Showing papers on "Cost effectiveness published in 2009"

Ongoing Revolution in Bacteriology: Routine Identification of Bacteria by Matrix-Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry

Abstract: Background. Matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry accurately identifies both selected bacteria and bacteria in select clinical situations. It has not been evaluated for routine use in the clinic. Methods. We prospectively analyzed routine MALDI-TOF mass spectrometry identification in parallel with conventional phenotypic identification of bacteria regardless of phylum or source of isolation. Discrepancies were resolved by 16S ribosomal RNA and rpoB gene sequence-based molecular identification. Colonies (4 spots per isolate directly deposited on the MALDI-TOF plate) were analyzed using an Autoflex II Bruker Daltonik mass spectrometer. Peptidic spectra were compared with the Bruker BioTyper database, version 2.0, and the identification score was noted. Delays and costs of identification were measured. Results. Of 1660 bacterial isolates analyzed, 95.4% were correctly identified by MALDI-TOF mass spectrometry; 84.1% were identified at the species level, and 11.3% were identified at the genus level. In most cases, absence of identification (2.8% of isolates) and erroneous identification (1.7% of isolates) were due to improper database entries. Accurate MALDI-TOF mass spectrometry identification was significantly correlated with having 10 reference spectra in the database (P = .01). The mean time required for MALDI-TOF mass spectrometry identification of 1 isolate was 6 minutes for an estimated 22%-32% cost of current methods of identification. Conclusions. MALDI-TOF mass spectrometry is a cost-effective, accurate method for routine identification of bacterial isolates in <1 h using a database comprising ≥10 reference spectra per bacterial species and a ≥1.9 identification score (Brucker system). It may replace Gram staining and biochemical identification in the near future.

Neuropathic pain: quality-of-life impact, costs and cost effectiveness of therapy.

Abstract: A number of different diseases or injuries can damage the central or peripheral nervous system and produce neuropathic pain (NP), which seems to be more difficult to treat than many other types of chronic pain. As a group, patients with NP have greater medical co-morbidity burden than age- and sex-adjusted controls, which makes determining the humanistic and economic burden attributable to NP challenging. Health-related quality of life (HR-QOL) is substantially impaired among patients with NP. Patients describe pain-related interference in multiple HR-QOL and functional domains, as well as reduced ability to work and reduced mobility due to their pain. In addition, the spouses of NP patients have been shown to experience adverse social consequences related to NP. In randomized controlled trials, several medications have been shown to improve various measures of HR-QOL. Changes in HR-QOL appear to be tightly linked to pain relief, but not to the development of adverse effects. However, in cross-sectional studies, many patients continue to have moderate or severe pain and markedly impaired HR-QOL, despite taking medications prescribed for NP. The quality of NP treatment appears to be poor, with few patients receiving recommended medications in efficacious dosages. The substantial costs to society of NP derive from direct medical costs, loss of the ability to work, loss of caregivers' ability to work and possibly greater need for institutionalization or other living assistance. No single study has measured all of these costs to society for chronic NP. The cost effectiveness of various interventions for the treatment or prevention of different types of NP has been assessed in several different studies. The most-studied diseases are post-herpetic neuralgia and painful diabetic neuropathy, for which tricyclic antidepressants (both amitriptyline and desipramine) have been found to be either cost effective or dominant relative to other strategies. Increasing the use of cost-effective therapies such as tricyclic antidepressants for post-herpetic neuralgia and painful diabetic neuropathy may improve the HR-QOL of patients and decrease societal costs. Head-to-head clinical trials comparing NP therapies are needed to help assess the relative clinical efficacy of treatments, ideally using HR-QOL and utility outcomes. The full costs to society of NP, including productivity loss costs, have not been determined for chronic NP. Improved relative efficacy, utility and cost estimates would facilitate future cost-effectiveness research in NP.

