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1.
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
2.
Health Technol Assess ; 22(19): 1-132, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29701167

RESUMO

BACKGROUND: Atrial fibrillation (AF) can be treated using a maze procedure during planned cardiac surgery, but the effect on clinical patient outcomes, and the cost-effectiveness compared with surgery alone, are uncertain. OBJECTIVES: To determine whether or not the maze procedure is safe, improves clinical and patient outcomes and is cost-effective for the NHS in patients with AF. DESIGN: Multicentre, Phase III, pragmatic, double-blind, parallel-arm randomised controlled trial. Patients were randomised on a 1 : 1 basis using random permuted blocks, stratified for surgeon and planned procedure. SETTING: Eleven acute NHS specialist cardiac surgical centres. PARTICIPANTS: Patients aged ≥ 18 years, scheduled for elective or in-house urgent cardiac surgery, with a documented history (> 3 months) of AF. INTERVENTIONS: Routine cardiac surgery with or without an adjunct maze procedure administered by an AF ablation device. MAIN OUTCOME MEASURES: The primary outcomes were return to sinus rhythm (SR) at 12 months and quality-adjusted life-years (QALYs) over 2 years after randomisation. Secondary outcomes included return to SR at 2 years, overall and stroke-free survival, drug use, quality of life (QoL), cost-effectiveness and safety. RESULTS: Between 25 February 2009 and 6 March 2014, 352 patients were randomised to the control (n = 176) or experimental (n = 176) arms. The odds ratio (OR) for return to SR at 12 months was 2.06 [95% confidence interval (CI) 1.20 to 3.54; p = 0.0091]. The mean difference (95% CI) in QALYs at 2 years between the two trial arms (maze/control) was -0.025 (95% CI 0.129 to 0.078; p = 0.6319). The OR for SR at 2 years was 3.24 (95% CI 1.76 to 5.96). The number of patients requiring anticoagulant drug use was significantly lower in the maze arm from 6 months after the procedure. There were no significant differences between the two arms in operative or overall survival, stroke-free survival, need for cardioversion or permanent pacemaker implants, New York Heart Association Functional Classification (for heart failure), EuroQol-5 Dimensions, three-level version score and Short Form questionnaire-36 items score at any time point. Sixty per cent of patients in each trial arm had a serious adverse event (p = 1.000); most events were mild, but 71 patients (42.5%) in the maze arm and 84 patients (45.5%) in the control arm had moderately severe events; 31 patients (18.6%) in the maze arm and 38 patients (20.5%) in the control arm had severe events. The mean additional cost of the maze procedure was £3533 (95% CI £1321 to £5746); the mean difference in QALYs was -0.022 (95% CI -0.1231 to 0.0791). The maze procedure was not cost-effective at £30,000 per QALY over 2 years in any analysis. In a small substudy, the active left atrial ejection fraction was smaller than that of the control patients (mean difference of -8.03, 95% CI -12.43 to -3.62), but within the predefined clinically equivalent range. LIMITATIONS: Low recruitment, early release of trial summaries and intermittent resource-use collection may have introduced bias and imprecise estimates. CONCLUSIONS: Ablation can be practised safely in routine NHS cardiac surgical settings and increases return to SR rates, but not survival or QoL up to 2 years after surgery. Lower anticoagulant drug use and recovery of left atrial function support anticoagulant drug withdrawal provided that good atrial function is confirmed. FURTHER WORK: Continued follow-up and long-term clinical effectiveness and cost-effectiveness analysis. Comparison of ablation methods. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82731440. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 19. See the NIHR Journals Library website for further project information.


Assuntos
Técnicas de Ablação/economia , Técnicas de Ablação/métodos , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/métodos , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Análise Custo-Benefício , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença , Medicina Estatal , Avaliação da Tecnologia Biomédica , Reino Unido
3.
Rofo ; 189(7): 611-623, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28651276

RESUMO

Background MRI is attractive for the guiding and monitoring of interventional procedures due to its high intrinsic soft tissue contrast and the possibility to measure physiologic parameters like flow and cardiac function. Method The current status of interventional MRI for the clinical routine was analyzed. Results The effort needed for the development of MR-safe monitoring systems and instruments initially resulted in the application of interventional MRI only for procedures that could not be performed by other means. Accordingly, biopsy of lesions in the breast, which are not detectable by other modalities, has been performed under MRI guidance for decades. Currently, biopsies of the prostate under MRI guidance are established in a similar fashion. At many sites blind biopsy has already been replaced by MR-guided biopsy or at least by the fusion of MR images with ultrasound. Cardiovascular interventions are performed at several centers for ablation as a treatment for atrial fibrillation. Conclusion Interventional MRI has been established in the clinical routine for a variety of indications. Broader application can be expected in the clinical routine in the future owing to the multiple advantages compared to other techniques. Key points · Due to the significant technical effort, MR-guided interventions are only recommended in the long term for regions in which MRI either facilitates or greatly improves the intervention.. · Breast biopsy of otherwise undetectable target lesions has long been established in the clinical routine. Prostate biopsy is currently being introduced in the clinical routine for similar reasons. Other methods such as MR-guided focused ultrasound for the treatment of uterine fibroids or tumor ablation of metastases represent alternative methods and are offered in many places.. · Endovascular MR-guided interventions offer advantages for a number of indications and have already been clinically established for the treatment of children with congenital heart defects and for atrial ablation at individual centers. Greater application can be expected in the future.. Citation format · Barkhausen J, Kahn T, Krombach GA et al. White Paper: Interventional MRI: Current Status and Potential for Development Considering Economic Perspectives, Part 1: General Application. Fortschr Röntgenstr 2017; 189: 611 - 623.


