摘要:

The ideal study design for demonstrating the possible health outcomes and costs associated with a new drug would be a naturalistic prospective study. However, it is not often feasible to derive the required information from scientifically sound prospective studies. In these cases, decision analytic models may provide some of the missing information. However, the use of a Delphi panel to gather data for these models is a major concern because of potential bias and data accuracy. Because reimbursement of pharmaceuticals is often based on economic data derived from modelling studies, it is obvious that potential bias due to the use of Delphi panels should be minimised.In this manuscript we present an alternative data source for modelling studies: the cross-sectional study. Data from such studies can be used to yield costs and utilities for Markov health states. The overall combined design may be considered a hybrid between a naturalistic prospective study and a modelling study by maximising the pros and minimising the cons of both types of design, including an increase of external validity. This hybrid design is based on bridging the probabilities derived from the literature and clinical trials with information on costs and utilities from a cross-sectional study. This design also has logistical advantages, namely a shorter required study duration compared with prospective naturalistic studies for chronic diseases. This combined design was illustrated using a Markov model for Parkinson's disease.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Economic analysis has been extensively used to guide the use of ACE inhibitors in chronic heart failure. More recently, it has been used to guide the use of ACE inhibitors after myocardial infarction. The results of major clinical trials leave us in no doubt that ACE inhibitors are useful in the treatment of patients after myocardial infarction. The results of economic analysis unanimously indicate that ACE inhibitors are cost effective when used to treat patients after myocardial infarction. Any comparison of the different treatment strategies available suggests that all are comparably cost effective and argues for the widest possible use of ACE inhibitors in this setting. The evidence suggests that, in this context as in so many others, ACE inhibitors remain underutilised.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Clinical and economic factors that are important to consider when selecting anaesthesia for day-case surgery can differ from those for inpatient anaesthesia. Patients undergoing day-case surgery tend to be healthier and have shorter durations of surgery. They expect less anxiety before surgery, amnesia for the surgical experience, a rapid return to normal (normal mentation with minimal pain and nausea) after surgery, and lower expenses. However, the latter 2 expectations can conflict; older generic drugs have lower acquisition costs but often impose longer recovery times. Longer recovery periods can increase costs by prolonging the time to discharge from labour-intensive areas such as the operating suite or the postanaesthesia recovery unit.The challenge for today's anaesthetist is to use newer drugs judiciously to minimise their expense without compromising the rate or quality of recovery. Several approaches can secure these aims. Most apply the least anaesthetic needed. ‘Least anaesthetic’ may mean the particular form of anaesthetic (e.g. local infiltration with monitored anaesthesia care versus a general anaesthetic), or may mean the delivery of the smallest effective dose, perhaps guided by anaesthetic monitors such as end-tidal analysers or the bispectral index.For patients requiring general anaesthesia, a combination of several drugs usually secures the closest approach to the ideal. Drug combinations used usually include a short-acting preoperative anxiolytic (e.g. midazolam), intravenous propofol (a short-acting potent anxiolytic and amnestic agent) for induction of anaesthesia (and sometimes for maintenance) and primary maintenance of anaesthesia with inhaled nitrous oxide combined with a poorly soluble (low solubility produces rapid recovery; the least soluble is desflurane) potent inhaled anaesthetic delivered at a low inflow rate (to minimise cost). Although old, nitrous oxide is inexpensive and has favourable pharmacokinetic and cardiovascular advantages; however, it is limited in its anaesthetic/amnestic potency, and has the capacity to increase nausea.In children, induction of anaesthesia is often accomplished with sevoflurane rather than desflurane; although sevoflurane is modestly more soluble than desflurane, it is nonpungent whereas desflurane is pungent. Moderate- or short-acting opioids (fentanyl is popular) or nonsteroidal anti-inflammatory agents (especially ketorolac), or local anaesthetics are added to secure analgesia during and after surgery. Similarly, when needed, moderate- or short-acting muscle relaxants are selected. Before the end of anaesthesia, an intravenous antiemetic may be given. With this drug combination, patients usually awaken within minutes after anaesthesia and can often move themselves to the vehicle for transport to the recovery unit. These combinations of anaesthetics and techniques minimise use of expensive drugs while expediting recovery (again minimising cost) with minimal or no compromise in the quality of recovery.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveTo evaluate the relationship between how much a new cardiovascular therapy improves clinical outcomes over current therapies and how much more it can cost while still remaining ‘economically attractive’.DesignWe developed a decision model to predict the 6-month cumulative cost savings and increased life expectancy that could be associated with new therapies for patients with non-ST elevation acute coronary syndrome.SettingThis modelling study used outcome and cost data from US sources.MethodsEvent probabilities at 30 days and 6 months were estimated from US patients with non-ST elevation in the Global Use of Strategies To Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO) IIb trial; cost estimates were derived from patients enrolled in the Economics and Quality of Life substudy of this trial. Patient life expectancy estimates were calculated using survival estimates for similar patients treated at Duke University Medical Center.ResultsWe found that new therapies costing up to $US2000 per episode that reduce 6-month mortality by 0.5%, death and nonfatal myocardial infarction (MI) by 1%, or death, nonfatal MI and revascularisation by 3%, may be cost effective by current standards. When new therapies costing up to $US1000 per episode reduce the absolute rate of death, nonfatal MI and revascularisation at 6 months by 6.5% or more, they may be cost saving.ConclusionOur analysis suggests that economic constraints should not inhibit the development of effective new therapies.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

