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2.
N Engl J Med ; 381(10): 912-922, 2019 09 05.
Artigo em Inglês | MEDLINE | ID: mdl-31483962

RESUMO

BACKGROUND: Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain. METHODS: In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire. RESULTS: Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of £20,000 ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery. CONCLUSIONS: In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of £20,000 ($28,433) per QALY. (Funded by the National Institute for Health Research; CLASS Current Controlled Trials number, ISRCTN51995477.).


Assuntos
Procedimentos Endovasculares , Terapia a Laser , Qualidade de Vida , Escleroterapia , Varizes/terapia , Adulto , Análise Custo-Benefício , Procedimentos Endovasculares/economia , Feminino , Seguimentos , Humanos , Análise de Intenção de Tratamento , Terapia a Laser/economia , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Escleroterapia/economia , Escleroterapia/métodos , Inquéritos e Questionários , Resultado do Tratamento , Ultrassonografia de Intervenção , Varizes/cirurgia
3.
Ann Otol Rhinol Laryngol ; 128(5): 401-405, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30739476

RESUMO

OBJECTIVE: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. METHOD: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. RESULTS: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. CONCLUSION: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.


Assuntos
Instituições de Assistência Ambulatorial/economia , Malformações Vasculares/terapia , Anestesia Geral/estatística & dados numéricos , Custos e Análise de Custo , Embolização Terapêutica/economia , Embolização Terapêutica/estatística & dados numéricos , Endoscopia/economia , Endoscopia/estatística & dados numéricos , Estudos de Viabilidade , Pessoal de Saúde/economia , Humanos , Terapia a Laser/economia , Terapia a Laser/estatística & dados numéricos , América do Norte , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Pediatria , Mecanismo de Reembolso , Estudos Retrospectivos , Salários e Benefícios/economia , Escleroterapia/economia , Escleroterapia/estatística & dados numéricos
4.
Value Health ; 21(8): 911-920, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30098668

RESUMO

OBJECTIVES: To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS: A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS: CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS: At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Varizes/complicações , Técnicas de Ablação/economia , Tratamento Conservador/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Terapia a Laser/economia , Cadeias de Markov , Escleroterapia/economia , Varizes/economia , Varizes/cirurgia
5.
Lasers Med Sci ; 33(7): 1505-1511, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29687409

RESUMO

Day surgery is being more and more adopted by clinicians. Higher wavelength lasers give patients better experience than lower wavelength lasers, which makes it more suitable for day surgery. This study compares the short- and mid-term efficacy, postoperative morbidity, and patient satisfaction of "1470-nm endovenous laser ablation (EVLA) combining foam sclerotherapy in day surgery" with "810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery" on great saphenous vein (GSV) insufficiency postoperatively. A single-institution historical cohort study of 194 patients was performed in Shanghai Ninth People's Hospital, China. Ninety-seven patients received 1470-nm EVLA combining foam sclerotherapy in day surgery ("1470-nm group"), and 97 patients received 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery recommended by guidelines ("810-nm group"). No significant difference was found between the 1470-nm group and the 810-nm group in terms of GSV occlusion rate (both 100%), complication rate, and recurrence rate (8.2 vs. 11.3%) during the period of 1-12 months after surgery. Serious complications in the 1470-nm group and 810-nm group were 0 and 1.0%. Minor complications in the 1470-nm group and 810-nm group were ecchymosis at 20.6 and 18.6%, edema at 69.1 and 63.9%, and paresthesia around ankle at 0 and 3.1%, respectively. Advantage of the 1470-nm group over the 810-nm group was statistically significant considering the patient perioperative comfort and economic cost. Treatment of 1470-nm EVLA combining foam sclerotherapy in day surgery has similar efficacy as the 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery in GSV insufficiency and is more comfortable with less incision, hospitalization procedure, and medical costs. It may be a new option for patients who are afraid or unable to be hospitalized.


