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OBJECTIVES: This study aimed to evaluate the cost-effectiveness (CE) of four hepatocellular carcinoma (HCC) surveillance strategies in the UK, the GAAD algorithm, which combines gender (biological sex) and age with Elecsys® biomarker assays, alpha-fetoprotein (AFP) and protein induced by vitamin K absence-II (PIVKA-II), ultrasound (US), US+AFP and GAAD+US. METHODS: A de novo micro-simulation state-transition Markov model was developed in Microsoft Excel® from the perspective of the UK National Health Service to calculate life years, quality-adjusted life-years (QALYs), costs, incremental CE ratios, and net monetary benefits. Parameters were sourced from peer-reviewed published literature, national guidelines, and public cost databases. Sensitivity and scenario analyses were performed to evaluate the impact of parameter and structural uncertainty on the results. RESULTS: In a simulated cohort of 100,000 patients, discounted costs and QALYs per patient were £8,663 and 6·066 for US, £9,095 and 6·076 for US+AFP, £8,719 and 6·078 for GAAD alone, and £9,114 and 6·086 for GAAD+US. At a CE threshold of £20,000/QALY, GAAD was the most cost-effective strategy; however, although most costly, GAAD+US was the most clinically effective. Sensitivity and scenario analyses indicated that HCC incidence along with costs associated with diagnostic performance influence CE. CONCLUSION: Considering the cost of US and low incidence of HCC in the UK, this study suggests that GAAD alone or in combination with US are cost-effective surveillance strategies compared with US and US+AFP. Whilst GAAD+US showed the highest QALY increase, GAAD alone is considered preferable regarding CE; however, better performance estimates for GAAD+US are needed to confirm.
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Liver transplantation is the only effective therapy to reduce the high mortality associated with acute liver failure and acute on chronic liver failure (ACLF). Single-pass albumin dialysis (SPAD) is an extracorporeal supportive therapy used as a bridge to liver transplantation or regeneration. We report a 44-year-old man with alcoholic cirrhosis admitted for critical COVID-19 pneumonia that evolves with ACLF. SPAD technique was performed completing six sessions, with a reduction of bilirubin and ammonia levels. He evolved with severe respiratory failure and refractory septic shock, dying. SPAD is a safe and efficient technique aimed to eliminate liver toxins, preventing multiorgan damage interrupting the process known as the "autointoxication hypothesis". It is easy to implement in any critical patient unit and has lower costs than other extracorporeal liver support therapies.
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Insuficiência Hepática Crônica Agudizada , COVID-19 , Transplante de Fígado , Masculino , Humanos , Adulto , Diálise Renal/métodos , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , COVID-19/complicações , Albuminas/uso terapêuticoRESUMO
BACKGROUND: The treatment of choice for advanced non-small cell lung cancer is selected according to the presence of specific alterations. Patients should undergo molecular testing for relevant modifications and the mutational status of EGFR and translocation of ALK and ROS1 are commonly tested to offer the best intervention. In addition, the tests costs should also be taken in consideration. Therefore, this work was performed in order to evaluate the cost-effectiveness of a unique exam using NGS (next generation sequencing) versus other routinely used tests which involve RT-PCR and FISH. METHODS: The target population was NSCLC, adenocarcinoma, and candidates to first-line therapy. Two strategies were undertaken, strategy 1 corresponded to sequential tests with EGFR RT-PCR, then FISH for ALK and ROS1. Strategy 2 differed from 1 in that ALK and ROS1 translocation testing were performed simultaneously by FISH. Strategy 3 considered single test next-generation sequencing, a platform that includes EGFR, ALK and ROS1 genes. A decision tree analysis was used to model genetic testing options. From the test results, a microsimulation model was nested to estimate survival outcomes and costs of therapeutic options. RESULTS: The use of NGS added 24% extra true cases as well as extra costs attributed to the molecular testing. The ICER comparing NGS with sequential tests was US$ 3479.11/correct case detected. The NGS improved a slight gain in life years and QALYs. CONCLUSION: Our results indicated that, although precise, the molecular diagnosis by NGS of patients with advanced stage NSCLC adenocarcinoma histology was not cost-effective in terms of quality-adjusted life years from the perspective of the Brazilian supplementary health system.