Assuntos
Imagem por Ressonância Magnética Intervencionista/economia , Imagem por Ressonância Magnética Intervencionista/tendências , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/tendências , Cirurgia Assistida por Computador/economia , Cirurgia Assistida por Computador/tendências , Técnicas de Ablação/economia , Técnicas de Ablação/instrumentação , Técnicas de Ablação/tendências , Biópsia/economia , Biópsia/instrumentação , Biópsia/tendências , Análise Custo-Benefício , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/tendências , Alemanha , Humanos , Imagem por Ressonância Magnética Intervencionista/instrumentação , Neuronavegação/economia , Neuronavegação/instrumentação , Neuronavegação/tendências , Cirurgia Assistida por Computador/instrumentação , Pesquisa Médica Translacional/economia , Pesquisa Médica Translacional/tendências
4.
Rev Esp Med Nucl Imagen Mol ; 36(6): 362-370, 2017.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28539216

RESUMO

OBJECTIVES: In thyroid cancer treatment, the thyroid-stimulating hormone (TSH) must be elevated before radioiodine ablation, either by exogenous (with recombinant human thyrotropin [rhTSH]) or endogenous stimulation by thyroid hormone withdrawal (THW). The use of rhTSH avoids hypothyroidism and favours the subsequent elimination of radioiodine, but involves the cost of the product. For this reason, a cost-effectiveness analysis was performed, taking into account all costs involved and the benefits associated with the use of this therapy. MATERIAL AND METHODS: Using a Markov modelling with two analysis arms (rhTSH and THW), stratified into high (100mCi/3700 MBq) and low (30mCi/1110 MBq) radioiodine doses, and using 17 weekly cycles, the incremental cost per quality-adjusted life-year (QALY) related to the use of rhTSH was determined. The clinical inputs included in the model were based on published studies and in a treatment survey conducted in Spain. RESULTS: Radioablation preparation with rhTSH is superior to THW, showing additional benefits (0.048 AVAC), as well as cost savings (-€614.16), with an incremental cost-effectiveness rate (ICER) of -€12,795/QALY. The univariate and multivariate sensitivity analyses showed the result to be robust. CONCLUSIONS: The use of rhTSH previous to radioablation in Spain has cost savings, as well as a series of health benefits for the patient, making it highly cost-effective.


Assuntos
Técnicas de Ablação/economia , Análise Custo-Benefício , Radioisótopos do Iodo/economia , Radioisótopos do Iodo/uso terapêutico , Neoplasias da Glândula Tireoide/economia , Neoplasias da Glândula Tireoide/terapia , Tireotropina/economia , Tireotropina/uso terapêutico , Técnicas de Ablação/métodos , Hospitais , Humanos , Modelos Econômicos , Proteínas Recombinantes/uso terapêutico , Espanha
5.
Clin Neurol Neurosurg ; 158: 33-39, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28458056

RESUMO

Posteroventral pallidotomy has already been considered the surgical procedure of choice for Parkinson's disease patients with motor complications. Recently, however, several factors led to its replacement by deep brain stimulation. Nevertheless, pallidotomy has a well-documented efficacy and safety evidence regarding the reduction of parkinsonian motor symptoms. Yet, there may be manysituations where it may be considered as a better option than neuromodulation. Herein we review those possible conditions, giving emphasis to the costs, which we found to be the most limiting factor. Importantly, a cost comparison between deep brain stimulation and pallidotomy was also provided.


