos
Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde , Medicare/economia , Neoplasias da Próstata/economia , Conduta Expectante/economia , Distribuição por Idade , Idoso , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Humanos , Incidência , Masculino , Gradação de Tumores , Valor Preditivo dos Testes , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/epidemiologia , Neoplasias da Próstata/terapia , Estudos Retrospectivos , Programa de SEER , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
11.
World J Urol ; 37(7): 1297-1303, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30276542

RESUMO

INTRODUCTION: Active surveillance (AS) seems to be a cost-effective strategy. However, most publications are based on simulation models of theoretical cohorts, and long-term implications are not usually considered. OBJECTIVE: To assess the real cost differences of two cohorts of men with low-risk prostate cancer (PCa) treated with AS or laparoscopic radical prostatectomy (LRP) in a public health system. MATERIALS AND METHODS: Patients diagnosed from 2005 to 2009 were included in an AS program (Group 1) or treated with LRP at diagnosis (Group 2), with a minimum follow-up of 5 years. Actual costs for each patient were calculated on an individual basis: Group 1: semiannual PSA measurements and repeat biopsies are scheduled every 1-3 years. Costs of outpatient clinic visits were calculated, as well as all tests required for monitoring or active treatment. Group 2: costs of the procedure, emergency visits, re-admissions and outpatient clinic visits were calculated, as well as costs of oncological salvage therapies or functional surgical procedures. RESULTS: Out of 151 men diagnosed with low-risk PC, 54 (35.8%) were included in an AS (Group 1) and 97 (64.2%) were submitted to LRP (Group 2). Mean follow-up for both groups was 6.5 years (SD 1.8) and 6.7 years (SD 1.4), respectively, p = 0.49. Group 1 had a total cost per patient of 2970.47€. Group 2 had a total cost per patient of 5694.06€. CONCLUSIONS: AS was associated with cost-saving over LRP. This cost reduction of AS in the management of low-risk PCa is based on the accounting of real costs of individual patients and confirms previously published estimation-based reports.


Assuntos
Custos de Cuidados de Saúde , Prostatectomia/economia , Neoplasias da Próstata/terapia , Conduta Expectante/economia , Idoso , Assistência Ambulatorial/economia , Biópsia/economia , Custos e Análise de Custo , Serviço Hospitalar de Emergência/economia , Hospitalização/economia , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Terapia de Salvação/economia , Espanha
12.
Cancer ; 125(6): 952-962, 2019 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-30561761

RESUMO

BACKGROUND: Active surveillance (AS) is a viable management option for approximately 50% of men who are newly diagnosed with prostate cancer. To the authors' knowledge, no direct comparisons between the different variants of AS protocols have been conducted to date. The authors developed a microsimulation decision model to evaluate which of 3 alternative AS protocols is optimal for men with low-risk prostate cancer, and compared each of these with immediate treatment. METHODS: Men who were diagnosed with low-risk prostate cancer at age 65 years were modeled as having been treated with either immediate therapy or via each of 3 AS protocols. Modeled AS protocols represent those in the literature; a modified AS protocol was included in a sensitivity analysis. Immediate therapy included radical prostatectomy, external-beam radiotherapy, or brachytherapy. Outcome measures were quality-adjusted life-years (QALYs) and costs. Cost-effectiveness analysis and deterministic and probabilistic sensitivity analyses were performed. RESULTS: Immediate therapy produced fewer QALYs than all variants of AS. Of the AS protocols evaluated, biennial biopsy was found to be the only efficient option, with an incremental cost-effectiveness ratio of $3490 per QALY compared with immediate therapy. It delayed the need for curative therapy by a mean of 56 months, and was found to be preferred in >86.9% of cases in probabilistic sensitivity analysis. A modified version of low-intensity AS dominated all other options. CONCLUSIONS: For a 65-year-old man with low-risk prostate cancer, AS with biennial biopsy appears to be highly cost-effective compared with common alternatives. An AS protocol using triennial biopsy was found to dominate all other strategies and should be considered for men who are comfortable with a longer period between biopsies. The optimal strategy depends on a patient's tolerance for periodic biopsies and comfort with delaying radical treatment. Physicians should incorporate these patient preferences into decision making.