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Adenocarcinoma de Pulmão/diagnóstico , Quinase do Linfoma Anaplásico/genética , Proteínas Tirosina Quinases/genética , Proteínas Proto-Oncogênicas/genética , Adenocarcinoma de Pulmão/economia , Adenocarcinoma de Pulmão/genética , Brasil , Análise Custo-Benefício/economia , Testes Diagnósticos de Rotina/economia , Receptores ErbB/genética , Testes Genéticos/economia , Sequenciamento de Nucleotídeos em Larga Escala/economia , Humanos , Mutação/genéticaRESUMO
BACKGROUND: Around 6% of total deaths are related to alcohol consumption worldwide. Mathematical models are important tools to estimate disease burden and to assess the cost-effectiveness of interventions to address this burden. METHODS: We carried out a systematic review on models, searching main health literature databases up to July 2017. Pairs of reviewers independently selected, extracted data and assessed the quality of the included studies. Discrepancies were resolved by consensus. We selected those models exploring: a) disease burden (main metrics being attributable deaths, disability-adjusted life years, quality-adjusted life years) or b) economic evaluations of health interventions or policies, based on models including the aforementioned outcomes. We grouped models into broad families according to their common central methodological approach. RESULTS: Out of 4295 reports identified, 63 met our inclusion criteria and were categorized in three main model families that were described in detail: 1) State transition -i.e Markov- models, 2) Life Table-based models and 3) Attributable fraction-based models. Most studies pertained to the latter one (n = 29, 48.3%). A few miscellaneous models could not be framed into these families. CONCLUSIONS: Our findings can be useful for future researchers and decision makers planning to undertake alcohol-related disease burden or cost-effectiveness studies. We found several different families of models. Countries interested in adopting relevant public health measures may choose or adapt the one deemed most convenient, based on the availability of existing data at the local level, burden of work, and public health and economic outcomes of interest.
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Consumo de Bebidas Alcoólicas/efeitos adversos , Transtornos Relacionados ao Uso de Álcool/epidemiologia , Transtornos Relacionados ao Uso de Álcool/prevenção & controle , Promoção da Saúde/economia , Análise Custo-Benefício , Humanos , Modelos Teóricos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVE: To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. METHODS: In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). RESULTS: The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. CONCLUSIONS: The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.
OBJETIVO: Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. MÉTODOS: Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). RESULTADOS: Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. CONCLUSÕES: As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.
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BACKGROUND: Cervical cancer (CC) and genital warts (GW) are a significant public health issue in Venezuela. Our objective was to assess the cost-effectiveness of the two available vaccines, bivalent and quadrivalent, against Human Papillomavirus (HPV) in Venezuelan girls in order to inform decision-makers. METHODS: A previously published Markov cohort model, informed by the best available evidence, was adapted to the Venezuelan context to evaluate the effects of vaccination on health and healthcare costs from the perspective of the healthcare payer in an 11-year-old girls cohort of 264,489. Costs and quality-adjusted life years (QALYs) were discounted at 5%. Eight scenarios were analyzed to depict the cost-effectiveness under alternative vaccine prices, exchange rates and dosing schemes. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: Compared to screening only, the bivalent and quadrivalent vaccines were cost-saving in all scenarios, avoiding 2,310 and 2,143 deaths, 4,781 and 4,431 CCs up to 18,459 GW for the quadrivalent vaccine and gaining 4,486 and 4,395 discounted QALYs respectively. For both vaccines, the main determinants of variations in the incremental costs-effectiveness ratio after running deterministic and probabilistic sensitivity analyses were transition probabilities, vaccine and cancer-treatment costs and HPV 16 and 18 distribution in CC cases. When comparing vaccines, none of them was consistently more cost-effective than the other. In sensitivity analyses, for these comparisons, the main determinants were GW incidence, the level of cross-protection and, for some scenarios, vaccines costs. CONCLUSIONS: Immunization with the bivalent or quadrivalent HPV vaccines showed to be cost-saving or cost-effective in Venezuela, falling below the threshold of one Gross Domestic Product (GDP) per capita (104,404 VEF) per QALY gained. Deterministic and probabilistic sensitivity analyses confirmed the robustness of these results.