The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation

Abstract: Objectives: to assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. Data sources: seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references Review methods: two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) ? 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI ? 40; BMI ? 30 and Results: a total of 5386 references were identified of which 26 were included in the clinical effectiveness review: three randomised controlled trials (RCTs) and three cohort studies compared surgery with non-surgical interventions and 20 RCTs compared different surgical procedures. Bariatric surgery was a more effective intervention for weight loss than non-surgical options. In one large cohort study weight loss was still apparent 10 years after surgery, whereas patients receiving conventional treatment had gained weight. Some measures of QoL improved after surgery, but not others. After surgery statistically fewer people had metabolic syndrome and there was higher remission of Type 2 diabetes than in non-surgical groups. In one large cohort study the incidence of three out of six comorbidities assessed 10 years after surgery was significantly reduced compared with conventional therapy. Gastric bypass (GBP) was more effective for weight loss than vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Laparoscopic isolated sleeve gastrectomy (LISG) was more effective than AGB in one study. GBP and banded GBP led to similar weight loss and results for GBP versus LISG and VBG versus AGB were equivocal. All comparisons of open versus laparoscopic surgeries found similar weight losses in each group. Comorbidities after surgery improved in all groups, but with no significant differences between different surgical interventions. Adverse event reporting varied; mortality ranged from none to 10%. Adverse events from conventional therapy included intolerance to medication, acute cholecystitis and gastrointestinal problems. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion. Bariatric surgery was cost-effective in comparison to non-surgical treatment in the reviewed published estimates of cost-effectiveness. However, these estimates are likely to be unreliable and not generalisable because of methodological shortcomings and the modelling assumptions made. Therefore a new economic model was developed. Surgical management was more costly than non-surgical management in each of the three patient populations analysed, but gave improved outcomes. For morbid obesity, incremental cost-effectiveness ratios (ICERs) (base case) ranged between £2000 and £4000 per QALY gained. They remained within the range regarded as cost-effective from an NHS decision-making perspective when assumptions for deterministic sensitivity analysis were changed. For BMI ? 30 and Conclusions: bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.

Cost-Effectiveness of Interventions to Promote Physical Activity: A Modelling Study

Abstract: Background Physical inactivity is a key risk factor for chronic disease, but a growing number of people are not achieving the recommended levels of physical activity necessary for good health. Australians are no exception; despite Australia's image as a sporting nation, with success at the elite level, the majority of Australians do not get enough physical activity. There are many options for intervention, from individually tailored advice, such as counselling from a general practitioner, to population-wide approaches, such as mass media campaigns, but the most cost-effective mix of interventions is unknown. In this study we evaluate the cost-effectiveness of interventions to promote physical activity. Methods and Findings From evidence of intervention efficacy in the physical activity literature and evaluation of the health sector costs of intervention and disease treatment, we model the cost impacts and health outcomes of six physical activity interventions, over the lifetime of the Australian population. We then determine cost-effectiveness of each intervention against current practice for physical activity intervention in Australia and derive the optimal pathway for implementation. Based on current evidence of intervention effectiveness, the intervention programs that encourage use of pedometers (Dominant) and mass media-based community campaigns (Dominant) are the most cost-effective strategies to implement and are very likely to be cost-saving. The internet-based intervention program (AUS$3,000/DALY), the GP physical activity prescription program (AUS$12,000/DALY), and the program to encourage more active transport (AUS$20,000/DALY), although less likely to be cost-saving, have a high probability of being under a AUS$50,000 per DALY threshold. GP referral to an exercise physiologist (AUS$79,000/DALY) is the least cost-effective option if high time and travel costs for patients in screening and consulting an exercise physiologist are considered. Conclusions Intervention to promote physical activity is recommended as a public health measure. Despite substantial variability in the quantity and quality of evidence on intervention effectiveness, and uncertainty about the long-term sustainability of behavioural changes, it is highly likely that as a package, all six interventions could lead to substantial improvement in population health at a cost saving to the health sector. Please see later in the article for Editors' Summary

The effectiveness and costs of speed reductions on emissions from international shipping

Abstract: Greenhouse gas emissions from international shipping are an increasing concern. The paper evaluates whether vessel speed reduction can be a potentially cost-effective CO2 mitigation option for ships calling on US ports. By applying a profit-maximizing equation to estimate route-specific, economically-efficient speeds, we explore policy impacts of a fuel tax and a speed reduction mandate on CO2 emissions. The profit-maximizing function incorporates opportunity costs associated with speed reduction that go unobserved in more traditional marginal abatement cost analyses. We find that a fuel tax of about $150/ton fuel will lead to average speed-related CO2 reductions of about 20–30%. Moreover, a speed reduction mandate targeted to achieve 20% CO2 reduction in the container fleet costs between $30 and $200 per ton CO2 abated, depending on how the fleet responds to a speed reduction mandate.