Assuntos
Técnicas de Ablação , Estimulação Encefálica Profunda , Palidotomia , Doença de Parkinson/cirurgia , Técnicas de Ablação/economia , Técnicas de Ablação/métodos , Técnicas de Ablação/normas , Estimulação Encefálica Profunda/economia , Estimulação Encefálica Profunda/métodos , Estimulação Encefálica Profunda/normas , Humanos , Palidotomia/economia , Palidotomia/métodos , Palidotomia/normas
6.
Am J Vet Res ; 78(4): 508-516, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28345996

RESUMO

OBJECTIVE To determine effects of repeated use and resterilization on structural and functional integrity of microwave ablation (MWA) antennas. SAMPLE 17 cooled-shaft MWA antennas (3 groups of 5 antennas/group and 2 control antennas). PROCEDURES 1, 2, and 3 ablations in the livers of bovine cadavers were performed at the maximum recommended settings. Antennas were cleaned and sterilized in hydrogen peroxide plasma, and the process was repeated (reprocessing cycle; n = 6). Control antennas were only sterilized (6 times). Aerobic and anaerobic bacterial cultures were performed, and antennas were microscopically assessed for damage. RESULTS 6 cycles were completed. Thirteen of 15 MWA antennas remained functional for up to 4 cycles, 10 were functional after 5 cycles, and only 7 were functional after 6 cycles. Progressive tearing of the silicone coating of the antennas was observed, with a negative effect of the number of cycles for silicone tearing. Size of the ablation zone decreased mildly over time after cycles 5 and 6; however, this was not considered clinically relevant. No significant changes in the shape of ablation zones were detected. All cultures yielded negative results, except for an isolated case, which was considered a contaminant. CONCLUSIONS AND CLINICAL RELEVANCE Structural and functional integrity of the microwave antennas remained acceptable during repeated use and reprocessing for up to 4 cycles. However, there was a decrease in functional integrity at cycles 5 and 6. We suggest that these microwave antennas be subjected to > 3 reprocessing cycles. Antennas should be carefully examined before reuse.


Assuntos
Técnicas de Ablação/instrumentação , Micro-Ondas , Esterilização , Técnicas de Ablação/economia , Animais , Cadáver , Bovinos , Reutilização de Equipamento , Peróxido de Hidrogênio , Fígado
7.
Adv Ther ; 33(4): 684-97, 2016 04.
Artigo em Inglês | MEDLINE | ID: mdl-26942725

RESUMO

INTRODUCTION: Published reports have demonstrated that many Barrett's esophagus patients are over-diagnosed as low-grade dysplasia (BE-LGD). We performed an analysis of the surveillance and treatment costs associated with the over-diagnosis of BE-LGD. METHODS: As the principal cost variables, we used endoscopic and histologic procedures performed during the recommended surveillance intervals for patients with BE-LGD, the national average Medicare reimbursement for the Current Procedural Terminology codes of the procedures performed, and a spreadsheet-based tool we created to determine the overall healthcare cost associated with the over-diagnosis of BE-LGD in the US population. RESULTS: The average excess cost (range) for every patient in the US who is over-diagnosed with BE-LGD is estimated to be $5557 ($3115 to $8072). The principal contributors to the excess cost of over-diagnosis of BE-LGD in these patients are: endoscopy ($2626 to $4639), pathologist biopsy review ($275 to $2185), and esophagogastroduodenoscopy-guided endoscopic ablation ($214 to $1249). CONCLUSIONS: The healthcare cost of over-diagnosis of BE-LGD is significant. To reduce the overall healthcare cost impact of over-diagnosis of BE-LGD, strict adherence to the recommendations of the American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy that pathology review of all BE biopsy specimens be performed by a gastrointestinal pathologist is warranted.


Assuntos
Técnicas de Ablação/economia , Esôfago de Barrett/complicações , Biópsia/economia , Neoplasias Esofágicas , Esofagoscopia/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Sobremedicalização , Técnicas de Ablação/métodos , Idoso , Biópsia/métodos , Current Procedural Terminology , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/etiologia , Neoplasias Esofágicas/patologia , Esofagoscopia/métodos , Feminino , Humanos , Masculino , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Fatores de Tempo , Estados Unidos
8.
J Vasc Surg ; 64(2): 446-451.e1, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26906977

RESUMO

OBJECTIVE: Endothermal ablation (ETA) of the great saphenous vein (GSV) is associated with a small but definite risk of endothermal heat-induced thrombosis (EHIT) extending into the common femoral vein. Follow-up duplex ultrasound imaging to detect EHIT after ETA is considered standard of care, although the exact timing of duplex ultrasound imaging to detect EHIT after ETA remains unclear. We hypothesized that an additional duplex ultrasound assessment 1 week after ETA would not identify a significant number of patients with EHIT and would significantly increase health care costs. METHODS: This was a retrospective review of consecutive ETA GSV procedures from 2007 to 2014. All patients were evaluated with duplex ultrasound imaging on postprocedure day 1, and 79% of patients underwent a second ultrasound assessment 1 week postprocedure. EHIT was considered present when proximal GSV closure progressed to level ≥4, based on a six-tier classification system. RESULTS: From January 1, 2007, until December 31, 2014, 842 patients underwent GSV ETA. Patients with EHIT were more likely to have had a prior deep venous thrombosis (DVT; P = .002) and a larger GSV (P = .006). Forty-three procedures (5.1%) were classified as having EHIT requiring anticoagulation, based on a level ≥4 proximal closure level. Of the 43 patients with EHIT, 20 (47%) were found on the initial ultrasound assessment performed 24 hours postprocedure, but 19 patients (44%) with EHIT would not have been identified with a single postoperative ultrasound scan performed 24 hours after intervention. These 19 patients had a level ≤3 closure level at the duplex ultrasound scan performed 24 hours postprocedure and progressed to EHIT on the delayed duplex ultrasound scan. Lastly, thrombotic complications in four patients (9%), representing three late DVT and one DVT/pulmonary embolism presenting to another hospital, would not have been identified regardless of the postoperative surveillance strategy. Maximum GSV diameter was the only significant predictor of progression to EHIT on multivariate analysis (P = .007). Based on 2014 United States dollars, the two-ultrasound surveillance paradigm is associated with health care charges of $31,109 per identified delayed venous thromboembolism event. CONCLUSIONS: Delayed duplex ultrasound assessment after ETA of the GSV comes with associated health care costs but does yield a significant number of patients with progression to EHIT. Better understanding of the timing, risk factors, and significance of EHIT is needed to cost-effectively care for patients after ETA for varicose veins.