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Condiloma Acuminado/prevenção & controle , Análise Custo-Benefício/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Cadeias de Markov , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/economia , Neoplasias do Colo do Útero/prevenção & controle , Adulto , Criança , Estudos de Coortes , Condiloma Acuminado/economia , Análise Custo-Benefício/economia , Feminino , Humanos , Infecções por Papillomavirus/economia , Vacinas contra Papillomavirus/administração & dosagem , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias do Colo do Útero/economia , VenezuelaRESUMO
PURPOSE: To derive a value set from Uruguayan general population using the EQ-5D-5L questionnaire and report population norms. METHODS: General population individuals were randomly assigned to value 10 health states using composite time trade off and 7 pairs of health states through discrete choice experiments. A stratified sampling with quotas by location, gender, age and socio-economic status was used to respect the Uruguayan population structure. Trained interviewers conducted face-to-face interviews. The EuroQol valuation technology was used to administer the protocol as well as to collect the data. OLS and maximum likelihood robust regression models with or without interactions were tested. RESULTS: We included 794 respondents between 20 and 83 years. Their characteristics were broadly similar to the Uruguayan population. The main effects robust model was chosen to derive social values. Values ranged from -0.264 to 1. States with a misery index = 6 had a mean predicted value of 0.965. When comparing the Uruguayan population with the Argentinian EQ-5D-5L crosswalk value set, the prediction for states which differed from full health only in having one of the dimensions at level 2 were about 0.05 higher in Uruguay. The mean index value, using the selected Uruguayan EQ-5D-5L value set, for the general population in Uruguay was 0.895. In general, older people had worse values and males had slightly better values than females. CONCLUSION: We derived the EQ-5D-5L Uruguayan value set, the first in Latin America. These results will help inform decision-making using economic evaluations for resource allocation decisions.
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Nível de Saúde , Qualidade de Vida , Inquéritos e Questionários , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Uruguai , Adulto JovemRESUMO
OBJECTIVE: To estimate the impact of Argentine policies to reduce trans fatty acids (TFA) on coronary heart disease (CHD), disability-adjusted life years (DALYs) and associated health-care costs. METHODS: We estimated the baseline intake of TFA before 2004 to be 1.5% of total energy intake. We built a policy model including baseline intake of TFA, the oils and fats used to replace artificial TFAs, the clinical effect of reducing artificial TFAs and the costs and DALYs saved due to averted CHD events. To calculate the percentage of reduction of CHD, we calculated CHD risks on a population-based sample before and after implementation. The effect of the policies was modelled in three ways, based on projected changes: (i) in plasma lipid profiles; (ii) in lipid and inflammatory biomarkers; and (iii) the results of prospective cohort studies. We also estimated the present economic value of DALYs and associated health-care costs of coronary heart disease averted. FINDINGS: We estimated that projected changes in lipid profile would avert 301 deaths, 1066 acute CHD events, 5237 DALYs and 17 million United States dollars (US$) in health-care costs annually. Based on the adverse effects of TFA intake reported in prospective cohort studies, 1517 deaths, 5373 acute CHD events, 26 394 DALYs and US$ 87 million would be averted annually. CONCLUSION: Even under the most conservative scenario, reduction of TFA intake had a substantial effect on public health. These findings will help inform decision-makers in Argentina and other countries on the potential public health and economic impact of this policy.