The Economic Burden of Insomnia: Direct and Indirect Costs for Individuals with Insomnia Syndrome, Insomnia Symptoms, and Good Sleepers

Abstract: INSOMNIA IS A PREVALENT PUBLIC HEALTH PROBLEM, WITH BETWEEN 6% AND 10% OF THE POPULATION MEETING DIAGNOSTIC CRITERIA FOR INSOMNIA syndrome1–3 and about a third of the population experiencing insomnia symptoms at any given moment.2 Despite its high prevalence, there is little information on the economic burden of insomnia. Information on the costs of illnesses, an indicator of their burden to society, is increasingly driving policy decisions about the funding and development of health care and research programs and priorities. Insurance companies are also concerned with the costs of illnesses and the impact that interventions may have in reducing symptoms and health care system utilization. Economic evaluations of the cost of illnesses or the cost effectiveness of treatments consider 2 broad categories of costs. These include direct costs associated with the consumption of resources (e.g., consultations, products, and testing), and indirect costs associated with the loss of resources (e.g., absenteeism, reduced productivity).4 While studies show a relationship between insomnia severity and the use of health-care service and product utilization,5–9 quantification of the associated costs is scarce. Similarly, some studies have reported a relationship between insomnia, increased absenteeism, and decreased productivity,10–13 yet the economic burden of this has been less frequently measured. The National Commission on Sleep Disorders Research estimated the direct costs of insomnia in the United States at $13.9 billion for the year 1995,14 whereas Leger et al.15 estimated the total cost of insomnia in France at about 10 million francs (or $2 billion US). The indirect costs associated with insomnia have received less attention in the literature, primarily because these costs are more difficult to estimate and quantify, there is no single database from which to draw, and measurement of these variables is more subject to interpretation and memory bias. Stoller16 attempted to quantify work-related deficits by combining data obtained in a study of workplace performance in Navy servicemen17 with her own insomnia prevalence estimate of 33% and a performance decrement estimate of 4%. The monetary value of absenteeism and lost productivity was estimated at $41.1 billion annually (1995 US$). A per person estimate was attempted by Chilcott and Shapiro,5 who suggest a decrease in work productivity due to insomnia of 10%. This amounts to $3,000 per insomnia sufferer per year. Stoller16 also looked at a number of other indirect costs, including insomnia-related accidents, alcoholism, and depression, estimating their costs at between $77.05 and $92.13 billion. Although these estimates have been criticized because they are based on liberal prevalence rates and relied on some questionable assumptions,9 they are still frequently used to describe the indirect economic consequences of insomnia. A French study18 concluded that insomnia is associated with increased absenteeism and reduced productivity, with associated costs about twice as high for insomnia patients as for good sleepers. The methods of costing did not allow, however, for an analysis of the proportional contribution of insomnia. There was also a methodological problem associated with double-counting costs that may have inflated cost estimates. Using existing data banks, Hillman et al.19 estimated the financial costs of all sleep disorders combined (e.g., insomnia, sleep apnea, periodic limb movements) for Australia at about $1,524 million, or 0.8% of the Australian gross domestic product. While an innovative approach was used to estimate fractions of other health impacts attributable to sleep disorders, this study did not permit the identification of costs associated with individual sleep disorders. A recent study by Ozminkowski et al.20 used medical claims data for health-care services, and absenteeism and short-term disability records to assess costs of insomnia occurring in adults in the US. After matching adult (aged 18–64) subsamples on variables determined by propensity score analysis, indirect costs combined were $1,253 higher in individuals with insomnia as compared to those without insomnia. The matching procedure and use of objective data lend strength to this study. However, costs related to reduced productivity, transportation, use of alcohol, and use of over-the-counter products were excluded from the analysis, suggesting that the results may underestimate the real cost of insomnia. Despite recent progress in documenting the economic burden of insomnia, some methodological weaknesses limit the current state of knowledge on this topic. The use of large administrative databases precludes analysis of potential confounding variables such as the reasons for consultations, use of OTC products, actual consumption of prescribed medications and, for some medications, the target ailment for which it was prescribed. When workplace records are used to obtain absenteeism data, reasons for absences are rarely provided and productivity data are not available. Similarly, the use of official accident records precludes identification of the contributing role of insomnia to these events. Studies typically use 2 groups—individuals with and without insomnia; the inclusion of an intermediate category would allow analysis of a linear relationship between costs and insomnia severity. The purpose of this study was to estimate, from the societal perspective, direct and indirect costs of insomnia. Costs were compared across three groups of participants classified as being good sleepers, having insomnia symptoms or having insomnia syndrome. The proportional contribution of insomnia to overall consultation costs and three indirect dependent cost variables, absenteeism, productivity and accidents, was also calculated.

Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume.

Abstract: Background Total knee arthroplasty (TKA) relieves pain and improves quality of life for persons with advanced knee osteoarthritis. However, to our knowledge, the cost-effectiveness of TKA and the influences of hospital volume and patient risk on TKA cost-effectiveness have not been investigated in the United States. Methods We developed a Markov, state-transition, computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. We projected lifetime costs and quality-adjusted life expectancy (QALE) for different risk populations and varied TKA intervention and hospital volume. Cost-effectiveness of TKA was estimated across all patient risk and hospital volume permutations. Finally, we conducted sensitivity analyses to determine various parameters' influences on cost-effectiveness. Results Overall, TKA increased QALE from 6.822 to 7.957 quality-adjusted life years (QALYs). Lifetime costs rose from $37 100 (no TKA) to $57 900 after TKA, resulting in an incremental cost-effectiveness ratio of $18 300 per QALY. For high-risk patients, TKA increased QALE from 5.713 to 6.594 QALY, yielding a cost-effectiveness ratio of $28 100 per QALY. At all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. Results were insensitive to variations of key input parameters within policy-relevant, clinically plausible ranges. The greatest variations were seen for the quality of life gain after TKA and the cost of TKA. Conclusions Total knee arthroplasty appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups. Policy decisions should be made on the basis of available local options for TKA. However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centers.

Carpal tunnel syndrome

Abstract: Carpal tunnel syndrome (CTS) is the most common neurologic entrapment disorder diagnosed in the upper limb Nevertheless, there is still debate about the most reliable test that should be performed to diagnose CTS Much of the argument has been drawn from the opinions of individuals or groups with varying degrees of expertise in the field; little has been based on actual data The purpose of this study was to investigate the diagnostic patterns of CTS in an academic medical setting in southern Taiwan The charts of 1,050 patients with a diagnosis of CTS over a 1-year period (2001–2002) were retrospectively reviewed Data on 622 patients with new-onset CTS were included in the analysis On the patient’s initial visit, physicians made a diagnosis of CTS in 349% of cases solely on the basis of the history of symptoms without resort to provocative tests, while 87% of cases were diagnosed on the basis of symptom characteristics alone in spite of negative provocative tests A CTS diagnosis was given according to symptoms and positive provocative tests in 55% of cases Apart from these, CTS diagnosis remained unchanged in 273% of cases without electrodiagnostic signs of CTS during follow-up visits An average of 16 diagnostic maneuvers were conducted for CTS patients, with nerve conduction velocity (NCV) studies (516 cases) being the most frequently performed, followed by Tinel’s sign (350 cases) and Phalen’s test (102 cases) Our findings imply that physicians are inclined to base their diagnosis on clinical history and physical examination for patients with suspected CTS Clear guidelines regarding the indications for referral for NCV studies should be established in response to the increased concerns about the cost effectiveness of diagnostic tests

KRAS codon 61, 146 and BRAF mutations predict resistance to cetuximab plus irinotecan in KRAS codon 12 and 13 wild-type metastatic colorectal cancer

