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1.
Lancet ; 395(10219): 212-224, 2020 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31954466

RESUMO

BACKGROUND: Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. METHODS: We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006. FINDINGS: Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. INTERPRETATION: Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. FUNDING: French Ministry of Social Affairs and Health.


Assuntos
Extração de Catarata/economia , Extração de Catarata/métodos , Análise Custo-Benefício , Terapia a Laser/economia , Facoemulsificação/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Extração de Catarata/efeitos adversos , Estudos de Equivalência como Asunto , Feminino , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Facoemulsificação/efeitos adversos , Facoemulsificação/métodos , Resultado do Tratamento
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.
Otolaryngol Head Neck Surg ; 161(5): 835-841, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31184268

RESUMO

OBJECTIVE: To identify costs and operative times for stapedotomy and evaluate factors influencing cost variation. STUDY DESIGN: Case series with cost analysis. SETTING: Multihospital network. SUBJECTS AND METHODS: A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of all patients undergoing stapedotomy from 2013 to 2017. Subjects with additional procedures were excluded. Correlations between variable factors and cost were calculated by Spearman correlation coefficients. Audiometric and cost data were compared with a Mann-Whitney U test. RESULTS: The study cohort included 176 stapedotomies performed by 23 surgeons at 10 hospitals. Mean ± SD patient age was 44.3 ± 17.4 years. Mean cut-to-close time was 61.1 ± 23.55 minutes. Mean total encounter cost was $3542.14 ± $1258.78 (US dollars). Significant factors correlating with increased total encounter cost were surgical supply cost (r = 0.74, P < .0001) and cut-to-close time (r = 0.66, P < .0001). Laser utilization ($563.37 ± $407.41) was the highest-cost surgical supply, with the carbon dioxide laser being significantly more costly than the potassium titanyl phosphate (KTP; $852.60 vs $230.55, P < .001). Additionally, the carbon dioxide laser was associated with a significantly higher mean total encounter cost than the KTP laser ($4645.43 vs $2903.00, P < .001) and cases where no laser was used ($4645.43 vs $2932.47, P < .001). There was no difference in mean total encounter cost between the KTP laser and cases of no laser use ($2903.00 vs $2932.47, P = .75). CONCLUSIONS: Significant cost variation exists in stapes surgery. Surgical supply cost, specifically laser use, may be associated with significantly increased costs. Reducing variation in costs while maintaining outcomes may improve health care value.


Assuntos
Custos de Cuidados de Saúde , Cirurgia do Estribo/educação , Adulto , Audiometria/economia , Estudos de Coortes , Feminino , Humanos , Terapia a Laser/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos
4.
Urol Clin North Am ; 46(2): 303-313, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30961862

RESUMO

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease.


Assuntos
Análise Custo-Benefício , Cálculos Renais/economia , Cálculos Renais/cirurgia , Efeitos Psicossociais da Doença , Assistência à Saúde/economia , Diagnóstico por Imagem/economia , Equipamentos Descartáveis/economia , Custos de Cuidados de Saúde , Humanos , Invenções/economia , Cálculos Renais/epidemiologia , Cálculos Renais/prevenção & controle , Terapia a Laser/economia , Terapia a Laser/instrumentação , Litotripsia/economia , Nefrolitíase/economia , Nefrolitíase/epidemiologia , Nefrolitíase/prevenção & controle , Nefrolitíase/cirurgia , Nefrolitotomia Percutânea/economia , Nefrolitotomia Percutânea/instrumentação , Nefrolitotomia Percutânea/métodos , Fibras Ópticas/economia , Ureteroscopia/economia , Ureteroscopia/instrumentação
5.
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
6.
Am J Ophthalmol ; 200: 187-200, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30684455