Assuntos
Terapia a Laser/métodos , Extremidade Inferior/patologia , Extremidade Inferior/cirurgia , Escleroterapia/métodos , Varizes/cirurgia , China , Estudos de Coortes , Feminino , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/economia , Extremidade Inferior/efeitos da radiação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Veia Safena/efeitos da radiação , Veia Safena/cirurgia , Escleroterapia/efeitos adversos , Escleroterapia/economia , Resultado do Tratamento
6.
Eur J Gastroenterol Hepatol ; 30(6): 626-630, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29505477

RESUMO

BACKGROUND AND AIM: Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices. PATIENTS AND METHODS: A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61). RESULTS: The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563). CONCLUSION: Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Esofagoscópios , Esofagoscopia/instrumentação , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/instrumentação , Polietilenoglicóis/administração & dosagem , Soluções Esclerosantes/administração & dosagem , Escleroterapia/instrumentação , China , Análise Custo-Benefício , Desenho de Equipamento , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/economia , Esofagoscópios/economia , Esofagoscopia/efeitos adversos , Esofagoscopia/economia , Estudos de Viabilidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/economia , Custos de Cuidados de Saúde , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/economia , Humanos , Masculino , Pessoa de Meia-Idade , Polidocanol , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/economia , Estudos Prospectivos , Recidiva , Soluções Esclerosantes/efeitos adversos , Soluções Esclerosantes/economia , Escleroterapia/efeitos adversos , Escleroterapia/economia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento
7.
J Ultrasound Med ; 37(6): 1423-1429, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29219197

RESUMO

OBJECTIVES: We compared the efficacy, safety, and cost-effectiveness of ultrasound-guided percutaneous polidocanol injection and percutaneous ethanol injection for the treatment of benign cystic and predominantly cystic thyroid nodules. METHODS: A total of 135 cystic thyroid nodules treated by percutaneous ethanol injection and 136 cystic thyroid nodules treated by percutaneous polidocanol injection were enrolled retrospectively in this study from May 2010 to March 2016. The nodules were followed after 1, 3, 6, and 12 months. Nodule volumes, symptoms scores, and cosmetic scores were assessed before treatment and at follow-up. The therapeutic success rate, safety, and cost-effectiveness between the groups were also compared. RESULTS: No significant differences in the reduction of the nodule volume, volume reduction rate, and therapeutic success were observed between the groups with cystic and predominantly cystic thyroid nodules during follow-up (P > .05). Neither the cosmetic scores (P = .59; P = .42) nor the symptom scores (P = .32; P = .73) in the cystic and predominantly cystic nodules were significantly different between the groups at the last follow-up. The complication rates for ethanol were higher than those for polidocanol (P < .05). However, the cost of polidocanol injection was higher than that of ethanol injection for cystic thyroid nodules (mean ± SD, US$97.18 ± US$22.17 versus US$43.36 ± US$5.51; P < .01). CONCLUSIONS: Ultrasound-guided percutaneous polidocanol injection can be an alternative for sclerotherapy of cystic or predominantly cystic thyroid nodules. However, its cost was higher than that of percutaneous ethanol injection.


Assuntos
Etanol/uso terapêutico , Polietilenoglicóis/uso terapêutico , Soluções Esclerosantes/uso terapêutico , Escleroterapia/métodos , Nódulo da Glândula Tireoide/diagnóstico por imagem , Nódulo da Glândula Tireoide/terapia , Ultrassonografia de Intervenção/métodos , Adolescente , Adulto , Idoso , Análise Custo-Benefício , Etanol/administração & dosagem , Etanol/economia , Feminino , Seguimentos , Humanos , Injeções Intralesionais , Masculino , Pessoa de Meia-Idade , Polidocanol , Polietilenoglicóis/administração & dosagem , Polietilenoglicóis/economia , Estudos Retrospectivos , Soluções Esclerosantes/administração & dosagem , Soluções Esclerosantes/economia , Escleroterapia/economia , Glândula Tireoide/diagnóstico por imagem , Resultado do Tratamento , Adulto Jovem
8.
Gastrointest Endosc ; 86(2): 307-315, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28082116