BackgroundUtility, a concept derived from economics, is the desirability or preference that individuals exhibit for a certain health state. Utility measurement could be viewed as an alternative means of appraising the quality of life of individuals affected by a chronic illness such as schizophrenia. Traditional techniques of utility measurement involve 2 steps: (i) identifying the different health states experienced by individuals during the course of an illness; and (ii) assigning them numerical values known as utilities.AimThe study examined the feasibility issues and psychometric aspects of obtaining accurate health state descriptions and their utilities from symptomatically stable patients with schizophrenia.MethodsThe study used a cross-sectional, case-controlled design, with a study group consisting of 120 clinically stabilised patients with schizophrenia and a control group of 32 treated and recovered patients with major depression. Patients were asked to provide detailed descriptions of 3 distinct health states associated with their illness: current state, worst state experienced since the onset of illness and a perfect state desired in the future. Further, patients were asked to assign utilities to these health states with the aid of a purpose-built evaluation protocol comprising Magnitude Estimation (ME), Rating Scale (RS), Standard Gamble (SG), Time Trade-Off (TTO) and Willingness-to-Pay (WTP) techniques. The battery was repeated after a 1-week interval. Independent raters assessed symptom severity, insight and quality of life, and nurse-clinicians involved in their care were asked to provide the utility ratings of their clients' mental health state. Patients' opinions about the acceptability of utility measurement techniques, and the respondent burden were also ascertained.ResultsCompared with control patients with treated depression, patients with schizophrenia were able to distinguish and describe the specified health states with an equal degree of ease and accuracy. RS, TTO and WTP techniques emerged as the favoured methods of utility evaluation. The test-retest reliability of utility ratings (r = 0.87 to 0.97; p < 0.001) was high, and concurrent validity with the quality of life measures was acceptable. Reliability and validity of patients' appraisals were unaffected by symptoms severity and insight. The accuracy of nurse-clinicians' appraisals were dependent on their close familiarity with the patients and their illness.ConclusionClinically stabilised patients with schizophrenia can provide accurate health state descriptions and assign them utilities with a fair degree of reliability and validity. Utility evaluations based on patients' self-appraisals can be seen as potential tools in outcome studies and clinical trials involving patients with schizophrenia, but the methodology requires further refinement to accommodate the limitations imposed by the patients' disturbed mental status.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveTo evaluate the economic implications for transplant centres, Medicare and society of treatment of corticosteroid-resistant Banff Grades I, II and III acute kidney transplant rejection with the antithymocyte globulins Thymoglobulin®or Atgam®.Design and settingThis was a cost analysis of a randomised double-blind multicentre clinical trial comparing the safety and efficacy of Thymoglobulin®and Atgam®that was performed at 25 centres in the US in 1994 to 1996.Patients and participantsThe study enrolled 163 patients, 82 in the Thymoglobulin®arm and 81 in the Atgam®arm.MethodsEstimates of the cost of care from the initiation of rejection therapy to 90 days post-therapy were derived from various publicly available sources and applied to patient-specific clinical events documented in the clinical trial. Patients received either intravenous Thymoglobulin®(1.5 mg/kg/day) for an average of 10 days or intravenous Atgam®(15 mg/kg/day) for an average of 9.7 days.ResultsOn average, Thymoglobulin®provided significant cost savings compared with Atgam®from the perspective of society [$US5977 (1996 values); 95% confidence interval (CI) $US3719 to $US8254], Medicare ($US4967; 95% CI $US3256 to $US6678) and the transplant centre ($US3087; 95% CI $US1512 to $US4667). The overall advantage attributable to Thymoglobulin®was primarily due to savings from fewer recurrent rejection treatments and less frequent return to dialysis.ConclusionsTreatment of acute renal transplant rejection with Thymoglobulin®is a cost saving strategy when compared with treatment with Atgam®.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveThis study considered the cost effectiveness of misoprostol prophylaxis for nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal damage, using data from the Misoprostol Ulcer Complications Outcomes Safety Assessment (MUCOSA) trial. The initial aim was to gain listing of misoprostol on the Australian National Formulary.DesignThe economic evaluation followed a 2-stage approach in considering the cost effectiveness of misoprostol, a ‘within-trial’ analysis followed by a simple modelled analysis which explored the implications of the trial results for life-years saved beyond the trial setting. The perspective of the evaluation is that of the healthcare system.SettingThree different populations were considered: the total trial population; patients with a history of peptic ulcer disease; and patients over 65 years of age.Study populationPatient data were taken from the MUCOSA trial, which involved 8843 patients receiving continuous NSAID therapy for the control of rheumatoid arthritis.InterventionsMisoprostol plus any NSAID therapy was compared with placebo (no misoprostol) plus any NSAID therapy.Main outcome measures and resultsThe study found the incremental cost per definite serious gastrointestinal complication avoided with misoprostol was 39 603 Australian dollars ($A) for the total trial population, $A5599 for patients with a history of peptic ulcer disease and $A35 405 for patients over 65 years of age. The incremental cost per life-year saved with misoprostol was $A41 866 for the whole group, $A6244 for patients with a history of peptic ulcer disease and $A40 322 for patients over 65 years of age.ConclusionsThe study found misoprostol to be cost effective in this setting.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectiveTo estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income.Design and settingUsing 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years.Main outcome measures and resultsPrevious measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars).ConclusionsEstimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.

ISSN:1170-7690    

出版商:ADIS    

年代:2000

数据来源: ADIS