Assuntos
Antígenos de Superfície/economia , Biópsia/economia , Exame Retal Digital/economia , Glutamato Carboxipeptidase II/economia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Conduta Expectante/economia , Idoso , Antígenos de Superfície/análise , Braquiterapia , Tomada de Decisão Clínica , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Glutamato Carboxipeptidase II/análise , Humanos , Masculino , Cadeias de Markov , Prostatectomia , Neoplasias da Próstata/metabolismo , Anos de Vida Ajustados por Qualidade de Vida
14.
Pediatr. aten. prim ; 20(80): 397-400, oct.-dic. 2018.
Artigo em Espanhol | IBECS | ID: ibc-180976

RESUMO

Conclusiones de los autores del estudio: el empleo apropiado de la actitud expectante para el manejo de la otitis media aguda podría simultáneamente mejorar los resultados de salud y ahorrar costes a la sociedad. En contraposición, los autores interpretan que esta actitud podría suponer un aumento de las visitas, requiriendo educación adicional de los padres y del personal sanitario. Comentario de los revisores: este análisis de coste-efectividad demuestra que la actitud expectante basada en las pautas de la Academia Americana de Pediatría para el manejo de la otitis media se asocia con menores costes totales y evita la pérdida de años de vida ajustados por discapacidad. Sería necesario realizar estudios de costes en Atención Primaria y adaptados a nuestro medio, donde se puede asegurar un seguimiento más exhaustivo de los pacientes obteniendo incluso costes menores


Author's conclusions: the appropriate use of watchful waiting for the management of acute otitis media could simultaneously improve health outcomes and save costs for society. In contrast, the authors interpret that this attitude could imply an increase in visits, requiring additional education from parents and health personnel. Reviewer's commentary: this cost-effectiveness analysis demonstrates that watchful waiting management for acute otitis media in patients meeting criteria of the AAP guidelines, stratifying by age and severity symptoms, is associated with lower total costs and also avoids the loss of years of life due to disability. It would be necessary to conduct cost studies in Primary Care, adapted to our environment where it can be ensured a more exhaustive monitoring of patients and the costs could be even lower


Assuntos
Humanos , Conduta Expectante/economia , Otite Média/terapia , Custos Diretos de Serviços/estatística & dados numéricos , Otite Média/epidemiologia , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício
15.
BMC Pediatr ; 18(1): 262, 2018 08 04.
Artigo em Inglês | MEDLINE | ID: mdl-30077184

RESUMO

BACKGROUND: Much controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants, especially in those born at a gestational age (GA) less than 28 weeks. No causal relationship has been proven between a (haemodynamically significant) PDA and neonatal complications related to pulmonary hyperperfusion and/or systemic hypoperfusion. Although studies show conflicting results, a common understanding is that medical or surgical treatment of a PDA does not seem to reduce the risk of major neonatal morbidities and mortality. As the PDA might have closed spontaneously, treated children are potentially exposed to iatrogenic adverse effects. A conservative approach is gaining interest worldwide, although convincing evidence to support its use is lacking. METHODS: This multicentre, randomised, non-inferiority trial is conducted in neonatal intensive care units. The study population consists of preterm infants (GA < 28 weeks) with an echocardiographic-confirmed PDA with a transductal diameter > 1.5 mm. Early treatment (between 24 and 72 h postnatal age) with the cyclooxygenase inhibitor (COXi) ibuprofen (IBU) is compared with an expectative management (no intervention intended to close a PDA). The primary outcome is the composite of mortality, and/or necrotising enterocolitis (NEC) Bell stage ≥ IIa, and/or bronchopulmonary dysplasia (BPD) defined as the need for supplemental oxygen, all at a postmenstrual age (PMA) of 36 weeks. Secondary outcome parameters are short term sequelae of cardiovascular failure, comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. Consequences regarding health economics are evaluated by cost effectiveness analysis and budget impact analysis. DISCUSSION: As a conservative approach is gaining interest, we investigate whether in preterm infants, born at a GA less than 28 weeks, with a PDA an expectative management is non-inferior to early treatment with IBU regarding to the composite outcome of mortality and/or NEC and/or BPD at a PMA of 36 weeks. TRIAL REGISTRATION: This trial is registered with the Dutch Trial Register NTR5479 (registered on 19 October 2015), the registry sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28 .