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Doença das Coronárias/economia , Doença das Coronárias/epidemiologia , Efeitos Psicossociais da Doença , Gorduras na Dieta/efeitos adversos , Indústria Alimentícia , Ácidos Graxos trans/efeitos adversos , Ácidos Graxos trans/provisão & distribuição , Argentina/epidemiologia , Doença das Coronárias/induzido quimicamente , Doença das Coronárias/mortalidade , Feminino , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Fatores de RiscoRESUMO
OBJECTIVES: Differential pricing, based on countries' purchasing power, is recommended by the World Health Organization to secure affordable medicines. However, in developing countries innovative drugs often have similar or even higher prices than in high-income countries. We evaluated the potential implications of trastuzumab global pricing policies in terms of cost-effectiveness (CE), coverage, and accessibility for patients with breast cancer in Latin America (LA). METHODS: A Markov model was designed to estimate life-years (LYs), quality-adjusted life-years (QALYs), and costs from a healthcare perspective. To better fit local cancer prognosis, a base case scenario using transition probabilities from clinical trials was complemented with two alternative scenarios with transition probabilities adjusted to reflect breast cancer epidemiology in each country. RESULTS: Incremental discounted benefits ranged from 0.87 to 1.00 LY and 0.51 to 0.60 QALY and incremental CE ratios from USD 42,104 to USD 110,283 per QALY (2012 U.S. dollars), equivalent to 3.6 gross domestic product per capita (GDPPC) per QALY in Uruguay and to 35.5 GDPPC in Bolivia. Probabilistic sensitivity analysis showed 0 percent probability that trastuzumab is CE if the willingness-to-pay threshold is one GDPPC per QALY, and remained so at three GDPPC threshold except for Chile and Uruguay (4.3 percent and 26.6 percent, respectively). Trastuzumab price would need to decrease between 69.6 percent to 94.9 percent to became CE in LA. CONCLUSIONS: Although CE in other settings, trastuzumab was not CE in LA. The use of health technology assessment to prioritize resource allocation and support price negotiations is critical to making innovative drugs available and affordable in developing countries.
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Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Custos e Análise de Custo , Trastuzumab/economia , Trastuzumab/uso terapêutico , Antineoplásicos/efeitos adversos , Análise Custo-Benefício , Países em Desenvolvimento , Humanos , América Latina , Cadeias de Markov , Modelos Econométricos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Trastuzumab/efeitos adversosRESUMO
Aim: To evaluate the cost-effectiveness of seven screening strategies for chronic hepatitis B (CHB) patients in China. Methods: A discrete event simulation model combining a decision tree and Markov structure was developed to simulate a CHB cohort aged ≥40 years on a lifetime horizon and evaluate the costs and health outcomes (quality-adjusted life years [QALYs] gained) of ultrasonography (US), alpha-fetoprotein (AFP), protein induced by vitamin K absence-II (PIVKA-II), AFP+US, AFP+PIVKA-II, GAAD (a diagnostic algorithm based on gender and age combined with results of AFP and PIVKA-II) and GAAD+US. Epidemiologic, clinical performance, utility and cost data were obtained from the literature, expert interviews and real-world data. Uncertainties on key parameters were explored through deterministic and probabilistic sensitivity analyses (DSA and PSA). Results: Compared with other strategies, GAAD+US detected the most HCC patients at early stage, and GAAD was the screening strategy with the lowest average cost per HCC case diagnosed. Using 3× China's 2022 GDP per capita ($38,233.34) as the threshold, the three strategies of US, GAAD and GAAD+US formed a cost-effectiveness frontier. Screening with US, GAAD, or GAAD+US was associated with costs of $6110.46, $7622.05 and $8636.32, and QALYs of 13.18, 13.48 and 13.52, respectively. The ICER of GAAD over US was $4993.39/QALY and the ICER of GAAD+US over GAAD was $26,691.45/QALY, which was less than 3× GDP per capita. Both DSA and PSA proved the stability of the results. Conclusion: GAAD+US was the most cost-effective strategy for early HCC diagnosis among CHB patients which could be considered as the liver cancer screening scheme for the high-risk population in China.
