OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

We gathered information on the cost-effectiveness of life-saving interventions in the United States from publicly available economic analyses. "Life-saving interventions" were defined as any behavioral and/or technological strategy that reduces the probability of premature death among a specified target population. We defined cost-effectiveness as the net resource costs of an intervention per year of life saved. To improve the comparability of cost-effectiveness ratios arrived at with diverse methods, we established fixed definitional goals and revised published estimates, when necessary and feasible, to meet these goals. The 587 interventions identified ranged from those that save more resources than they cost, to those costing more than 10 billion dollars per year of life saved. Overall, the median intervention costs $42,000 per life-year saved. The median medical intervention cost $19,000/life-year; injury reduction $48,000/life-year; and toxin control $2,800,000/life-year. Cost/life-year ratios and bibliographic references for more than 500 life-saving interventions are provided.

Five-hundred life-saving interventions and their cost-effectiveness.

We estimated the possible effects of the next influenza pandemic in the United States and analyzed the economic impact of vaccine-based interventions. Using death rates, hospitalization data, and outpatient visits, we estimated 89,000 to 207,000 deaths; 314,000 to 734,000 hospitalizations; 18 to 42 million outpatient visits; and 20 to 47 million additional illnesses. Patients at high risk (15% of the population) would account for approximately 84% of all deaths. The estimated economic impact would be US$71.3 to $166.5 billion, excluding disruptions to commerce and society. At $21 per vaccinee, we project a net savings to society if persons in all age groups are vaccinated. At $62 per vaccinee and at gross attack rates of 25%, we project net losses if persons not at high risk for complications are vaccinated. Vaccinating 60% of the population would generate the highest economic returns but may not be possible within the time required for vaccine effectiveness, especially if two doses of vaccine are required.

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The economic impact of pandemic influenza in the United States: priorities for intervention.

Cost-effectiveness analyses, particularly in the USA, commonly use a figure of $50,000 per life-year or quality-adjusted life-year gained as a threshold for assessing the cost-effectiveness of an intervention. The history of this practice is ill defined, although it has been linked to the end-stage renal disease kidney dialysis cost-effectiveness literature from the 1980s. The use of $50,000 as a benchmark for assessing the cost-effectiveness of an intervention first emerged in 1992 and became widely used after 1996. The appeal of the $50,000 figure appears to lie in the convenience of a round number rather than in the value of renal dialysis. Rather than arbitrary thresholds, estimates of willingness to pay and the opportunity cost of healthcare resources are needed.

Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.

BACKGROUND: The objective of the review was to evaluate the extent, quality and value of computer simulation modelling in population health and health care delivery.
METHODS: A narrative systematic review was carried out of world literature from 1980 to 1999, searching Medline, INSPEC, Embase, HealthSTAR, Science Citation Index, CINAHL, MathSci, INFORMS Online and SIGLE databases, and researchers in the field were contacted. Papers were included if they contained a computer simulation model of individuals in a stochastic system and the topic or setting related to population health or health service delivery.
RESULTS: A total of 182 papers met the inclusion criteria. Simulation modelling has been undertaken in a wide range of health care topic areas, including hospital scheduling and organization, communicable disease, screening, costs of illness and economic evaluation. However, the quality of published papers was variable and few reported on the outcomes of implementation of models, so that the value of modelling could not be assessed.
CONCLUSION: Simulation modelling is a powerful method for modelling both small and large populations to inform policy makers in the provision of health care. It has been applied to a wide variety of health care problems. Although the number of modelling papers has grown substantially over recent years, further research is required to assess the value of modelling.

Systematic review of the use and value of computer simulation modelling in population health and health care delivery

We examined the survival time and costs of therapy for patients with end-stage renal disease. A computer simulation model of the current system was constructed to estimate the cost-effecti...

Cost-Effective Care of End-Stage Renal Disease: A Billion Dollar Question

This paper provides an introduction to the Johnson translation system of probability distributions, and it describes methods for using the Johnson system to model input processes in simulation experiments. The fitting methods based on available data are incorporated into the public-domain software package FITTR1. To handle situations in which little or no data is available, we present a visual interactive method for subjective distribution fitting that has been implemented in the public-domain software package VISIFIT. We present several examples illustrating the use of FITTR1 and VISIFIT for simulation input modeling.

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Input modeling with the Johnson system of distributions

• In a search for a way to recognize the patients who are at higher risk of unexpected hospitalizations, the characteristics of patients with diabetes mellitus were examined after their last office visit prior to hospitalization. Six characteristics contributed significantly in distinguishing 256 patients who were subsequently hospitalized from 512 patients who were not. The six characteristics included the following: frequent emergency room visits, low serum albumin level, cardiomegaly, anemia, hypotension, and hyperglycemia. The sensitivity of prediction was 43.2%, specificity was 77.4%, and the relative risk by odds ratio was 2.60:1. The intensity of care, as estimated by the level of the provider, and the intended intensity of care, as measured by the scheduled return-visit interval, were not clinically consistent with the magnitude of risk. The characteristics of patients at higher risk of unexpected hospitalizations were identified and provide a direction for increased intensity of ambulatory care. ( Arch Intern Med 1983;143:41-47)

Unexpected hospital admissions among patients with diabetes mellitus.

Quantifying uncertainty in medical decisions

Excerpt When the outcome of a clinical trial shows that one treatment increases survival over alternative therapies, the result may be expected to establish a new standard of medical practice, part...

Stephen D. Roberts

Papers

Cost-Effective Care of End-Stage Renal Disease: A Billion Dollar Question

Input modeling with the Johnson system of distributions

Unexpected hospital admissions among patients with diabetes mellitus.

Quantifying uncertainty in medical decisions

Cost-Effective Oxygen Therapy