Assuntos
Inibidores de Ciclo-Oxigenase/uso terapêutico , Permeabilidade do Canal Arterial/tratamento farmacológico , Ibuprofeno/uso terapêutico , Lactente Extremamente Prematuro , Doenças do Prematuro/tratamento farmacológico , Conduta Expectante , Análise Custo-Benefício , Permeabilidade do Canal Arterial/complicações , Permeabilidade do Canal Arterial/mortalidade , Permeabilidade do Canal Arterial/cirurgia , Enterocolite Necrosante/etiologia , Humanos , Recém-Nascido , Doenças do Prematuro/mortalidade , Ligadura , Projetos de Pesquisa , Tempo para o Tratamento , Conduta Expectante/economia
16.
HPB (Oxford) ; 20(12): 1206-1214, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30064727

RESUMO

BACKGROUND: Branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) presents a clinical conundrum. Rigorous long-term surveillance or surgical resection is recommended. The economic consequences of the management have not been fully investigated. METHODS: A Markov decision model compared 4 strategies for low-risk BD-IPMN: I = upfront total pancreatectomy, II = upfront partial pancreatectomy, III = initial surveillance, IV = watchful waiting. Surveillance was based on the Swedish Guidelines for Pancreatic Cancer. Probabilities and costs were obtained from the participating unit and from the scientific literature. The incremental cost-effectiveness ratios (ICERs) were calculated and sensitivity analyses were performed by varying relevant parameters. Survival was reported in quality-adjusted life-years (QALYs). RESULTS: Strategy III was the most cost-effective strategy with an ICER of €31 682 compared to strategy IV. Strategy I was the most expensive but yielded the best QALY (9.32). Total number of years, annual risk of pancreatic cancer and annual risk of a low-risk BD-IPMN turning into a high-risk lesion had the greatest impact in the model. CONCLUSIONS: Initial surveillance seems to be the most cost-effective strategy in the management of low-risk asymptomatic BD-IPMN. However, the possibility of personalized approaches remains to be investigated.


Assuntos
Custos de Cuidados de Saúde , Pancreatectomia/economia , Neoplasias Intraductais Pancreáticas/economia , Neoplasias Intraductais Pancreáticas/terapia , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/terapia , Conduta Expectante/economia , Redução de Custos , Análise Custo-Benefício , Humanos , Cadeias de Markov , Modelos Econômicos , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Neoplasias Intraductais Pancreáticas/mortalidade , Neoplasias Intraductais Pancreáticas/patologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
Am J Surg ; 216(4): 760-763, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30054004

RESUMO

OBJECTIVE: To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND: The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS: A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's. RESULTS: ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION: This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.


Assuntos
Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hérnia Hiatal/terapia , Herniorrafia/economia , Conduta Expectante/economia , Técnicas de Apoio para a Decisão , Hérnia Hiatal/diagnóstico , Hérnia Hiatal/economia , Hérnia Hiatal/mortalidade , Humanos , Cadeias de Markov , Medicare , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Estudos Retrospectivos , Estados Unidos
18.
Surgery ; 164(6): 1330-1335, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30055789

RESUMO

BACKGROUND: In an effort to reduce overdiagnosis of low-risk thyroid cancer, recent clinical guidelines increased the size-based biopsy thresholds for thyroid nodules. The cost-effectiveness of these guidelines is largely unknown. We hypothesized that ultrasound surveillance in lieu of immediate fine needle aspiration biopsy would be cost effective for a 1.0 cm thyroid nodule with American Thyroid Association Intermediate Suspicion sonographic features. METHODS: A Markov transition-state model was constructed to compare immediate fine needle aspiration versus ultrasound surveillance. Univariate and multivariate sensitivity analyses were used to examine the uncertainty of cost, probability, and utility estimates in the model. RESULTS: Ultrasound surveillance was $1,829 less costly and 0.016 quality-adjusted life years more effective than immediate fine needle aspiration. Immediate fine needle aspiration became cost effective when the probability of malignancy increased from 15% to 84% or the cost of ultrasound increased from $129 to $793. Immediate fine needle aspiration was cost-effective if the quality adjustment factor for observation following a benign fine needle aspiration result exceeded the quality adjustment factor for observation without a biopsy. CONCLUSION: Ultrasound surveillance is more cost-effective than immediate fine needle aspiration for 1.0 cm thyroid nodules with an intermediate-suspicion sonographic pattern. Additional investigation of health-related quality of life in patients undergoing fine needle aspiration or surveillance is necessary.