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Carcinoma Hepatocelular , Hepatite B Crônica , Neoplasias Hepáticas , Masculino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Carcinoma Hepatocelular/diagnóstico , Hepatite B Crônica/complicações , Hepatite B Crônica/diagnóstico , alfa-Fetoproteínas/metabolismo , Análise de Custo-Efetividade , Antígeno Prostático Específico , Análise Custo-Benefício , China , Anos de Vida Ajustados por Qualidade de Vida , Vitamina KRESUMO
OBJECTIVES: Preeclampsia (PE) is a hypertensive disorder of pregnancy that can cause severe complications and adverse fetal/maternal outcomes. We aimed to estimate the annual economic impact of incorporating Elecsys® sFlt-1/PlGF PE ratio, which measures soluble fms-like tyrosine kinase-1 and placental growth factor, into routine clinical practice in Argentina to aid diagnosis of PE and hemolysis, elevated liver enzymes, and low platelets syndrome from second trimester onward in pregnancies with clinical suspicion of PE. METHODS: A decision tree was used to estimate annual economic impact on the Argentine health system as a whole, including relevant costs associated with diagnosis, follow-up, and treatment from initial presentation of clinically suspected PE to delivery. Annual costs of a standard-of-care scenario and a scenario including PE ratio (reference year 2021) were analyzed. RESULTS: The economic model estimated that using the sFlt-1/PlGF ratio would enable the overall health system to save â¼$6987 million Argentine pesos annually (95% confidence interval $12 045-$2952 million), a 39.1% reduction in costs versus standard of care, mainly due to reduced hospitalizations of women with suspected PE. The economic impact calculation estimated net annual savings of approximately $80 504 Argentine pesos per patient with suspected PE. Based on the assumed uncertainty of the parameters, the likelihood the intervention would be cost saving was 100% for the considered scenarios. CONCLUSION: Our analysis suggests that the implementation of the sFlt-1/PlGF ratio in women with suspected PE in Argentina will enable the health system to achieve significant savings, contributing to more efficient clinical management through the likely reduction of unnecessary hospitalizations, depending on assumptions. Results rest on the payers' ability to recover savings generated by the intervention.
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Pré-Eclâmpsia , Feminino , Humanos , Gravidez , Argentina , Biomarcadores , Seguimentos , Fator de Crescimento Placentário , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/metabolismo , GestantesRESUMO
BACKGROUND /OBJECTIVE: Acute kidney injury (AKI) is a significant complication in critical care units (CCU). Non-neurological complications such as AKI are an independent predictor of poor clinical outcomes, with an increase in morbidity and mortality, financial costs, and worse functional recovery. This work aims to estimate the incidence of AKI and evaluate the risk factors and complications of AKI in neurocritical patients hospitalized in the CCU. METHODS: A retrospective cohort study was conducted. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed in regard to the incidence, risk factors, and outcomes of AKI. RESULTS: The study population comprised 213 neurocritical patients. The incidence of AKI was 23.5%, with 58% KDIGO 1 and 2% requiring renal replacement therapy. AKI was an independent predictor of prolonged use of mechanical ventilation, cerebral edema, and mortality. Cerebral edema [OR 4.40 (95% CI 1.98-9.75) p < 0.001] and a change in chloride levels greater than 4 mmol/L at 48 h (OR 2.44 (95% CI 1.10-5.37) p = 0.027) were risk factors for developing AKI in the first 14 days of hospitalization. CONCLUSION: There is a high incidence of AKI in neurocritical patients; it is associated with worse clinical outcomes regardless of the CCU admission etiology or AKI severity.