RESUMO

PURPOSE: To determine factors predictive of anatomic, visual, and financial outcomes after traditional and nontraditional primary pneumatic retinopexy (PR) for rhegmatogenous retinal detachment (RD). DESIGN: Retrospective interventional case series and cost comparison. METHODS: Participants: Total of 178 eyes (156 patients) with PR-repaired primary RD by a single surgeon at a clinical practice from January 2001 to December 2013 and followed for ≥1 year. The cohort had 2 subgroups: traditional (TPR) and nontraditional (NTPR) PR. MAIN OUTCOME MEASURES: Characteristics associated with best-corrected visual acuity (BCVA) and anatomic outcomes. Cost analysis and potential cost savings comparing PR to scleral buckle and vitrectomy. RESULTS: One hundred thirty-one of 178 eyes (73.5%) were successfully treated at 1 year (postoperative year 1): 72.8% (75/103) in TPR and 74.6% (56/75) in NTPR. Macula-off detachment (-0.44 logMAR, P < .001) and clock hours of RD (-0.84 logMAR, P < .001) correlated with improved BCVA; pseudophakia (0.26 logMAR, P = .002) and inferior retinal tears (0.62 logMAR, P = .009) correlated with worsening BCVA. Pseudophakia (-0.15, P = .03), inferior quadrant RD (-0.27, P < .001), and proliferative vitreoretinopathy (-0.68, P < .001) correlated with anatomic failure. Total average cost for TPR and NTPR was $1248.37 ± $882.11 and $1471.91 ± $942.84, respectively (P = .10). PR had a potential cost savings of 62% and 60.8% when compared to scleral buckle and vitrectomy, respectively. CONCLUSIONS: PR results in successful anatomic and visual outcomes in both TPR and NTPR repair of primary RD. Preoperative pseudophakia is associated with worse visual outcomes and less anatomic success. The cost of primary PR and subsequent procedures to achieve final anatomic success was not significantly different between TPR and NTPR, and supports the possible cost-effectiveness of expanded indications for PR.


Assuntos
Crioterapia/economia , Custos de Cuidados de Saúde , Terapia a Laser/economia , Descolamento Retiniano/economia , Descolamento Retiniano/cirurgia , Acuidade Visual/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Crioterapia/métodos , Tamponamento Interno , Feminino , Humanos , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Descolamento Retiniano/fisiopatologia , Estudos Retrospectivos , Recurvamento da Esclera/economia , Hexafluoreto de Enxofre/administração & dosagem , Resultado do Tratamento , Vitrectomia/economia
7.
Medicine (Baltimore) ; 98(2): e14026, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30633194

RESUMO

OBJECTIVES: Open-angle glaucoma (OAG) imposes high disease burden in South Korea. Although various effective interventions are available to manage the progression of OAG, there is limited data on the cost-effectiveness of these treatment strategies in South Korea. METHODS: Using a Markov cohort model, we evaluated the cost-effectiveness of 3 major treatment strategies (medication, laser trabeculoplasty, and trabeculectomy) for South Korean patients with OAG. We projected a 25-year time horizon to study a hypothetical cohort of 10,000 patients of age 40 with mild OAG. The outcome measures were quality-adjusted life-years (QALYs) gained, cost from the societal perspective, and the incremental cost-effectiveness ratio (ICER) of medication, laser trabeculoplasty, and trabeculectomy. Interventions were evaluated at a willingness-to-pay (WTP) threshold of 30,000,000 KRW ($29,152) per QALY gained. Deterministic and probabilistic sensitivity analyses were conducted to address the model uncertainty. RESULTS: The mean costs for medication, laser trabeculoplasty, and trabeculectomy were 29,661,740 KRW, 17,34,1342 KRW, and 22,275,438 KRW, respectively. The mean QALYs gained were 15.7, 15.3, and 14.8 for medication, laser trabeculoplasty, and trabeculectomy, respectively. Surgery was strongly dominated because it generated fewer expected QALYs but incurred greater expected cost than laser. The ICER was 30,885,179 KRW per QALY for medication versus laser trabeculoplasty. Laser was cost-effective, however, at a lower WTP threshold of 21,000,000 KRW per QALY gained or below. The results were most sensitive to the progression rates from mild to moderate glaucoma under laser treatment. CONCLUSION: Under the WTP threshold of 30,000,000 KRW per QALY, medication was cost-effective compared with laser trabeculoplasty and trabeculectomy for treating mild OAG in South Korean population. Laser, however, can be a cost-effective alternative in more resource-limited settings.