Assuntos
Técnicas de Ablação/efeitos adversos , Veia Femoral/diagnóstico por imagem , Veia Safena/cirurgia , Ultrassonografia Doppler Dupla , Insuficiência Venosa/cirurgia , Trombose Venosa/diagnóstico por imagem , Técnicas de Ablação/economia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Doença Crônica , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Valor Preditivo dos Testes , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla/economia , Insuficiência Venosa/diagnóstico por imagem , Insuficiência Venosa/economia , Insuficiência Venosa/fisiopatologia , Trombose Venosa/tratamento farmacológico , Trombose Venosa/economia , Trombose Venosa/etiologia
9.
Prog Urol ; 26(2): 89-95, 2016 Feb.
Artigo em Francês | MEDLINE | ID: mdl-26718411

RESUMO

OBJECTIVE: The stage of discovery and treatment of kidney cancer have changed. Partial nephrectomy is the standard treatment for small renal masses (SRM). Also are recommended the thermal ablative techniques. The cost of these treatments for the establishment and society is often unclear. The purpose of this study was to calculate the cost of treatment of SRM in order to assess the profitability for a health institution that invests in innovation. MATERIALS AND METHODS: A retrospective single-center study was conducted with 124 patients treated for SMR (T1a) by open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (LRPN), radio frequency (RF) and cryotherapy (CT) between 2009 and 2011. We calculated the price of stay of each patient, searched the amount billed to health insurance and calculated the profitability of treatment for the establishment. RESULTS: The OPN cost on average 7884±1201€ and reported 451±1861€, the LPN cost on average 6973±3503€ and reported 2271±3370€, the cost of the LRPN was on average 9600±4595€ and resulted in a deficit of 838±3007€. The radiofrequency cost on average 2724±813€ and caused a deficit of 954±684€, cryotherapy cost on average 6702±857€ and resulted in a deficit of 4723±941€. CONCLUSION: According to current repayment terms, the LPN was the treatment of SRM that offered the best profitability.


Assuntos
Custos e Análise de Custo , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Técnicas de Ablação/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Criocirurgia/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/economia , Estudos Retrospectivos , Resultado do Tratamento , Carga Tumoral , Adulto Jovem
10.
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
11.
Health Technol Assess ; 19(49): 1-490, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26140518

