RESUMO
BACKGROUND: The aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used. METHODS: The impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost-effectiveness ratio of 30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness. RESULTS: Routine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation. CONCLUSIONS: Routine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Análise Custo-Benefício/economia , Ecocardiografia Transesofagiana/economia , Cuidados Intraoperatórios/economia , Cuidados Intraoperatórios/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Simulação por Computador , Análise Custo-Benefício/estatística & dados numéricos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
PurposePopulation-based carrier screening for fragile X syndrome (FXS) is still not universally endorsed by professional organizations due to concerns around genetic counseling for complex information and potential for psychosocial harms.MethodsWe determined uptake levels, decision making, and psychosocial impact in a prospective study of pregnant and nonpregnant Australian women offered FXS carrier screening in clinical settings. Women received pretest genetic counseling, and completed questionnaires when deciding and one month later.ResultsOf 1,156 women recruited, 83.1% returned the first questionnaire with 70.6% nonpregnant and 58.8% pregnant women choosing testing (χ2=16.98, P<0.001). Overall, informed choice was high in both nonpregnant (77.4%) and pregnant (72.9%) women (χ2=0.21, P=0.644), and more tested (76.0%) than not-tested (66.7%) women (χ2=6.35, P=0.012) made an informed choice. Measures of depression, stress, and anxiety were similar to population norms for ~85% of women. Decisional conflict and regret were generally low; however, decisional uncertainty and regret were greater in pregnant than nonpregnant women, and not-tested than tested women (uncertainty: χ2=18.51, P<0.001 and χ2=43.11, P<0.001, respectively; regret: χ2=6.61, P<0.037 and χ2=35.54, P<0.001, respectively).ConclusionWe provide evidence to inform guidelines that population FXS carrier screening can be implemented with minimal psychosocial harms following appropriate information and prescreening genetic counseling.
Assuntos
Tomada de Decisões , Síndrome do Cromossomo X Frágil/epidemiologia , Heterozigoto , Adolescente , Adulto , Idoso , Comportamento de Escolha , Feminino , Síndrome do Cromossomo X Frágil/diagnóstico , Síndrome do Cromossomo X Frágil/genética , Síndrome do Cromossomo X Frágil/psicologia , Testes Genéticos , Humanos , Programas de Rastreamento , Pessoa de Meia-Idade , Vigilância da População , Gravidez , Psicologia , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Prostate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While surgery remains the most commonly received treatment for localised disease in Australia more recently a robotic approach has emerged as an alternative to open and laparoscopic surgery. However, high level data is not yet available to support this as a superior approach or to guide treatment decision making between the alternatives. This paper presents the design of a randomised trial of Robotic and Open Prostatectomy for men newly diagnosed with localised prostate cancer that seeks to answer this question. METHODS/DESIGN: 200 men per treatment arm (400 men in total) are being recruited after diagnosis and before treatment through a major public hospital outpatient clinic and randomised to 1) Robotic Prostatectomy or 2) Open Prostatectomy. All robotic prostatectomies are being performed by one surgeon and all open prostatectomies are being performed by one other surgeon. Outcomes are being measured pre-operatively and at 6 weeks and 3, 6, 12 and 24 months post-surgery. Oncological outcomes are being related to positive surgical margins, biochemical recurrence +/- the need for further treatment. Non-oncological outcome measures include: pain, physical and mental functioning, fatigue, summary (preference-based utility scores) and domain-specific QoL (urinary incontinence, bowel function and erectile function), cancer specific distress, psychological distress, decision-related distress and time to return to usual activities. Cost modelling of each approach, as well as full economic appraisal, is also being undertaken. DISCUSSION: The study will provide recommendations about the relative benefits of Robotic and Open Prostatectomy to support informed patient decision making about treatment for localised prostate cancer; and to assist in treatment services planning for this patient group. TRIAL REGISTRATION: ACTRN12611000661976.