Assuntos
Glaucoma de Ângulo Aberto/economia , Glaucoma de Ângulo Aberto/terapia , Terapia a Laser/economia , Fármacos Neuroprotetores/economia , Trabeculectomia/economia , Adulto , Análise Custo-Benefício , Humanos , Terapia a Laser/métodos , Cadeias de Markov , Modelos Teóricos , Fármacos Neuroprotetores/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde , Anos de Vida Ajustados por Qualidade de Vida , República da Coreia , Trabeculectomia/métodos
8.
World J Urol ; 37(5): 861-866, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30116964

RESUMO

PURPOSE: To assess the cost-utility of the photovaporization of the prostate (PVP) with GreenLight™ laser 180 W XPS compared to transurethral resection of the prostate with monopolar energy (M-TURP) for lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) from a healthcare perspective in Colombia. METHODS: We designed a Markov model to compare four health states following treatment with either PVP or M-TURP to estimate expected costs and outcomes. We used the results of the only randomized clinical trial published to date comparing PVP versus M-TURP to estimate surgical outcomes, complications, re-operation and re-intervention rates. Time horizon was defined at 2 years with four cycles of 6 months each. Resource-use estimation involved a random selection of clinical records from a local institution and cost list from public healthcare system. Costs were obtained in Colombian pesos and converted to US dollars. Threshold was defined at three-times the Colombian gross domestic product (GDP) per capita. Quality-adjusted-life-years (QALYs) were used based on the utilities of the available literature. Uncertainty was analyzed with deterministic and probabilistic models using a Monte Carlo simulation. RESULTS: Patients who underwent PVP gained 1.81 QALYs compared to 1.59 with M-TURP. Costs were US$6797.98 and US$7777.59 for M-TURP and PVP, respectively. Incremental cost-effectiveness ratio was US$4452.81 per QALY, favoring PVP as a cost-effective alternative in our context. CONCLUSIONS: In Colombia, with current prices, PVP is cost-effective when compared to M-TURP for LUTS due to BPE for a 2-year time horizon.


Assuntos
Terapia a Laser/métodos , Sintomas do Trato Urinário Inferior/cirurgia , Hiperplasia Prostática/cirurgia , Ressecção Transuretral da Próstata/métodos , Colômbia , Análise Custo-Benefício , Humanos , Terapia a Laser/economia , Sintomas do Trato Urinário Inferior/etiologia , Masculino , Método de Monte Carlo , Complicações Pós-Operatórias/epidemiologia , Hiperplasia Prostática/complicações , Anos de Vida Ajustados por Qualidade de Vida , Reoperação , Ressecção Transuretral da Próstata/economia
9.
Asian J Surg ; 42(1): 367-372, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29804709

RESUMO

BACKGROUND: This study represented an effort to design an alternative to Harmonic Scalpel™ with the same effectiveness but at a lower cost. The concomitant use of Starion™ and Harmonic Scalpel™ had been evaluated to determine the differences in terms of the effectiveness immediately after the operation and 3 years post-operatively. METHODS: 114 patients in the SH group (Starion™ hemorrhoidectomy) and 107 patients in the HSH group (Harmonic Scalpel™) were contacted for cumulative inspection 1 week, 4 weeks, and 3 years post-operatively to check for the recurrence rate. RESULTS: No significant difference in the pain score was observed at post-operative week 1, with the SH group scoring 2.08 ± 0.96 and the HSH group scoring 2.29 ± 1.00 (p = 0.112). No significant difference in patient satisfaction was observed at post-operative week 4, with the SH group scoring 8.63 ± 1.28 and the HSH group scoring 8.60 ± 1.32 (p = 0.847). No significant difference in wound healing was observed, with the SH group showing 18.24 ± 3.13 days and the HSH group showing 18.21 ± 2.96 days (p = 0.943). The post-operative recurrence rate was 3.5% (4/114) in the SH group at the 3-year follow-up compared to 4.7% (5/107) in the HSH group without any statistically significant difference (p = 0.662). CONCLUSIONS: Starion™ was a safe, rapid, and effective method for the treatment of Grade III or IV hemorrhoids.


Assuntos
Hemorroidectomia/instrumentação , Hemorroidas/cirurgia , Terapia a Laser/instrumentação , Instrumentos Cirúrgicos , Adulto , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Terapia a Laser/economia , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/prevenção & controle , Satisfação do Paciente , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Recidiva , Índice de Gravidade de Doença , Instrumentos Cirúrgicos/economia , Fatores de Tempo , Resultado do Tratamento
10.
Cardiovasc Intervent Radiol ; 42(4): 520-527, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30506168