RESUMO

BACKGROUND: For people with localised prostate cancer, active treatments are effective but have significant side effects. Minimally invasive treatments that destroy (or ablate) either the entire gland or the part of the prostate with cancer may be as effective and cause less side effects at an acceptable cost. Such therapies include cryotherapy, high-intensity focused ultrasound (HIFU) and brachytherapy, among others. OBJECTIVES: This study aimed to determine the relative clinical effectiveness and cost-effectiveness of ablative therapies compared with radical prostatectomy (RP), external beam radiotherapy (EBRT) and active surveillance (AS) for primary treatment of localised prostate cancer, and compared with RP for salvage treatment of localised prostate cancer which has recurred after initial treatment with EBRT. DATA SOURCES: MEDLINE (1946 to March week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (29 March 2013), EMBASE (1974 to week 13, 2013), Bioscience Information Service (BIOSIS) (1956 to 1 April 2013), Science Citation Index (1970 to 1 April 2013), Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2013), Cochrane Database of Systematic Reviews (CDSR) (issue 3, 2013), Database of Abstracts of Reviews of Effects (DARE) (inception to March 2013) and Health Technology Assessment (HTA) (inception to March 2013) databases were searched. Costs were obtained from NHS sources. REVIEW METHODS: Evidence was drawn from randomised controlled trials (RCTs) and non-RCTs, and from case series for the ablative procedures only, in people with localised prostate cancer. For primary therapy, the ablative therapies were cryotherapy, HIFU, brachytherapy and other ablative therapies. The comparators were AS, RP and EBRT. For salvage therapy, the ablative therapies were cryotherapy and HIFU. The comparator was RP. Outcomes were cancer related, adverse effects (functional and procedural) and quality of life. Two reviewers extracted data and carried out quality assessment. Meta-analysis used a Bayesian indirect mixed-treatment comparison. Data were incorporated into an individual simulation Markov model to estimate cost-effectiveness. RESULTS: The searches identified 121 studies for inclusion in the review of patients undergoing primary treatment and nine studies for the review of salvage treatment. Cryotherapy [3995 patients; 14 case series, 1 RCT and 4 non-randomised comparative studies (NRCSs)], HIFU (4000 patients; 20 case series, 1 NRCS) and brachytherapy (26,129 patients; 2 RCTs, 38 NRCSs) studies provided limited data for meta-analyses. All studies were considered at high risk of bias. There was no robust evidence that mortality (4-year survival 93% for cryotherapy, 99% for HIFU, 91% for EBRT) or other cancer-specific outcomes differed between treatments. For functional and quality-of-life outcomes, the paucity of data prevented any definitive conclusions from being made, although data on incontinence rates and erectile dysfunction for all ablative procedures were generally numerically lower than for non-ablative procedures. The safety profiles were comparable with existing treatments. Studies reporting the use of focal cryotherapy suggested that incontinence rates may be better than for whole-gland treatment. Data on AS, salvage treatment and other ablative therapies were too limited. The cost-effectiveness analysis confirmed the uncertainty from the clinical review and that there is no technology which appears superior, on the basis of current evidence, in terms of average cost-effectiveness. The probabilistic sensitivity analyses suggest that a number of ablative techniques are worthy of further research. LIMITATIONS: The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction. CONCLUSIONS: The findings indicate that there is insufficient evidence to form any clear recommendations on the use of ablative therapies in order to influence current clinical practice. Research efforts in the use of ablative therapies in the management of prostate cancer should now be concentrated on the performance of RCTs and the generation of standardised outcomes. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012002461. FUNDING: The National Institute for Health Research Health Technology Assessment programme.


Assuntos
Técnicas de Ablação , Neoplasias da Próstata/cirurgia , Anos de Vida Ajustados por Qualidade de Vida , Medicina Estatal/economia , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/economia , Técnicas de Ablação/métodos , Técnicas de Ablação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Bases de Dados Bibliográficas , Disfunção Erétil/etiologia , Humanos , Incidência , Efeitos Adversos de Longa Duração , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Prevalência , Prognóstico , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/economia , Neoplasias da Próstata/epidemiologia , Análise de Sobrevida , Reino Unido , Incontinência Urinária/etiologia
12.
J Vasc Interv Radiol ; 26(6): 787-91, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25866239

RESUMO

PURPOSE: To perform a national analysis of the safety and cost of percutaneous image-guided lung malignancy ablation. MATERIALS AND METHODS: Using the National (Nationwide) Inpatient Sample, we evaluated complications, need for further intervention, in-hospital mortality, length of hospitalization, and hospital charges for patients undergoing inpatient percutaneous image-guided lung ablation in the United States during the period 2007-2011. Additionally, an analysis of the relationship between specific patient factors, procedural complications, and mortality was performed. RESULTS: The study group consisted of 3,344 patients, including 2,072 (61.9%) patients treated for primary lung carcinomas and 1,277 (38.1%) patients treated for pulmonary metastatic disease. In-hospital mortality occurred after 43 (1.3%) ablation procedures. A Charlson comorbidity index score ≥ 4 was associated with higher mortality (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.16-6.91). Pneumothorax was the most common complication (38.4%), followed by pneumonia (5.7%) and effusion (4.0%). Neither pneumothorax nor chest tube insertion was associated with higher in-hospital mortality rates (pneumothorax, OR, 1.10; 95% CI, 0.59-2.04, and chest tube insertion, OR, 1.45; 95% CI, 0.78-2.68). Surgical reintervention via thoracoscopy or thoracotomy occurred in 31 cases (0.9%). Median length of hospitalization was 1 day (interquartile range, 1-3 d), and median hospital charges were $22,320 (interquartile range, $13,705-$43,026). CONCLUSIONS: Percutaneous image-guided lung ablation of primary and metastatic disease has an acceptable safety profile, and surgical reintervention is rarely required. The most frequent complications of percutaneous lung ablation were not associated with increased in-hospital mortality.