RESUMO

BACKGROUND AND AIMS: Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS: This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS: The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS: Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Escleroterapia , Terapia Combinada/efeitos adversos , Terapia Combinada/economia , Varizes Esofágicas e Gástricas/etiologia , Feminino , Febre/etiologia , Ectasia Vascular Gástrica Antral/complicações , Hemorragia Gastrointestinal/etiologia , Humanos , Ligadura/efeitos adversos , Ligadura/economia , Cirrose Hepática/complicações , Masculino , Complicações Pós-Operatórias/etiologia , Recidiva , Escleroterapia/efeitos adversos , Escleroterapia/economia , Taxa de Sobrevida
9.
Ann Vasc Surg ; 39: 256-263, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27671459

RESUMO

BACKGROUND: To evaluate the effect of ultrasound-guided foam sclerotherapy (UGFS) in a single session combined with great saphenous vein (GSV) high ligation for severe lower extremity varicosis classified as C4-C6, compared with GSV stripping plus multistab avulsion or transilluminated powered phlebectomy (TIPP). METHODS: From January 2012 to December 2014, 177 patients with primary GSV insufficiency, classified as C4-C6, were randomized into the UGFS group or the control group. The UGFS group was managed by GSV high ligation and foam sclerotherapy in one session under the surveillance of ultrasonography, whereas the control group received GSV high ligation and stripping combined with multistab avulsion or TIPP. The patients were followed up at 1, 6, and 12 months after treatment. Outcome assessments included reflux recurrence rate, procedure-related adverse events, hemodynamic parameters, revised Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ) score. The medical cost and operating time of the 2 groups were also compared. RESULTS: In total, 73 patients received UGFS, whereas 90 patients underwent traditional surgery. Sixty-five patients in the UGFS group (89.0%) and 74 patients in the control group (82.2%) completed the follow-up. At the end of 12 months, the cumulative reflux recurrence rate was 13.8% in the UGFS group and 13.5% in the control group (P = 0.955). In the UGFS and control groups, minor complications (27.7% vs. 21.6%, P = 0.406) and major complications (3.1% vs. 2.7%, P = 0.895) were not significantly different. Compared with baseline values, obvious improvements of the venous filling index, VCSS, and AVVQ scores after treatment were confirmed in both groups (P < 0.001). The average operating and recovery times were much shorter (38.3 vs. 81.2 min, 5.4 vs. 9.6 days, P < 0.001, respectively), and the average hospital cost was much lower ($853 vs. $1,575, P < 0.001) in the UGFS group than in the control group. The patient satisfaction rate reached 92.3% in the UGFS group and 89.2% in the control group 12 months after operation (P = 0.270). CONCLUSIONS: Our outcomes indicated that UGFS combined with GSV high ligation was safe and effective for severe lower extremity varicosis.


Assuntos
Polietilenoglicóis/administração & dosagem , Veia Safena/cirurgia , Soluções Esclerosantes/administração & dosagem , Escleroterapia/métodos , Ultrassonografia de Intervenção , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , China , Terapia Combinada , Análise Custo-Benefício , Feminino , Hemodinâmica , Custos Hospitalares , Humanos , Tempo de Internação , Ligadura , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Satisfação do Paciente , Polidocanol , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/economia , Estudos Prospectivos , Recidiva , Retratamento , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Soluções Esclerosantes/efeitos adversos , Soluções Esclerosantes/economia , Escleroterapia/efeitos adversos , Escleroterapia/economia , Índice de Gravidade de Doença , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/economia , Varizes/diagnóstico por imagem , Varizes/economia , Varizes/fisiopatologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/economia
10.
J Vasc Surg Venous Lymphat Disord ; 5(1): 75-81.e1, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27987615