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Injúria Renal Aguda , Edema Encefálico , Humanos , Estudos Retrospectivos , Edema Encefálico/complicações , Unidades de Terapia Intensiva , Incidência , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/terapia , Fatores de Risco , Mortalidade HospitalarRESUMO
In Belgium, antibiotic resistance leads to approximately 530 deaths with a 24 million financial burden annually. This study estimated the impact of procalcitonin-guided antibiotic stewardship programs to reduce antibiotic consumption versus standard of care in patients with suspected sepsis. A decision analytic tree modelled health and budget outcomes of procalcitonin-guided antibiotic stewardship programs for patients admitted to the intensive care unit (ICU). A literature search, a survey with local clinical experts, and national database searches were conducted to obtain model input parameters. The main outcomes were total budget impact per patient, reduction in number of antibiotic resistance cases, and cost per antibiotic day avoided. To evaluate the impact of parameter uncertainty on the source data, a deterministic sensitivity analysis was performed. A scenario analysis was conducted to investigate budget impact when including parameters for reduction in length of ICU stay and mechanical ventilation duration, in addition to base-case parameters. Based on model predictions, procalcitonin-guided antibiotic stewardship programs could reduce the number of antibiotic days by 66,868, resulting in 1.98 million savings towards antibiotic treatment in current clinical practice. Antibiotic resistance cases could decrease by 7.7% (6.1% vs 9.2%) in the procalcitonin-guided setting compared with standard of care. The base-case budget impact suggests an investment of 1.90 per patient. The sensitivity analysis showed uncertainty, as the main drivers can alter potential cost savings. The scenario analysis indicated a saving of 1,405 per patient, with a reduction of 1.5 days in the ICU (14.8 days vs 12.8 days), and a reduction of 22.7% (18.1-27.2%) in mechanical ventilation duration. The associated sensitivity analysis was shown to be robust in all parameters. Procalcitonin-guided antibiotic stewardship programs are associated with clinical benefits that positively influence antimicrobial resistance in Belgium. A small investment per patient to implement procalcitonin testing may lead to considerable cost savings.
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Gestão de Antimicrobianos , Sepse , Humanos , Pró-Calcitonina/uso terapêutico , Bélgica , Padrão de Cuidado , Biomarcadores , Sepse/tratamento farmacológico , Unidades de Terapia Intensiva , Antibacterianos/uso terapêuticoRESUMO
BACKGROUND: Worldwide, 1 % of the population receives anticoagulation therapy, with prevalence higher in older adults. Difficulties in the adequate management of these patients have led to the development of strategies focused on achieving therapeutic control and reducing adverse events with efficient use of resources. OBJECTIVE: To estimate the cost utility and budget impact on the Argentinean health system of implementation of anticoagulation clinics (ACs) (with and without use of point-of-care [POC] CoaguChek® devices [Roche Diagnostics International Ltd]) compared with the traditional laboratory method (non-AC settings) for the management of anticoagulated patients. METHODS: For the cost-utility analysis, a cohort-based state transition model was designed to compare costs and health outcomes of implementing ACs for outpatient management of anticoagulated patients. The budget impact analysis used an analytical model to estimate the differential costs of implementing an AC and the expected adverse events avoided, and the differential costs of an international normalized ratio (INR) determination using a POC device rather than a conventional laboratory. RESULTS: We calculated the study outcomes for a cohort of 1000 patients. Considering a 5 % discount rate, the use of ACs generated 13.9 additional quality-adjusted life-years (0.014 per patient) and 12.5 additional life-years (0.013 per patient). Incremental cost-effectiveness ratios of AC implementation with and without the use of POC devices compared with the scenario without ACs were dominant in both cases. In the probabilistic sensitivity analysis, nearly all simulated results were cost effective (i.e., below the 1 or 3 gross domestic product per capita thresholds). Budget impact analysis results showed AC implementation generated savings from the first year of implementation, with savings of AR $265,325 by year 5. The addition of POC devices in the ACs also generated savings as early as the first year of implementation, with savings of AR $488,072 by year 5 (AR $488 per patient). CONCLUSIONS: Anticoagulation clinics are estimated to be cost effective and generate notable savings in the treatment of patients on long-term oral anticoagulant therapy when compared with non-AC settings. These savings are considerably higher when POC devices are added as part of the patient management, due to lower laboratory technician costs per INR determination.