Assuntos
Técnicas de Ablação , Custos Hospitalares , Neoplasias Pulmonares/cirurgia , Complicações Pós-Operatórias , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/economia , Técnicas de Ablação/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Comorbidade , Bases de Dados Factuais , Feminino , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/secundário , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Radiol Manage ; 36(4): 12-7; quiz 18-9, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25174139

RESUMO

Microwave ablation, radiofrequency ablation, cryoablation, and irreversible electroporation are percutaneous ablation modalities commonly employed to treat tumors. The procedure cost of treating the same lesion with each of the four modalities is compared. A cost model was created for each ablation modality estimating the cost of treating a tumor based on the number of probes required, which is estimated by the tumor size.Total cost of treating a 3 cm kidney lesion with each modality was individually calculated. There was a strongly positive and statistically significant relationship between estimated cost based on the cost modules and actual cost for all procedures. The number of required probes is the dominant factor in determining the cost of an ablation procedure. The most expensive ablation modalities in decreasing order are irreversible electroporation, cryoablation, and microwave and radiofrequency ablations.


Assuntos
Técnicas de Ablação/economia , Neoplasias/cirurgia , Educação Continuada , Humanos , Reembolso de Seguro de Saúde/economia , Modelos Econômicos , Estados Unidos
14.
J Vasc Interv Radiol ; 25(10): 1558-64; quiz 1565, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25130308

RESUMO

PURPOSE: To compare medical costs for a matched-pair cohort of Medicare patients with early-stage non-small-cell lung cancer (NSCLC) who underwent treatment with sublobar resection or thermal ablation. MATERIALS AND METHODS: Patients at least 65 years of age with stage IA/IB NSCLC treated with sublobar resection or thermal ablation from 2007 to 2009 were identified from Surveillance, Epidemiology, and End Results/Medicare-linked data and matched by propensity scores. The primary outcome of interest, cost from the payer's perspective, was derived from Medicare claims data. A partitioned inverse probability-weighted estimator was used to calculate mean and median treatment-related costs and costs at 1, 3, 12, 18, and 24 months after treatment. Baseline characteristics, Kaplan-Meier survival curves, and calculated cost variables were compared between the two groups. RESULTS: The final matched cohort of 128 patients had similar baseline characteristics and overall survival (P = .52). Patients who underwent ablation had significantly lower treatment-related costs than those who underwent sublobar resection (P < .001). The difference in median treatment-related cost was $16,105. At 1 month, 3 months, and 12 months after treatment, cumulative costs remained significantly different (P ≤ .011). Lower cost associated with ablations performed in the outpatient setting was a major contributor to the differences between the two treatment modalities, although inpatient ablations maintained a small cost advantage over sublobar resections. CONCLUSIONS: Among matched Medicare patients with stage I NSCLC, thermal ablation resulted in significantly lower treatment-related costs and cumulative medical costs 1 month, 3 months, and 12 months after treatment compared with sublobar resection.


Assuntos
Técnicas de Ablação/economia , Carcinoma Pulmonar de Células não Pequenas/economia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Custos de Cuidados de Saúde , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/cirurgia , Pneumonectomia/economia , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Redução de Custos , Análise Custo-Benefício , Feminino , Gastos em Saúde , Humanos , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Análise por Pareamento , Medicare/economia , Modelos Econômicos , Estadiamento de Neoplasias , Pontuação de Propensão , Estudos Retrospectivos , Programa de SEER , Resultado do Tratamento , Estados Unidos
15.
Health Technol Assess ; 18(7): vii-viii, 1-283, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24484609