RESUMO

PURPOSE: Minimally invasive alternatives to transurethral resection of the prostate (TURP) such as prostate arterial embolization (PAE) and photoselective vaporization of the prostate (PVP) are being explored as adjuncts in the care of patients with benign prostatic hyperplasia. However, there are conflicting reports of the costs of these procedures. The purpose of this study was to compare the direct and indirect hospital costs of TURP, PAE and PVP. MATERIALS AND METHODS: A chart review was performed in patients who underwent TURP, PVP and PAE from April 2015 to March 2017. All hospital costs were collected in accordance with the Ontario Case Costing Initiative, a standardized medical case costing system. Costs were characterized as direct or indirect and fixed or variable. Probabilistic sensitivity analysis was conducted to study cost uncertainty. RESULTS: During the study period, a total of 209 men underwent TURP, 28 PVP and 21 PAE. Mean age (years) was as follows: TURP 71.43; PVP 73.66; PAE 70.77 (p = 0.366). Mean length of stay (days) was as follows: TURP 1.63; PVP 1.55; PAE 1 (p = 0.076). Total costs of the PAE group ($3829, SD $1582) were less than both PVP ($5719, SD $1515) and TURP groups ($5034, SD $1997, p < 0.001). There was no significant difference in direct costs between the groups. Monte Carlo simulation demonstrated that PAE was the least costly alternative majority of the time. CONCLUSIONS: The total hospital costs of PAE at our institution are significantly lower than those of PVP and TURP.


Assuntos
Análise Custo-Benefício/economia , Embolização Terapêutica/economia , Custos Hospitalares/estatística & dados numéricos , Terapia a Laser/economia , Hiperplasia Prostática/terapia , Ressecção Transuretral da Próstata/economia , Idoso , Humanos , Masculino , Hiperplasia Prostática/economia , Resultado do Tratamento
11.
BJU Int ; 122(5): 879-888, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30113127

RESUMO

OBJECTIVE: To evaluate the cost-effectiveness of using a surgery, such as transurethral resection of the prostate (TURP) or photoselective vaporisation of the prostate using greenlight laser (GL-PVP), as initial treatment for men with moderate-to-severe benign prostate hyperplasia (BPH) compared to the standard practice of using pharmacotherapy as initial treatment followed by surgery if symptoms do not resolve. PATIENTS AND METHODS: We compared a combination of eight strategies involving upfront pharmacotherapy (i.e., α-blocker, 5α-reductase inhibitor, or combination) followed by surgery (e.g. TURP or GL-PVP) upon failure vs TURP or GL-PVP as initial treatment, for a target population of men with moderate-to-severe BPH symptoms, with a mean age of 65 years and no contraindications for treatment. A microsimulation decision-analytic model was developed to project the costs and quality-adjusted life years (QALYs) of the target population over the lifetime. The model was populated and validated using published literature. Incremental cost-effectiveness ratios (ICERs) were determined. Cost-effectiveness was evaluated using a public payer perspective, a lifetime horizon, a discount rate of 1.5%, and a cost-effectiveness threshold of $50 000 (Canadian dollars)/QALY. Sensitivity and probabilistic analyses were performed. RESULTS: All options involving an upfront pharmacotherapy followed by TURP for those who fail were economically unattractive compared to strategies involving a GL-PVP for those who fail, and compared to using either BPH surgery as initial treatment. Overall, upfront TURP was the most costly and effective option, followed closely by upfront GL-PVP. On average, upfront TURP costs $1015 more and resulted in a small gain of 0.03 QALYs compared to upfront GL-PVP, translating to an incremental cost per QALY gained of $29 066. Results were robust to probabilistic analysis. CONCLUSIONS: Surgery is cost-effective as initial therapy for BPH. However, the health and economic evidence should be considered concurrently with patient preferences and risk attitudes towards different therapy options.


Assuntos
Hiperplasia Prostática , Inibidores de 5-alfa Redutase/economia , Inibidores de 5-alfa Redutase/uso terapêutico , Idoso , Análise Custo-Benefício , Humanos , Terapia a Laser/economia , Terapia a Laser/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/economia , Hiperplasia Prostática/epidemiologia , Hiperplasia Prostática/cirurgia , Anos de Vida Ajustados por Qualidade de Vida , Ressecção Transuretral da Próstata/economia , Ressecção Transuretral da Próstata/estatística & dados numéricos
12.
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
13.
Graefes Arch Clin Exp Ophthalmol ; 256(11): 2181-2189, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30132278