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BACKGROUND: Prone positioning is currently applied in time-limited daily sessions up to 24 h which determines that most patients require several sessions. Although longer prone sessions have been reported, there is scarce evidence about the feasibility and safety of such approach. We analyzed feasibility and safety of a continuous prolonged prone positioning strategy implemented nationwide, in a large cohort of COVID-19 patients in Chile. METHODS: Retrospective cohort study of mechanically ventilated COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS), conducted in 15 Intensive Care Units, which adhered to a national protocol of continuous prone sessions ≥ 48 h and until PaO2:FiO2 increased above 200 mm Hg. The number and extension of prone sessions were registered, along with relevant physiologic data and adverse events related to prone positioning. The cohort was stratified according to the first prone session duration: Group A, 2-3 days; Group B, 4-5 days; and Group C, > 5 days. Multivariable regression analyses were performed to assess whether the duration of prone sessions could impact safety. RESULTS: We included 417 patients who required a first prone session of 4 (3-5) days, of whom 318 (76.3%) received only one session. During the first prone session the main adverse event was grade 1-2 pressure sores in 97 (23.9%) patients; severe adverse events were infrequent with 17 non-scheduled extubations (4.2%). 90-day mortality was 36.2%. Ninety-eight patients (24%) were classified as group C; they exhibited a more severe ARDS at baseline, as reflected by lower PaO2:FiO2 ratio and higher ventilatory ratio, and had a higher rate of pressure sores (44%) and higher 90-day mortality (48%). However, after adjustment for severity and several relevant confounders, prone session duration was not associated with mortality or pressure sores. CONCLUSIONS: Nationwide implementation of a continuous prolonged prone positioning strategy for COVID-19 ARDS patients was feasible. Minor pressure sores were frequent but within the ranges previously described, while severe adverse events were infrequent. The duration of prone session did not have an adverse effect on safety.
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BACKGROUND: Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS: A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS: The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS: Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.
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Anti-Infecciosos/uso terapêutico , Gestão de Antimicrobianos/economia , Análise Custo-Benefício , Pró-Calcitonina/uso terapêutico , Infecções Respiratórias/tratamento farmacológico , Sepse/tratamento farmacológico , Argentina/epidemiologia , Clostridioides difficile/isolamento & purificação , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/microbiologia , Sepse/epidemiologiaRESUMO
OBJECTIVES: Cervical cancer (ICC) is the fourth leading cause of mortality in women in Argentina and primary screening with conventional cytology (Papanicolaou smear) is the most widely used strategy despite its limitations. Strategies based on human papillomavirus (HPV) testing have the potential to improve detection and reduce mortality. The objective of this study is to evaluate the cost-effectiveness and budgetary impact of a strategy based on HPV testing with genotyping. METHODS: We used a decision model to compare the ICC screening strategies. The population consisted of 30- to 65-year-old females suitable for screening in Argentina. Inputs comprised epidemiologic, diagnostic performance, and costs data. The clinical impact was represented by the number of ICC detected and ICC-related mortality. Incremental cost-effectiveness ratio, estimated in terms of Argentinean pesos per life-year gained, and the budgetary impact were calculated at 5, 10, and 20 years. Univariate and probabilistic sensitivity analyses were performed. RESULTS: Primary screening with HPV testing would prevent 1853 ICC deaths and reduce mortality by 13% at year 10 compared with Papanicolaou smear. With an incremental cost-effectiveness ratio of AR$329 042 in the base case, it would be cost-effective for a cost-effectiveness threshold of 1 gross domestic product per capita. It would imply an additional expense in the first 5 years and probably savings in the subsequent ones. Sensitivity analyses confirm the robustness of the findings. CONCLUSIONS: The primary screening strategy based on HPV testing with genotyping compared with conventional cytology is most likely a cost-effective strategy in Argentina.
