Author
Brita Pekarsky
Other affiliations: Flinders University, Baker IDI Heart and Diabetes Institute, The Heart Research Institute ...read more
Bio: Brita Pekarsky is an academic researcher from University of South Australia. The author has contributed to research in topics: Health care & Shadow price. The author has an hindex of 14, co-authored 41 publications receiving 458 citations. Previous affiliations of Brita Pekarsky include Flinders University & Baker IDI Heart and Diabetes Institute.
Topics: Health care, Shadow price, Population, Cost effectiveness, Public health
Papers
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TL;DR: Routine screening of colorectal cancers by mismatch repair IHC identifies individuals at low risk of relapse, and can prevent unnecessary adjuvant treatments in a significant number of individuals.
Abstract: This study prospectively examines the accuracy of immunohistochemical staining in the identification of mismatch repair defective (MMRD) colorectal cancer in routine clinical practice. The potential impact of this information on decisions regarding adjuvant treatment and germline testing were quantified. A consecutive series of fresh tissue (836 cancers) was obtained from 786 individuals undergoing curative surgery for colorectal cancer at one institution. As part of normal practice, each tumour was screened for the expression of MLH1 and MSH2 by immunohistochemical staining (IHC) and relevant clinicopathological details were documented. Microsatellite instability (MSI) was assessed using standard markers. Overall, 108 (13%) tumours showed loss of staining for either MLH1 (92 tumours) or MSH2 (16 tumours). The positive predictive value of mismatch repair IHC when used alone in the detection of MSI tumours was 88%, and the negative predictive value was 97%. Specificity and positive predictive value were improved by correlation with microsatellite status. Tumour stage (HR 3.5, 95% CI 2.0-6.0), vascular space invasion (HR 1.9, 95% CI 1.2-3.0) and mismatch repair deficiency (HR 0.2, 95% CI 0.05-0.87) were independent prognostic factors in stages II and III disease. Screening by mismatch repair IHC could reasonably have been expected to prevent ineffective treatment in 3.6% of stage II and 7.6% of stage III patients. The frequency of germline mismatch repair mutations was 0.8%, representing six unsuspected hereditary non-polyposis colorectal cancer (HNPCC) cases. Routine screening of colorectal cancers by mismatch repair IHC identifies individuals at low risk of relapse, and can prevent unnecessary adjuvant treatments in a significant number of individuals. Abnormal immunohistochemistry should be confirmed by microsatellite testing to ensure that false-positive results do not adversely impact on treatment decisions.
54 citations
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TL;DR: This work critically examines the conditions under which displaced services would represent an economically meaningful threshold value for the effects of a new technology as part of a reimbursement process when budgets are fixed and identifies the most cost-effective alternative strategy for reimbursement.
Abstract: In current literature, displaced services have been suggested to provide a basis for determining a threshold value for the effects of a new technology as part of a reimbursement process when budgets are fixed. We critically examine the conditions under which displaced services would represent an economically meaningful threshold value. We first show that if we assume that the least cost-effective services are displaced to finance a new technology, then the incremental cost-effectiveness ratio (ICER) of the displaced services (d) only coincides with that related to the opportunity cost of adopting that new technology, the ICER of the most cost-effective service in expansion (n), under highly restrictive conditions—namely, complete allocative efficiency in existing provision of health care interventions. More generally, reimbursement of new technology with a fixed budget comprises two actions; adoption and financing through displacement and the effect of reimbursement is the net effect of these two actions. In order for the reimbursement process to be a pathway to allocative efficiency within a fixed budget, the net effect of the strategy of reimbursement is compared with the most cost-effective alternative strategy for reimbursement: optimal reallocation, the health gain maximizing expansion of existing services financed by the health loss minimizing contraction. The shadow price of the health effects of a new technology, \( \beta_{c} = \left( {\frac{1}{n} + \frac{1}{d} - \frac{1}{m}} \right)^{ - 1} , \) accounts for both imperfect displacement (the ICER of the displaced service, d < m, the ICER of the least cost-effective of the existing services in contraction) and the allocative inefficiency (n < m) characteristic of health systems.
46 citations
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TL;DR: To the extent that the AUSFTA medicines provisions may represent animportant precedent in a global strategy by industry on cost-effectiveness evaluation of pharmaceuticals, the study will be of great interest to policy makers in other jurisdictions.
Abstract: On 1 January 2005, a controversial trade agreement entered into force between Australia and the United States. Though heralded by the parties as facilitating the removal of barriers to free trade (in ways not achievable in multilateral fora), it also contained many trade-restricting intellectual property provisions and others uniquely related to altering pharmaceutical regulation and public health policy in Australia. The latter appear to have particularly focused on the world-respected process of federal government reimbursement after expert cost-effectiveness evaluation, popularly known as the Pharmaceutical Benefits Scheme ('PBS'). It remains uncertain what sort of impacts – if any – the Australia-United States Free Trade Agreement ('AUSFTA') will have on PBS processes such as reference pricing and their important role in facilitating equitable and affordable access to essential medicines. This is now the field of inquiry for a major three year Australian Research Council ('ARC')-funded study bringing together a team of senior researchers in regulatory theory from the Australian National University and pharmacoeconomics from the University of Newcastle. The project proposes to monitor, assess and analyse the real and potential impacts of the AUSFTA in this area, providing Australian policy-makers with continuing expertise and options. To the extent that the AUSFTA medicines provisions may represent an important precedent in a global strategy by industry on cost-effectiveness evaluation of pharmaceuticals, the study will also be of great interest to policy makers in other jurisdictions.