RESUMO

OBJECTIVE: The purpose of this study was to assess practice patterns of endovenous ablation therapy for the treatment of venous reflux disease among the vein specialist members of the American Venous Forum (AVF). METHODS: An online survey was conducted of AVF members designed to identify demographics, treatment practices, and clinical variables in the selection of vein ablation devices. RESULTS: The survey was distributed to 798 practicing physicians, of whom 129 (16%) responded. The specialty distribution of respondents was as follows: vascular surgeons, 54%; phlebologists, 14%; general surgeons, 11%; interventional radiologists, 9%; and other specialties, 6%. The majority (81%) were from the United States, and 65% were self-employed. Almost half (47%) were in practice for >20 years, with 33% of all respondents performing three to five saphenous vein ablations per week. Three-quarters (79%) of respondents preferred radiofrequency ablation (RFA), with 47% believing that it was more cost-effective and more than half (57%) reporting improved patient satisfaction with this technique. Most of them (63%) responded that previous capital investment played a significant role in their choice of vein ablation device along with the associated cost of disposable equipment. A large majority (77%) of physicians responded that they had a significant role in choosing the treatment device, whereas only 17% thought that patients' choice played a major role in device choice. The capital investment affected choice of modality more significantly in newer practices (P < .0.5). CONCLUSIONS: The majority of AVF vein specialists prefer an RFA technique to laser, believing that RFA is associated with improved patient outcomes and is more cost-effective. Advances in technology, device costs, and reimbursement levels may have an impact on such preferences in the future.


Assuntos
Técnicas de Ablação/métodos , Procedimentos Endovasculares/métodos , Padrões de Prática Médica/estatística & dados numéricos , Varizes/cirurgia , Insuficiência Venosa/cirurgia , Técnicas de Ablação/instrumentação , Atitude do Pessoal de Saúde , Ablação por Cateter/instrumentação , Ablação por Cateter/métodos , Tomada de Decisão Clínica , Análise Custo-Benefício , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Custos de Cuidados de Saúde/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Humanos , Terapia a Laser/instrumentação , Terapia a Laser/métodos , Satisfação do Paciente , Padrões de Prática Médica/economia , Veia Safena/cirurgia , Escleroterapia/economia , Escleroterapia/instrumentação , Escleroterapia/métodos , Estados Unidos
11.
Phlebology ; 31(1 Suppl): 80-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26916774

RESUMO

Varicose veins affect one-quarter to one-third of Western adult populations and consume an increasing amount of health care resources. Much of this increased utilization has been driven by the advent of minimally invasive technology including endovenous thermal ablation, foam sclerotherapy, and more recently mechanicochemical and cyanoacrylate glue ablation. This has largely been driven by patient and physician preferences in the absence of robust evidence that one therapy is truly superior to another. This partially arises from misunderstandings about appropriate outcomes measures and what truly constitutes effective treatment of varicose veins. Technical outcomes, such as saphenous closure rates, have frequently been used as surrogates for effective treatment but are poorly correlated with symptom improvement, quality of life, and risk of recurrence. Although there does appear to be a trend towards higher recurrence with ultrasound-guided foam sclerotherapy, the data are occasionally conflicting and there does not appear to be substantial differences between the various modalities. Similarly, there do not appear to be major differences in late quality of life measures between these treatment options. As long-term differences in recurrence and quality of life are small, overall cost effectiveness is driven primarily by initial treatment costs and ultrasound-guided foam sclerotherapy is the most cost-effective strategy in many models. However, there continues to be substantial uncertainty surrounding cost estimates and other factors of importance to the patient may ultimately drive treatment decisions. The benefits of some adjuncts to the treatment of axial superficial reflux, such as the concurrent versus staged management of tributary varicosities, remain ill-defined while that of others, such as routine post-procedural ultrasound surveillance and compression, need critical re-evaluation.


Assuntos
Procedimentos Endovasculares , Hipertermia Induzida , Qualidade de Vida , Escleroterapia , Varizes , Adulto , Custos e Análise de Custo , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Feminino , Humanos , Hipertermia Induzida/economia , Hipertermia Induzida/métodos , Masculino , Recidiva , Fatores de Risco , Escleroterapia/economia , Escleroterapia/métodos , Varizes/economia , Varizes/terapia
12.
Minerva Chir ; 71(4): 223-32, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26046959