Assuntos
Alphapapillomavirus , Papillomaviridae , Adulto , Idoso , Argentina , Análise Custo-Benefício , Feminino , Genótipo , Humanos , Pessoa de Meia-Idade , Papillomaviridae/genéticaRESUMO
BACKGROUND: Acute kidney injury (AKI) is a public health problem that affects millions of hospitalized patients worldwide. In Argentina, evidence suggests that its incidence has risen in recent years. When severe, AKI may require a renal replacement therapy (RRT) where continuous RRT (CRRT) and intermittent RRT (IRRT) are plausible options for patients in the intensive care unit. OBJECTIVE: To evaluate the cost utility of CRRT versus IRRT for the National Institute of Social Services for Retirees and Pensioners, the largest social security health insurance for elders in Argentina. METHODS: This was a model-based cost-utility analysis. Long-term costs and health outcomes were estimated for a hypothetical cohort with a Markov model. Parameters used were obtained from published literature and validated with local experts. Local costs were estimated and expressed in $AR of 2016. Several sensitivity analyses were run to analyze the impact of uncertainty on results. RESULTS: Continuous RRT dominated IRRT by cumulating over the model more quality-adjusted life years and less costs. Total discounted quality-adjusted life years for both cohorts were 1049 and 1034, respectively, and total costs were $95 362 and $103 871. Cost-effectiveness (CE) results reflect these differences in favor of CRRT with a deterministic cost-saving incremental CE ratio and a probability of CRRT being CE of 65.4%, considering a CE threshold of 1 gross domestic product per capita. CONCLUSIONS: Continuous RRT for patients with AKI eligible for CRRT or IRRT would probably be a cost-effective intervention for the National Institute of Social Services for Retirees and Pensioners' view. Nevertheless, there is considerable uncertainty around results, mainly due to the lack of adequate controlled studies and local data on the prognosis of these patients in Argentina.
Assuntos
Injúria Renal Aguda/economia , Terapia de Substituição Renal Contínua/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Terapia de Substituição Renal Intermitente/economia , Serviço Social/economia , Injúria Renal Aguda/terapia , Idoso , Argentina , Redução de Custos/economia , Redução de Custos/métodos , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Cadeias de Markov , Anos de Vida Ajustados por Qualidade de Vida , Serviço Social/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Protease inhibitor monotherapy is a simplified treatment strategy for virally suppressed HIV-positive patients that has the potential for cost savings, as fewer drugs are used than with combination therapy. However, evidence for its economic value is limited. OBJECTIVES: We assessed the cost-effectiveness of lopinavir/ritonavir monotherapy followed by treatment intensification in case of viral load rebound versus combination antiretroviral therapy (cART) with efavirenz/emtricitabine/tenofovir in HIV-1 infected patients with viral suppression in the ANRS 140 DREAM trial. METHODS: DREAM was conducted in 36 French Hospitals between 2009 and 2013. For each treatment strategy, we estimated the unadjusted and multivariate-adjusted mean costs (in , year 2010 values) and quality-adjusted life-years (QALYs) per patient, as well as incremental costs and QALYs per patient. We then assessed uncertainty using the cost-effectiveness acceptability curve, scenario analyses and cost-effectiveness price-threshold (CEPT) analysis. RESULTS: In the base-case analysis considering 2009-2013 antiretroviral drug (ARV) prices, adjusted incremental costs and QALYs were - 3296 (95% confidence interval [CI] - 5202 to - 1391) and 0.006 (95% CI - 0.021 to 0.033), respectively, over 2 years, suggesting that monotherapy was cost-effective with a probability of 100% at various cost-effectiveness thresholds. In scenario analyses considering 2018 ARV prices, monotherapy remained cost-effective but with a lower probability (94% vs. 100% in the base-case analysis). The current price of cART would have to decrease by 34% to be cost-effective with a probability of 95%. CONCLUSION: Monotherapy appears to be cost-effective compared with cART for virologically suppressed HIV-positive patients in France. CEPT analysis is a useful tool to identify the preferred strategy to adopt given that ARV prices change rapidly. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00946595.