Assuntos
Nódulo da Glândula Tireoide/diagnóstico por imagem , Conduta Expectante/economia , Adulto , Progressão da Doença , Humanos , Método de Monte Carlo , Anos de Vida Ajustados por Qualidade de Vida , Nódulo da Glândula Tireoide/economia , Nódulo da Glândula Tireoide/patologia , Ultrassonografia
19.
Curr Opin Urol ; 28(2): 219-226, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29334506

RESUMO

PURPOSE OF REVIEW: To review the current literature regarding the role of multiparametric MRI and fusion-guided biopsies in urologic practice. RECENT FINDINGS: Fusion biopsies consistently show an increase in the detection of clinically significant cancers and decrease in low-risk disease that may be more suitable for active surveillance. Although, when to incorporate multiparametric MRI into workup is not clearly agreed upon, studies have shown a clear benefit in both biopsy naïve and those with prior negative biopsies in determining the appropriate treatment strategy. More recently, cost-analysis models have been published that show that upfront MRIs are more cost-effective when considering missed cancers and treatment courses. SUMMARY: With improved accuracy over systematic biopsies, fusion biopsies are a superior method for detection of the true grade of cancer for both biopsy naïve and patients with prior negative biopsies, choosing appropriate candidates for active surveillance, and monitoring progression on active surveillance.


Assuntos
Biópsia com Agulha de Grande Calibre/métodos , Biópsia Guiada por Imagem/métodos , Próstata/patologia , Neoplasias da Próstata/diagnóstico , Biópsia com Agulha de Grande Calibre/efeitos adversos , Biópsia com Agulha de Grande Calibre/economia , Análise Custo-Benefício , Reações Falso-Negativas , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Biópsia Guiada por Imagem/economia , Imagem por Ressonância Magnética Intervencionista/métodos , Masculino , Imagem Multimodal/economia , Imagem Multimodal/métodos , Seleção de Pacientes , Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Ultrassonografia de Intervenção/economia , Ultrassonografia de Intervenção/métodos , Conduta Expectante/economia , Conduta Expectante/métodos
20.
J Urol ; 199(2): 401-406, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28847481

RESUMO

PURPOSE: We investigated predictive factors of failure and performed a resource consumption analysis in patients who underwent active surveillance for nonmuscle invasive bladder cancer. MATERIALS AND METHODS: This prospective observational study monitored patients with a history of pathologically confirmed stage pTa (grade 1-2) or pT1a (grade 2) nonmuscle invasive bladder cancer, and recurrent small size and number of tumors without hematuria and positive urine cytology. The primary end point was the failure rate of active surveillance. Assessment of failure predictive variables and per year direct hospital resource consumption analysis were secondary outcomes. Descriptive statistical analysis and Cox regression with univariable and multivariable analysis were done. RESULTS: Of 625 patients with nonmuscle invasive bladder cancer 122 with a total of 146 active surveillance events were included in the protocol. Of the events 59 (40.4%) were deemed to require treatment after entering active surveillance. Median time on active surveillance was 11 months (IQR 5-26). Currently 76 patients (62.3%) remain under observation. On univariable analysis only time from the first transurethral resection to the start of active surveillance seemed to be inversely associated with recurrence-free survival (HR 0.99, 95% CI 0.98-1.00, p = 0.027). Multivariable analysis also revealed an association with age at active surveillance start (HR 0.97, 95% CI 0.94-1.00, p = 0.031) and the size of the lesion at the first transurethral resection (HR 1.55, 95% CI 1.06-2.27, p = 0.025). The average specific annual resource consumption savings for each avoided transurethral bladder tumor resection was €1,378 for each intervention avoided. CONCLUSIONS: Active surveillance might be a reasonable clinical and cost-effective strategy in patients who present with small, low grade pTa/pT1a recurrent papillary bladder tumors.


Assuntos
Análise Custo-Benefício , Cistectomia/economia , Recidiva Local de Neoplasia/diagnóstico , Neoplasias da Bexiga Urinária/diagnóstico , Conduta Expectante/economia , Idoso , Utilização de Instalações e Serviços/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/economia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias da Bexiga Urinária/economia , Neoplasias da Bexiga Urinária/cirurgia
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