RESUMO

BACKGROUND: This registry study evaluated low-cost outpatient surgery (mini-S) for venous insufficiency as an alternative to stripping. METHODS: This 20-year follow-up is focused on the recurrence of varices and on the long-term efficacy of the mini-S (group 1) in comparison with controls (2, stripping), sclerotherapy (3) or a combination of mini-S+sclerotherapy (4). Costs were compared. RESULTS: At 20-years of follow-up, considering recurrence/development of new varicose veins, 24.05% of the limbs treated with mini-S developed new varices in comparison with 64.4% in group 2, 24.1% in group 3 and 15.4% in group 4 (P<0.05). New surgical procedures were needed in 18.9% of mini-S patients vs. 58.5% in group 2, 21.9% in group 3 and 19.7% in group 4 (P<0.05 between group 2 and the other groups). Sclerotherapy (in the years following the initial treatment) was used in 37.9% of mini-S patients in comparison with 67.7% of subjects in group 2 patients, 33.1% in group 3 and 22.8% in group 4 (P<0.05 between outpatient treatment and group 2). The superficial venous system was incompetent in 21% of mini-S patients in comparison with 38.8% in group 2 (P<0.05), 20.7% in group 3 and 17.9% of group 4. At 20 years edema was present in 10.5% of limbs in group 2 in comparison with a <3% (range 2.2-2.1%) in the other groups. Edema was more significant after stripping. Ambulatory venous pressure measurements in subgroups was lower in groups 1, 3 and 4 with a lower refilling time (P<0.05). The cost of in-hospital, daily surgical treatments were €1978 (covered by the heathcare provider). The cost of mini-S was on average €488 per limb (covered by patients). CONCLUSIONS: Outpatients procedures, in particular the mini-S management plan, were cheaper than stripping and more effective at 20-years follow-up. They could be a model for emerging contries with restricted budgets for vein surgery. Also being cheaper more people may have benefits from treatment when/where hospital procedures are not covered by an healthcare provider.


Assuntos
Custos e Análise de Custo , Pacientes Ambulatoriais , Escleroterapia/economia , Varizes/economia , Varizes/terapia , Adulto , Índice de Massa Corporal , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Itália , Ligadura/economia , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Veia Safena , Escleroterapia/métodos , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/cirurgia
13.
Phlebology ; 31(8): 573-81, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26341394

RESUMO

OBJECTIVES: To conduct economic evaluations of radiofrequency ablation, ultrasound-guided foam sclerotherapy and surgery for great saphenous vein ablation. METHOD: A cost-utility and cohort analysis from societal perspective was performed to estimate incremental cost-effectiveness ratio. Transitional probabilities were from meta-analysis. Direct medical, direct non-medical, indirect costs, and utility were from standard Thai costings and cohort. Probabilistic sensitivity analysis was performed to assess parameter uncertainties. RESULTS: Seventy-seven patients (31 radiofrequency ablation, 19 ultrasound-guided foam sclerotherapy, and 27 surgeries) were enrolled from October 2011 to February 2013. Compared with surgery, radiofrequency ablation costed 12,935 and 20,872 Baht higher, whereas ultrasound-guided foam sclerotherapy costed 6159 lower and 1558 Bath higher for outpatient and inpatient, respectively. At one year, radiofrequency ablation had slightly lower quality-adjusted life-year, whereas ultrasound-guided foam sclerotherapy yielded additional 0.025 quality-adjusted life-year gained. Because of costing lower and greater quality-adjusted life-year than other compared alternatives, outpatient ultrasound-guided foam sclerotherapy was an option being dominant. Probabilistic sensitivity analysis resulted that at the Thai ceiling threshold of 160,000 Baht/quality-adjusted life-year gained, ultrasound-guided foam sclerotherapy had chances of 0.71 to be cost-effective. CONCLUSIONS: Ultrasound-guided foam sclerotherapy seems to be cost-effective for treating great saphenous vein reflux compared to surgery in Thailand at one-year results.


Assuntos
Ablação por Cateter/economia , Veia Safena/cirurgia , Escleroterapia/economia , Varizes , Adulto , Idoso , Ablação por Cateter/métodos , Custos e Análise de Custo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escleroterapia/métodos , Tailândia , Varizes/economia , Varizes/terapia
14.
Ir J Med Sci ; 185(1): 107-10, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25413474

RESUMO

BACKGROUND: Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. AIMS: The aim of this study was to directly compare RFA and open saphenofemoral ligation. METHODS: This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. RESULTS: During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. CONCLUSIONS: Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.