RESUMO

BACKGROUND: Many deaths from cancer are caused by metastatic burden. Prognosis and survival rates vary, but survival beyond 5 years of patients with untreated metastatic disease in the liver is rare. Treatment for liver metastases has largely been surgical resection, but this is feasible in only approximately 20-30% of people. Non-surgical alternatives to treat some liver metastases can include various forms of ablative therapies and other targeted treatments. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of the different ablative and minimally invasive therapies for treating liver metastases. DATA SOURCES: Electronic databases including MEDLINE, EMBASE and The Cochrane Library were searched from 1990 to September 2011. Experts were consulted and bibliographies checked. REVIEW METHODS: Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of ablative therapies and minimally invasive therapies used for people with liver metastases. Studies were any prospective study with sample size greater than 100 participants. A probabilistic model was developed for the economic evaluation of the technologies where data permitted. RESULTS: The evidence assessing the clinical effectiveness and cost-effectiveness of ablative and other minimally invasive therapies was limited. Nine studies of ablative therapies were included in the review; each had methodological shortcomings and few had a comparator group. One randomised controlled trial (RCT) of microwave ablation versus surgical resection was identified and showed no improvement in outcomes compared with resection. In two prospective case series studies that investigated the use of laser ablation, mean survival ranged from 41 to 58 months. One cohort study compared radiofrequency ablation with surgical resection and five case series studies also investigated the use of radiofrequency ablation. Across these studies the median survival ranged from 44 to 52 months. Seven studies of minimally invasive therapies were included in the review. Two RCTs compared chemoembolisation with chemotherapy only. Overall survival was not compared between groups and methodological shortcomings mean that conclusions are difficult to make. Two case series studies of laser ablation following chemoembolisation were also included; however, these provide little evidence of the use of these technologies in combination. Three RCTs of radioembolisation were included. Significant improvements in tumour response and time to disease progression were demonstrated; however, benefits in terms of survival were equivocal. An exploratory survival model was developed using data from the review of clinical effectiveness. The model includes separate analyses of microwave ablation compared with surgery and radiofrequency ablation compared with surgery and one of radioembolisation in conjunction with hepatic artery chemotherapy compared with hepatic artery chemotherapy alone. Microwave ablation was associated with an incremental cost-effectiveness ratio (ICER) of £3664 per quality-adjusted life-year (QALY) gained, with microwave ablation being associated with reduced cost but also with poorer outcome than surgery. Radiofrequency ablation compared with surgical resection for solitary metastases < 3 cm was associated with an ICER of -£266,767 per QALY gained, indicating that radiofrequency ablation dominates surgical resection. Radiofrequency ablation compared with surgical resection for solitary metastases ≥ 3 cm resulted in poorer outcomes at lower costs and a resultant ICER of £2538 per QALY gained. Radioembolisation plus hepatic artery chemotherapy compared with hepatic artery chemotherapy was associated with an ICER of £37,303 per QALY gained. CONCLUSIONS: There is currently limited high-quality research evidence upon which to base any firm decisions regarding ablative therapies for liver metastases. Further trials should compare ablative therapies with surgery, in particular. A RCT would provide the most appropriate design for undertaking any further evaluation and should include a full economic evaluation, but the group to be randomised needs careful selection. SOURCE OF FUNDING: Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.


Assuntos
Técnicas de Ablação/economia , Embolização Terapêutica/economia , Neoplasias Hepáticas/terapia , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/métodos , Idoso , Análise Custo-Benefício , Progressão da Doença , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Feminino , Humanos , Neoplasias Hepáticas/economia , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Análise de Sobrevida , Fatores de Tempo , Reino Unido
16.
Obstet Gynecol Clin North Am ; 40(4): 687-95, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24286996

RESUMO

Global endometrial ablation techniques are a relatively new surgical technology for the treatment of heavy menstrual bleeding that can now be used even in an outpatient clinic setting. A comparison of global ablation versus earlier ablation technologies notes no significant differences in success rates and some improvement in patient satisfaction. The advantages of the newer global endometrial ablation systems include less operative time, improved recovery time, and decreased anesthetic risk. Ablation procedures performed in an outpatient surgical or clinic setting provide advantages both of potential cost savings for patients and the health care system and improved patient convenience.


Assuntos
Técnicas de Ablação , Procedimentos Cirúrgicos Ambulatórios/métodos , Endométrio/cirurgia , Menorragia/cirurgia , Técnicas de Ablação/economia , Técnicas de Ablação/métodos , Técnicas de Ablação/normas , Procedimentos Cirúrgicos Ambulatórios/economia , Análise Custo-Benefício , Feminino , Humanos , Satisfação do Paciente , Seleção de Pacientes , Complicações Pós-Operatórias , Resultado do Tratamento
17.
Ont Health Technol Assess Ser ; 13(12): 1-87, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24228075

RESUMO

BACKGROUND: As part of ongoing efforts to improve the Ontario health care system, a mega-analysis examining the optimization of chronic disease management in the community was conducted by Evidence Development and Standards, Health Quality Ontario (previously known as the Medical Advisory Secretariat [MAS]). OBJECTIVE: The purpose of this report was to identify health technologies previously evaluated by MAS that may be leveraged in efforts to optimize chronic disease management in the community. DATA SOURCES: The Ontario Health Technology Assessment Series and field evaluations conducted by MAS and its partners between January 1, 2006, and December 31, 2011. REVIEW METHODS: Technologies related to at least 1 of 7 disease areas of interest (type 2 diabetes, coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, stroke, and chronic wounds) or that may greatly impact health services utilization were reviewed. Only technologies with a moderate to high quality of evidence and associated with a clinically or statistically significant improvement in disease management were included. Technologies related to other topics in the mega-analysis on chronic disease management were excluded. Evidence-based analyses were reviewed, and outcomes of interest were extracted. Outcomes of interest included hospital utilization, mortality, health-related quality of life, disease-specific measures, and economic analysis measures. RESULTS: Eleven analyses were included and summarized. Technologies fell into 3 categories: those with evidence for the cure of chronic disease, those with evidence for the prevention of chronic disease, and those with evidence for the management of chronic disease. CONCLUSIONS: The impact on patient outcomes and hospitalization rates of new health technologies in chronic disease management is often overlooked. This analysis demonstrates that health technologies can reduce the burden of illness; improve patient outcomes; reduce resource utilization intensity; be cost-effective; and be a viable contributing factor to chronic disease management in the community. PLAIN LANGUAGE SUMMARY: People with chronic diseases rely on the health care system to help manage their illness. Hospital use can be costly, so community-based alternatives are often preferred. Research published in the Ontario Health Technology Assessment Series between 2006 and 2011 was reviewed to identify health technologies that have been effective or cost-effective in helping to manage chronic disease in the community. All technologies identified led to better patient outcomes and less use of health services. Most were also cost-effective. Two technologies that can cure chronic disease and 1 that can prevent chronic disease were found. Eight technologies that can help manage chronic disease were also found. Health technologies should be considered an important part of chronic disease management in the community.