32 citations
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TL;DR: Ticagrelor is likely to be cost-effective even for individuals not carrying a CYP2C19 LoF allele, and the incremental cost-effectiveness compared with the genotyping strategy was generally within what is considered acceptable.
Abstract: Aims: This study aims to assess the cost–effectiveness in Australia of screening CYP2C19 loss-of-function (LoF) alleles to guide selection of clopidogrel or ticagrelor for individuals with acute coronary syndrome who are likely to undergo coronary stenting Methods: Three treatment strategies were compared: universal clopidogrel therapy, universal ticagrelor therapy and genotyping CYP2C19 with use of ticagrelor for individuals with a LoF allele and clopidogrel for individuals without a LoF allele Lifetime costs and quality-adjusted life years for each treatment strategy were estimated using a Markov model The risks of events were primarily derived from the genetic substudy of the pivotal randomized controlled trial Results: CYP2C19 genotyping resulted in greater effectiveness and was cost-effective when compared with universal use of clopidogrel However, universal use of ticagrelor was the most effective strategy overall and the incremental cost–effectiveness compared with the genotyping strategy was
29 citations
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TL;DR: The AUSFTA medicines provisions may represent animportant precedent in a global strategy by industry on cost-effectiveness evaluation of pharmaceuticals, the study will also beof great interest to policy makers in other jurisdictions as mentioned in this paper.
Abstract: On 1 January 2005, a controversial trade agreement entered into force between Australia and the United States. Though heralded by the parties as facilitating the removal of barriers to free trade (in ways not achievable in multilateral fora), it also contained many trade-restricting intellectual property provisions and others uniquely related to altering pharmaceutical regulation and public health policy in Australia. The latter appear to have particularly focused on the world-respected process of federal government reimbursement after expert cost-effectiveness evaluation, popularly known as the Pharmaceutical Benefits Scheme ('PBS'). It remains uncertain what sort of impacts – if any – the Australia-United States Free Trade Agreement ('AUSFTA') will have on PBS processes such as reference pricing and their important role in facilitating equitable and affordable access to essential medicines. This is now the field of inquiry for a major three year Australian Research Council ('ARC')-funded study bringing together a team of senior researchers in regulatory theory from the Australian National University and pharmacoeconomics from the University of Newcastle. The project proposes to monitor, assess and analyse the real and potential impacts of the AUSFTA in this area, providing Australian policy-makers with continuing expertise and options. To the extent that the AUSFTA medicines provisions may represent animportant precedent in a global strategy by industry oncost-effectiveness evaluation of pharmaceuticals, the study will also beof great interest to policy makers in other jurisdictions.
29 citations
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844 citations
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TL;DR: The usefulness of defective mismatch repair, BRAF, and KRAS mutations in predicting tumor recurrence and sensitivity to chemotherapy is investigated and MMR assays identify patients with a low risk of recurrence.
Abstract: Purpose It is uncertain whether modest benefits from adjuvant chemotherapy in stage II colorectal cancer justify the toxicity, cost, and inconvenience. We investigated the usefulness of defective mismatch repair (dMMR), BRAF, and KRAS mutations in predicting tumor recurrence and sensitivity to chemotherapy. Patients and Methods Immunohistochemistry for dMMR and pyrosequencing for KRAS/BRAF were performed for 1,913 patients randomly assigned between fluorouracil and folinic acid chemotherapy and no chemotherapy in the Quick and Simple and Reliable (QUASAR) trial. Results Twenty-six percent of 695 right-sided colon, 3% of 685 left-sided colon, and 1% of 407 rectal tumors were dMMR. Similarly, 17% of right colon, 2% of left colon, and 2% of rectal tumors were BRAF mutant. KRAS mutant tumors were more evenly distributed: 40% right colon, 28% left colon, and 36% rectal tumors. Recurrence rate for dMMR tumors was half that for MMR-proficient tumors (11% [25 of 218] v 26% [438 of 1,695] recurred; risk ratio [RR]...
594 citations
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TL;DR: This study confirmed the association between MSI and favourable prognosis as determined by both OS and DFS of CRC patients and proposed that this inconclusive result is due to the use of a single marker, such as MSI, that cannot account alone for the complexity of the mechanisms underlying 5-FU cytotoxicity.
331 citations
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01 Oct 2011
TL;DR: Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs, and additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment.
Abstract: Summary Background The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension. Methods We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies—further blood pressure measurement in the clinic, at home, and with an ambulatory monitor—in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness. Findings Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from −£56 [95% CI −105 to −10] in men aged 75 years to −£323 [−389 to −222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive. Interpretation Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs. Funding National Institute for Health Research and the National Institute for Health and Clinical Excellence.
309 citations
01 Jan 2015
TL;DR: This report gives the latest information on how Aboriginal and Torres Strait Islander people in the Northern Territory are faring according to a range of measures of health status and outcomes, determinants of health and health system performance.
Abstract: 'This report gives the latest information on how Aboriginal and Torres Strait Islander people in the Northern Territory are faring according to a range of measures of health status and outcomes, determinants of health and health system performance. Indicators are based on the Aboriginal and Torres Strait Islander Health Performance Framework. The report highlights the main areas of improvement and continuing concern.' - Back cover
260 citations