Assuntos
Ablação por Cateter/economia , Ablação por Cateter/métodos , Veia Safena/cirurgia , Varizes/cirurgia , Insuficiência Venosa/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Ligadura/economia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Escleroterapia/economia , Escleroterapia/métodos
15.
Phlebology ; 30(2 Suppl): 18-23, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26556698

RESUMO

Foam sclerotherapy is a minimally invasive treatment for lower limb varicose veins. Current evidence indicates that its efficacy may not be as high as surgery or endovenous ablation. The minimally invasive nature of the treatment however means that it has a wide application, and it can be particularly useful in patients who are not suitable for other types of treatment. NICE guidelines recommend its use as a second line after endovenous ablation. Complication rates are low and most of these are of little clinical consequence.


Assuntos
Escleroterapia/efeitos adversos , Escleroterapia/economia , Escleroterapia/métodos , Varizes/terapia , Ablação por Cateter , Análise Custo-Benefício , Procedimentos Endovasculares , Cefaleia/etiologia , Humanos , Terapia a Laser , Infarto do Miocárdio/etiologia , Doenças do Sistema Nervoso/etiologia , Guias de Prática Clínica como Assunto , Embolia Pulmonar/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Veia Safena/cirurgia , Soluções Esclerosantes/uso terapêutico , Tetradecilsulfato de Sódio/química , Tensoativos/química , Tromboflebite/etiologia , Resultado do Tratamento , Varizes/patologia , Trombose Venosa/etiologia
16.
Eur J Vasc Endovasc Surg ; 50(6): 794-801, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26433594

RESUMO

OBJECTIVE: The aim was to investigate the cost-effectiveness of interventional treatment for varicose veins (VV) in the UK NHS, and to inform the national clinical guideline on VV, published by the National Institute of Health and Care Excellence. DESIGN: An economic analysis was constructed to compare the cost-effectiveness of surgery, endothermal ablation (ETA), ultrasound-guided foam sclerotherapy (UGFS), and compression stockings (CS). The analysis was based on a Markov decision model, which was developed in consultation with members of the NICE guideline development group (GDG). METHODS: The model had a 5-year time horizon, and took the perspective of the UK National Health Service. Clinical inputs were based on a network meta-analysis (NMA), informed by a systematic review of the clinical literature. Outcomes were expressed as costs and quality-adjusted life years (QALYs). RESULTS: All interventional treatments were found to be cost-effective compared with CS at a cost-effectiveness threshold of £20,000 per QALY gained. ETA was found to be the most cost-effective strategy overall, with an incremental cost-effectiveness ratio of £3,161 per QALY gained compared with UGFS. Surgery and CS were dominated by ETA. CONCLUSIONS: Interventional treatment for VV is cost-effective in the UK NHS. Specifically, based on current data, ETA is the most cost-effective treatment in people for whom it is suitable. The results of this research were used to inform recommendations within the NICE guideline on VV.


Assuntos
Técnicas de Ablação/economia , Custos de Cuidados de Saúde , Escleroterapia/economia , Meias de Compressão/economia , Ultrassonografia de Intervenção/economia , Varizes/economia , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/economia , Técnicas de Ablação/efeitos adversos , Redução de Custos , Análise Custo-Benefício , Humanos , Cadeias de Markov , Modelos Econômicos , Anos de Vida Ajustados por Qualidade de Vida , Escleroterapia/efeitos adversos , Medicina Estatal/economia , Meias de Compressão/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Reino Unido , Varizes/complicações , Varizes/diagnóstico , Procedimentos Cirúrgicos Vasculares/efeitos adversos
17.
Acta Clin Croat ; 54(2): 136-42, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26415309