Assuntos
Tecnologia Biomédica/economia , Doença Crônica/terapia , Serviços de Saúde Comunitária , Gerenciamento Clínico , Medicina Baseada em Evidências , Pesquisa sobre Serviços de Saúde , Técnicas de Ablação/economia , Cirurgia Bariátrica/economia , Doença Crônica/economia , Doença Crônica/epidemiologia , Análise Custo-Benefício , Desfibriladores Implantáveis/economia , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/cirurgia , Órgãos Governamentais , Cardiopatias/mortalidade , Cardiopatias/cirurgia , Hospitalização/estatística & dados numéricos , Humanos , Tratamento de Ferimentos com Pressão Negativa/economia , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Ontário/epidemiologia , /estatística & dados numéricos , Intervenção Coronária Percutânea/economia , Modalidades de Fisioterapia/economia , Lesão por Pressão/epidemiologia , Lesão por Pressão/prevenção & controle , Lesão por Pressão/terapia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/terapia , Melhoria de Qualidade , Qualidade de Vida , Abandono do Hábito de Fumar/economia , Acidente Vascular Cerebral/epidemiologia , Reabilitação do Acidente Vascular Cerebral , Terapia Trombolítica/economia , Vacinação/economia
18.
Tech Vasc Interv Radiol ; 16(4): 201-8, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24238375

RESUMO

Tumor ablation services have increased in prevalence across the country and can now be found in modern health care systems of all sizes. These services have become an integral part of the coordinated multidisciplinary approach to patient care that must take place at any oncologic center of excellence. However, building a reputable tumor ablation practice at an institutional level can be a very difficult task as there are many financial, political, and material considerations that must be addressed during the early phases of operation to ensure its success. This article discusses each of these considerations in turn and provides insight into ways to overcome the inherent challenges faced when bringing all of the necessary elements together to create a thriving tumor ablation practice at an institutional level.


Assuntos
Técnicas de Ablação , Oncologia/organização & administração , Neoplasias/cirurgia , Administração da Prática Médica/organização & administração , Cirurgia Assistida por Computador , Técnicas de Ablação/economia , Técnicas de Ablação/instrumentação , Técnicas de Ablação/normas , Redes Comunitárias , Prestação Integrada de Cuidados de Saúde , Fidelidade a Diretrizes , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Reembolso de Seguro de Saúde , Oncologia/economia , Oncologia/normas , Determinação de Necessidades de Cuidados de Saúde , Neoplasias/diagnóstico , Neoplasias/economia , Objetivos Organizacionais , Guias de Prática Clínica como Assunto , Administração da Prática Médica/economia , Administração da Prática Médica/normas , Área de Atuação Profissional , Encaminhamento e Consulta , Cirurgia Assistida por Computador/economia , Cirurgia Assistida por Computador/instrumentação , Cirurgia Assistida por Computador/normas
19.
Dermatol Online J ; 18(8): 7, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22948057

RESUMO

Brooke-Spiegler syndrome is an uncommon disease. Patients have a predisposition to develop cutaneous adnexal neoplasms such as cylindromas, trichoepitheliomas, spiradenomas, trichoblastomas, basal cell carcinomas, follicular cysts, and organoid nevi. Malignant transformation of preexisting tumors also occurs in these individuals. Various techniques have been used for the treatment of trichoepitheliomas and cylindromas including excision, electrocautery, carbon dioxide laser ablation, cryosurgery, and radiotherapy. In our case, cylindromas were ablated by radiofrequency in multiple sittings. Trichoepitheliomas were ablated using coagulation mode with power # 3 to 3.5. Cosmetically acceptable results were obtained in 100 percent of the cylindromas and 70 percent of the trichoepitheliomas (Visual Analog Scale). The radiofrequency ablation technique under different modes can be used in both large tumors as well as smaller ones, especially in developing countries because it is very cost effective and easily accessible.


Assuntos
Técnicas de Ablação/métodos , Carcinoma Adenoide Cístico/cirurgia , Síndromes Neoplásicas Hereditárias/cirurgia , Neoplasias Cutâneas/cirurgia , Técnicas de Ablação/economia , Carcinoma Adenoide Cístico/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Síndromes Neoplásicas Hereditárias/patologia , Neoplasias Cutâneas/patologia , Resultado do Tratamento
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