RESUMO

PURPOSE: To produce an economic comparison of the iStent ab interno trabecular microbypass implant accompanying cataract surgery and selective laser trabeculoplasty (SLT) as first-line treatment versus topical medications for open-angle glaucoma in New Zealand in 2016. METHODS: The current annual costs of 19 available fully subsidised topical glaucoma medications by Pharmaceutical Management Agency (Pharmac) in 2016 were identified. Adjustments for pharmacist prescribing charges and previously described wastage levels were applied. The costs to perform iStent implantation and the cost to perform SLT were obtained from the local distributors, with the latter taking into account staff and consumable cost. Procedure costs divided by eye drops' cost produced a break-even level in equivalent years of eye drops use. RESULTS: The range of annual eye drop cost was NZD$42.25 to NZD$485.11, with an average of NZD$144.81. Comparison of annual eye drop cost with iStent cost revealed 3 of 19 (15.8%) drops breaking even within 5 years, 9 of 19 (47.3%) within 10 years, and 12 of 19 (63.2%) within 15 years. The cost of bilateral SLT performed by a consultant was NZD$102.30 (breaking even in 0.71 years). The equivalent cost for a registrar was NZD$97.59 (breaking even in 0.67 years). CONCLUSION: Economically, the iStent would appear to be a reasonably cost-effective treatment for glaucoma patients undergoing cataract surgery in a public healthcare setting in New Zealand, particularly for those using more expensive topical glaucoma medications, whilst SLT appears to be a worthwhile consideration as a first-line treatment for glaucoma in New Zealand.


Assuntos
Anti-Hipertensivos/economia , Extração de Catarata/economia , Análise Custo-Benefício , Implantes para Drenagem de Glaucoma/economia , Glaucoma de Ângulo Aberto/economia , Custos de Cuidados de Saúde , Trabeculectomia/economia , Idoso , Custos de Medicamentos , Feminino , Glaucoma de Ângulo Aberto/tratamento farmacológico , Glaucoma de Ângulo Aberto/cirurgia , Pesquisa sobre Serviços de Saúde , Humanos , Pressão Intraocular , Terapia a Laser/economia , Lasers de Estado Sólido/uso terapêutico , Masculino , Nova Zelândia , Soluções Oftálmicas/economia , Saúde Pública
15.
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
16.
J Vasc Surg Venous Lymphat Disord ; 6(4): 471-476.e6, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29602759

RESUMO

BACKGROUND: In mid-2007, endovenous ablation (EVA) of the great saphenous vein was introduced into the publicly funded health care system in Saskatchewan, Canada. We hypothesize that the introduction of EVA resulted in a decrease in use of high ligation and stripping (HL/S), decreased costs to the health care system, and increased demand of patients for great saphenous vein ablative procedures. METHODS: We retrospectively reviewed administrative data to capture cases of HL/S between 2003 and 2014 and cases of EVA of the great saphenous vein (endovenous laser treatment and radiofrequency ablation) between 2007 and 2014. Accounting for the change in practice pattern that occurred slowly between 2007 and 2009, we divided our patients into the pre-EVA era (2003-2006) and the post-EVA era (2010-2014). Procedure costs were determined with models used by our health region for this purpose. RESULTS: Utilization rates for great saphenous vein intervention remained similar in the pre-EVA (90 procedures per year) and post-EVA (92 procedures per year; P = .83) eras. Case costs of HL/S ($1965.12/case) were higher than those of EVA (endovenous laser treatment, $1295.08/case; radiofrequency ablation, $1410.54/case). The total annual costs of great saphenous vein intervention decreased from $176,861 in the pre-EVA era to $134,525 (P = .02). CONCLUSIONS: Introduction of publicly funded EVA has reduced rates of HL/S and reduced costs to our health system by approximately $42,000 per year, without increasing great saphenous vein intervention rates.