Assuntos
Próstata/cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Robótica/métodos , Adulto , Idoso , Austrália , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Próstata/patologia , Qualidade de Vida , Inquéritos e Questionários , Resultado do TratamentoAssuntos
Medicina Baseada em Evidências , Programas Nacionais de Saúde/economia , Avaliação da Tecnologia Biomédica , Austrália , Política de Saúde , Humanos , Avaliação da Tecnologia Biomédica/economia , Avaliação da Tecnologia Biomédica/métodos , Avaliação da Tecnologia Biomédica/organização & administraçãoRESUMO
A randomised trial of robotic and open prostatectomy commenced in October 2010 and is progressing well. Clinical and quality of life outcomes together with economic costs to individuals and the health service are being examined critically to compare outcomes.
Assuntos
Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Robótica , Humanos , Masculino , Estudos Prospectivos , Queensland , Relatório de PesquisaRESUMO
Cardiac magnetic resonance (CMR) imaging may allow more appropriate selection of patients for cardiac device implantation and/or cardiac surgery. In this prospective observational study we evaluated the impact of CMR imaging on cardiac device and surgical therapy. All CMR examinations performed in a single centre over a 2 year period were prospectively recorded in a dedicated database under 4 clinical pathways [cardiomyopathy, viability, tumour/mass and arrythmogenic right ventricular cardiomyopathy (ARVC)]. Baseline data entered included planned cardiac device implantation and/or cardiac surgical intervention. Patients were contacted 6 months following CMR to evaluate the impact of CMR on planned therapy. Cost savings due to CMR were calculated as the number of surgical or device procedures averted following CMR scanning multiplied by their respective cost weights. Of 732 CMR examinations performed, the clinical pathway was cardiomyopathy in 488 (67 %), ARVC in 118 (16 %), viability in 92 (12 %) and tumour/mass in 34 (5 %). Six month follow-up was available in 666/732 patients. Following CMR, 56/150 (37 %) of patients with an initial plan for device implantation or cardiac surgery, did not undergo the planned intervention (P < 0.001, one-sample exact binomial test). Of 516 patients without an initial device or surgical plan, 33 (6 %) CMR resulted in device implantation or cardiac surgery (P < 0.001, Chi squared). Overall, the estimated saving due to CMR-guided management changes was AUD$737,270. CMR has a significant impact on patient management and offers potential cost savings with respect to selection of device and surgical therapy for cardiac disease.
Assuntos
Estimulação Cardíaca Artificial , Procedimentos Cirúrgicos Cardíacos , Técnicas de Apoio para a Decisão , Cardioversão Elétrica , Cardiopatias/diagnóstico , Cardiopatias/terapia , Imagem Cinética por Ressonância Magnética , Seleção de Pacientes , Adulto , Idoso , Análise de Variância , Estimulação Cardíaca Artificial/economia , Procedimentos Cirúrgicos Cardíacos/economia , Distribuição de Qui-Quadrado , Análise Custo-Benefício , Desfibriladores Implantáveis , Cardioversão Elétrica/economia , Cardioversão Elétrica/instrumentação , Feminino , Custos de Cuidados de Saúde , Cardiopatias/economia , Cardiopatias/cirurgia , Humanos , Imagem Cinética por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial , Valor Preditivo dos Testes , Estudos Prospectivos , Adulto JovemRESUMO
OBJECTIVE: To estimate Pharmaceutical Benefits Scheme (PBS) subsidies for drugs to treat smoking-related cardiovascular disease (CVD) in 2001-02, and over the period of the government's Intergenerational Report (IGR), assuming current smoking prevalence rates and a 5% absolute reduction. DESIGN AND SETTING: An Australian epidemiological study, using prescribing data, aetiological fraction methodology, and IGR trends. MAIN OUTCOME MEASURES: Estimated smoking-related PBS subsidy costs in 2001-02 and predicted cumulative subsidies until 2041-42, under current and reduced smoking prevalence assumptions. RESULTS: The PBS costs of smoking-related CVD in 2001-02 were $126 million, 9.77% of the cost of drugs for CVD and 2.96% of total PBS subsidies. The cumulative difference in these costs over the 40-year period with a 5% drop in smoking prevalence was predicted to be $4.5 billion, a 17% reduction. The saving would be $1.14 billion discounting future costs at 5% per year. CONCLUSIONS: Further investment in tobacco control interventions could curb the increasing cost of the PBS and contribute to government efforts to ensure the viability of Australia's healthcare-financing programs. The net present value of a campaign to reduce smoking prevalence was estimated at $1 billion, with an internal rate of return of 33%.