RESUMO

The aim is to present our experience and observations regarding varicose vein treatment by means of ultrasound guided foam sclerotherapy (UGFS). The study included 81 patients, 54 with insufficient main stem superficial veins in one limb and 27 with both limbs affected. Great saphenous vein insufficiency was diagnosed in 68, small saphenous insufficiency in 18, anterior accessory saphenous vein insufficiency in 11, and Giacomini vein insufficiency in 3 limbs. Seven limbs had combined insufficiency of great saphenous vein and small saphenous vein, and 1 limb had combined insufficiency of Giacomini vein and small saphenous vein. UGFS was employed to treat main stem vein reflux and their tributaries. Within a month after treatment, all main stem veins were occluded and only small corrections were performed occasionally to treat residual varices. Regarding side effects, skin darkening and hard lumps at the sites of varicose veins were most commonly observed. We also recorded several episodes of thrombophlebitis. Few patients experienced dry cough, visual disturbances and headache following the treatment. After six months, repeat UGFS of main stem veins had to be performed in few patients. Very few patients expressed dissatisfaction a year after treatment, mainly because of residual skin darkening. In conclusion, UGFS proved to be the simplest, quickest and cheapest method of varicose vein treatment. According to our experience, it yielded satisfactory functional and cosmetic results. Side effects do occur, but are acceptable, in particular at long term.


Assuntos
Custos de Cuidados de Saúde , Veia Safena , Escleroterapia/economia , Escleroterapia/métodos , Ultrassonografia Doppler Dupla/economia , Varizes/tratamento farmacológico , Adulto , Idoso , Custos e Análise de Custo , Croácia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Ultrassonografia Doppler Dupla/métodos , Varizes/economia
19.
Health Technol Assess ; 19(27): 1-342, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25858333

RESUMO

BACKGROUND: Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. DESIGN: A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. SETTING: Eleven UK specialist vascular centres. PARTICIPANTS: Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). INTERVENTIONS: Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). PRIMARY OUTCOME MEASURES: Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. SECONDARY OUTCOME MEASURES: Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. RESULTS: The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. CONCLUSIONS: Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. FUTURE WORK: Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN51995477. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.


Assuntos
Análise Custo-Benefício , Terapia a Laser , Anos de Vida Ajustados por Qualidade de Vida , Escleroterapia , Varizes/terapia , Atividades Cotidianas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/economia , Terapia a Laser/métodos , Terapia a Laser/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva , Escleroterapia/efeitos adversos , Escleroterapia/economia , Escleroterapia/métodos , Escleroterapia/estatística & dados numéricos , Índice de Gravidade de Doença , Medicina Estatal/economia , Avaliação da Tecnologia Biomédica , Reino Unido , Varizes/economia , Varizes/cirurgia , Adulto Jovem
20.
Dermatol Surg ; 41(1): 121-5, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25521102

RESUMO

BACKGROUND: Sclerotherapy is the treatment of reticular veins and telangiectasias of the lower extremities. Sclerosants destroy endothelial tissue and expose subendothelial collagen fibers, which lead to subsequent fibrosis of vessels, thus preventing recanalization. There are several available sclerosants including sodium tetradecyl sulfate (STS), polidocanol (POL), and chromated glycerin (CG) with varying efficacy, potency, side effect profile, and cost. OBJECTIVE: To identify the possible bacterial contamination and potency of CG beyond the current recommended shelf life of 3 months and to prove if CG is as cost effective as other available sclerosants. METHODS: Samples of 72% CG underwent bacterial endotoxin, sterility, and potency analysis at Days 0, 24, and 183. In addition, cost comparison was performed with other commercially available sclerosants including STS and POL. RESULTS: No samples of CG showed any bacterial contamination. All aliquots of glycerin remained sterile at Day 14. Potency at Day 24 was 99.2%, which was the same at Day 183. Cost comparison with other sclerosants revealed that CG is lower cost per milliliter than STS and POL. CONCLUSION: Seventy-two percent CG has no contamination and maintains its reported potency up to 6 months while comparable with the cost of other commercially available sclerosants.


Assuntos
Cromatos/química , Glicerol/química , Soluções Esclerosantes/química , Escleroterapia , Cromatos/economia , Contagem de Colônia Microbiana , Custos e Análise de Custo , Armazenamento de Medicamentos , Endotoxinas/análise , Glicerol/economia , Polidocanol , Polietilenoglicóis/economia , Soluções Esclerosantes/economia , Escleroterapia/economia , Tetradecilsulfato de Sódio/economia , Esterilização , Fatores de Tempo
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