Assuntos
Ablação por Cateter/economia , Assistência à Saúde/economia , Procedimentos Endovasculares/economia , Custos de Cuidados de Saúde , Planejamento Hospitalar/economia , Terapia a Laser/economia , Saúde Pública/economia , Veia Safena/cirurgia , Varizes/economia , Varizes/cirurgia , Demandas Administrativas em Assistência à Saúde , Ablação por Cateter/efeitos adversos , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Necessidades e Demandas de Serviços de Saúde/economia , Humanos , Terapia a Laser/efeitos adversos , Determinação de Necessidades de Cuidados de Saúde/economia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Saskatchewan , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/fisiopatologia
17.
J Cosmet Laser Ther ; 20(4): 248-251, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29384405

RESUMO

INTRODUCTION: Fractional CO2 has many indications in medicine including in treatment of acne scars and rejuvenation. The aim of this study was to evaluate the safety, efficacy, and cost-effectiveness of Fractional CO2 Laser in comparison with other methods of rejuvenation and acne scar treatment. MATERIALS AND METHODS: Several databases including Medline, OVID, EMBASE, CINHAL, SCOPUS, Web of science, CRD, and Cochrane were searched. After conducting the search and evaluation of selected publications, critical appraisal was done and eligible studies were accepted for inclusion in the systematic review. RESULTS AND DISCUSSION: From 2667 identified publications two of the trials were eligible. The effectiveness and complications of Fractional CO2 laser were comparable with Er:YAG but Fractional CO2 laser was 14.7% (p = 0.01) more effective than Q-Switched ND:YAG laser. Cost affectivity of this method was the same as other alternative lasers. In conclusion Fractional CO2 laser is an effective and safe method for curing of several kinds of skin diseases. Nevertheless there was not sufficient evidence to support its advantage. This device has equal or lower price in comparison to competent technologies except for the non- fractional ablative CO2 laser that has the same or lower price and comparable effects.


Assuntos
Cicatriz/cirurgia , Lasers de Gás/uso terapêutico , Lasers de Estado Sólido/uso terapêutico , Envelhecimento da Pele , Acne Vulgar/complicações , Cicatriz/etiologia , Análise Custo-Benefício , Humanos , Terapia a Laser/efeitos adversos , Terapia a Laser/economia , Lasers de Gás/efeitos adversos , Lasers de Estado Sólido/efeitos adversos , Rejuvenescimento
18.
PLoS One ; 13(1): e0190742, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29300755

RESUMO

OBJECTIVE: To investigate the economic impact of introducing targeted screening and laser photocoagulation treatment for sight-threatening diabetic retinopathy and macular edema in a setting with no previous screening or laser treatment for diabetic retinopathy in sub-Saharan Africa. MATERIALS AND METHODS: A cohort Markov model was built to compare combined targeted screening and laser treatment for patients with sight-threatening diabetic retinopathy and macular edema against no intervention. Primary outcomes were incremental cost per quality-adjusted life year (QALY) gained and per disability-adjusted life year (DALY) averted. Primary data were collected on 357 participants from the Malawi Diabetic Retinopathy Study, a prospective, observational cohort study. Multiple scenarios were explored and a probabilistic sensitivity analysis was performed. RESULTS: In the base case (age: 50 years, service utilization rate: 80%), the cost of the intervention and the years of severe visual impairment averted per patient screened were $209 and 2.2 years respectively. Applying the World Health Organization threshold of cost-effectiveness for Malawi ($679), the base case was cost-effective when QALYs were used ($400 per QALY gained) but not when DALYs were used ($766 per DALY averted). The intervention was more cost-effective when it targeted younger patients (age: 30 years) and less cost-effective when the utilization rate was lowered to 50%. CONCLUSIONS: Annual photographic screening of diabetic patients attending medical diabetes clinics in Malawi, with the provision of laser treatment for those with sight-threatening diabetic retinopathy and macular edema, appears to be cost-effective in terms of QALYs gained, in our base case scenario. Cost-effectiveness improves if services are utilized more intensively and extended to younger patients.


Assuntos
Análise Custo-Benefício , Retinopatia Diabética/economia , Terapia a Laser/economia , Edema Macular/economia , Programas de Rastreamento/economia , Adulto , Fatores Etários , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/terapia , Humanos , Edema Macular/diagnóstico , Edema Macular/terapia , Malaui , Cadeias de Markov , Pessoa de Meia-Idade , Estudos Prospectivos
19.
Br J Ophthalmol ; 102(5): 593-598, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28903966

RESUMO

PURPOSE: The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial aims to establish whether initial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication for primary open-angle glaucoma (POAG) or ocular hypertension (OHT). DESIGN: The LiGHT Trial is a prospective, unmasked, multicentre, pragmatic, randomised controlled trial. 718 previously untreated patients with POAG or OHT were recruited at six collaborating centres in the UK between 2012 and 2014. The trial comprises two treatment arms: initial SLT followed by conventional medical therapy as required, and medical therapy without laser therapy. Randomisation was provided online by a web-based randomisation service. Participants will be monitored for 3 years, according to routine clinical practice. The target intraocular pressure (IOP) was set at baseline according to an algorithm, based on disease severity and lifetime risk of loss of vision at recruitment, and subsequently adjusted on the basis of IOP control, optic disc and visual field. The primary outcome measure is health-related quality of life (HRQL) (EQ-5D five-level). Secondary outcomes are treatment pathway cost and cost-effectiveness, Glaucoma Utility Index, Glaucoma Symptom Scale, Glaucoma Quality of Life, objective measures of pathway effectiveness, visual function and safety profiles and concordance. A single main analysis will be performed at the end of the trial on an intention-to-treat basis. CONCLUSIONS: The LiGHT Trial is a multicentre, pragmatic, randomised clinical trial that will provide valuable data on the relative HRQL, clinical effectiveness and cost-effectiveness of SLT and topical IOP-lowering medication. TRIAL REGISTRATION NUMBER: ISRCTN32038223, Pre-results.


Assuntos
Glaucoma de Ângulo Aberto/cirurgia , Terapia a Laser/métodos , Hipertensão Ocular/cirurgia , Projetos de Pesquisa , Trabeculectomia/métodos , Idoso , Anti-Hipertensivos/uso terapêutico , Feminino , Glaucoma de Ângulo Aberto/tratamento farmacológico , Humanos , Pressão Intraocular/fisiologia , Terapia a Laser/economia , Masculino , Pessoa de Meia-Idade , Hipertensão Ocular/tratamento farmacológico , Estudos Prospectivos , Qualidade de Vida , Trabeculectomia/economia , Resultado do Tratamento , Acuidade Visual/fisiologia
20.
Br J Ophthalmol ; 102(5): 599-603, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28982956

RESUMO

PURPOSE: The laser in glaucoma and ocular hypertension (LiGHT) trial aims to establish whether initial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication for primary open angle glaucoma (POAG) or ocular hypertension (OHT). DESIGN: LiGHT is a prospective unmasked, multicentre, pragmatic, randomised controlled trial (RCT). PARTICIPANTS: 718 previously untreated patients with POAG or OHT were recruited at 6 UK centres between 2012 and 2014. METHODS: Patients were randomised to initial SLT followed by medical therapy or medical therapy without laser. Participants will be monitored for 3 years, according to routine clinical practice. The primary outcome is EQ-5D-5L. Secondary outcomes are treatment pathway cost and cost-effectiveness, Glaucoma Utility Index (GUI), Glaucoma Symptom Scale, Glaucoma Quality of Life (GQL), pathway effectiveness, visual function, safety and concordance. RESULTS: A total of 555 patients had POAG and 163 OHT; 518 patients had both eyes eligible. The mean age for patients with POAG was 64 years and for OHT 58 years. 70% of all participants were white. Median IOP for OHT eyes was 26 mm Hg and 23 mm Hg for POAG eyes. Median baseline visual field mean deviation was -0.81 dB for OHT eyes and -2.82 dB for POAG eyes. There was no difference between patients with POAG and patients with OHT on the EQ-5D-5DL; the difference between OHT and POAG on the GUI was -0.02 and 1.23 on the GQL. CONCLUSIONS: The LiGHT trial is the first RCT to compare the two treatment options in a real-world setting. The baseline characteristics of the LiGHT cohort compare well with other landmark glaucoma studies. TRIAL REGISTRATION NUMBER: ISRCTN32038223, Pre-results.


Assuntos
Glaucoma de Ângulo Aberto/cirurgia , Terapia a Laser/métodos , Hipertensão Ocular/cirurgia , Trabeculectomia/métodos , Idoso , Anti-Hipertensivos/uso terapêutico , Feminino , Glaucoma de Ângulo Aberto/tratamento farmacológico , Humanos , Pressão Intraocular/fisiologia , Terapia a Laser/economia , Masculino , Pessoa de Meia-Idade , Hipertensão Ocular/tratamento farmacológico , Estudos Prospectivos , Qualidade de Vida , Trabeculectomia/economia , Resultado do Tratamento , Acuidade Visual/fisiologia
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