Abstract: RAS and RAF proteins play a key role in the control of cellular growth, proliferation and differentiation (Bos, 1989; Wickenden et al, 2008) KRAS-activating mutations reduce or abolish intrinsic GTPase activity of the protein, leading to its constitutive activation (Conlin et al, 2005) Similarly BRAF V600E mutation induces structural changes in RAF protein which increase its kinase activity (Wan et al, 2004) Activated RAS and RAF are responsible for the disregulation of RAS/RAF/MAPKs signalling pathway. KRAS codons 12 and 13 activating mutations are widely recognised as predictors of resistance to the treatment with anti-EGFR monoclonal antibodies (moAbs) in metastatic colorectal cancer (mCRC) patients (Karapetis et al, 2008; Amado et al, 2008). Based on retrospectively collected data and post hoc analyses of large phase III studies, the European Medicines Agency has restricted the use of cetuximab to the treatment of patients with KRAS codons 12 and 13 wild-type disease (about the 60% of the overall population; EMEA, 2008) and the American Society of Clinical Oncology has similarly recommended in a recent provisional clinic opinion not to administer anti-EGFR moAbs to patients with KRAS codons 12 or 13 mutated tumours (Allegra et al, 2009). Nevertheless, in a systematic review and meta-analysis, Linardou et al reported a very high specificity (0.93, (0.83–0.97)) and a much lower sensitivity (0.47, (0.43–0.52)) of KRAS analysis in predicting resistance to anti-EGFR moAbs in mCRC, thus underlining the need for additional predictive markers to be combined with KRAS codons 12 and 13 evaluation, for a more accurate patients' selection (Linardou et al, 2008). A recently published experience found a correlation between BRAF V600E-activating mutation, mutually exclusive with KRAS ones, and resistance to the treatment with cetuximab and panitumumab administered alone or in combination with chemotherapy (Di Nicolantonio et al, 2008). On the basis of the above-mentioned evidences, around 50% of candidate patients would be excluded from receiving anti-EGFR moAbs, with a significant improvement of the treatment's cost effectiveness. However, as cetuximab or panitumumab monotherapies determine a response rate of about 10% regardless of the line of treatment and no more than 23% of patients respond to the combination of cetuximab and irinotecan (Cunningham et al, 2004; Van Cutsem et al, 2007; Jonker et al, 2007) it is plausible that the selection of candidate patients to receive an anti-EGFR moAb might be further slightly refined. Additional KRAS-activating mutations, involving codons 61 and 146 (Edkins et al, 2006) occur with frequencies ranging from 1 to 4% in CRCs. These relatively rare mutations, as well as codons 12 and 13 mutations, are responsible for the oncogenic constitutive activation (Buhrman et al, 2007; Feig and Cooper, 1988) of RAS/RAF/MAPKs pathway and they might account for up to a 10% of resistant patients bearing KRAS codons 12 and 13 and BRAF wild-type tumours. To optimise the selection of patients who are more likely to benefit from anti-EGFR we investigated in a cohort of patients treated with the combination of cetuximab and irinotecan and bearing KRAS codons 12 and 13 wild-type tumours, the association of KRAS codons 61 and 146 mutations and BRAF V600E mutation with clinical outcomes.

A Meta-Analytic Review of the Penn Resiliency Program’s Effect on Depressive Symptoms

Abstract: The purpose of this review was to evaluate whether the Penn Resiliency Program (PRP), a group cognitive-behavioral intervention, is effective in targeting depressive symptoms in youths. We identified 17 controlled evaluations of PRP (N = 2,498) in which depressive symptoms had been measured via an online search of PsycInfo, Medline, ERIC, and ProQuest Dissertations and Theses and by requesting data from PRP researchers. We combined effect sizes (ESs; Glass's d), using random effects models at postintervention and two follow-up assessments (6-8 and 12 months postintervention). PRP participants reported fewer depressive symptoms at postintervention and both follow-up assessments compared with youths receiving no intervention, with ESs ranging from 0.11 to 0.21. Subgroup analyses showed that PRP's effects were significant at 1 or more follow-up assessments among studies with both targeted and universal approaches, when group leaders were research team members and community providers, among participants with both low and elevated baseline symptoms, and among boys and girls. Limited data showed no evidence that PRP is superior to active control conditions. Preliminary analyses suggested that PRP's effects on depressive disorders may be smaller than those reported in a larger meta-analysis of depression prevention programs for older adolescents and adults. We found evidence that PRP significantly reduces depressive symptoms through at least 1-year postintervention. Future PRP research should examine whether PRP's effects on depressive symptoms lead to clinically meaningful benefits for its participants, whether the program is cost-effective, whether CB skills mediate program effects, and whether PRP is effective when delivered under real-world conditions.

The role of rapid diagnostic tests in managing malaria

Abstract: Zeno Bisoffi and colleagues discuss a new clinical trial in Zanzibar comparing symptom-based clinical diagnosis of malaria versus clinical diagnosis plus rapid diagnostic tests.

Factors Affecting Teachers' Use of Information and Communication Technology.

Abstract: Research studies in the past decade have shown that computer technology is an effective means for widening educational opportunities, but most teachers neither use technology as an instructional delivery system nor integrate technology into their curriculum. Studies reveal a number of factors influencing teachers’ decisions to use ICT in the classroom: non-manipulative and manipulative school and teacher factors. These factors are interrelated. The success of the implementation of ICT is not dependent on the availability or absence of one individual factor, but is determined through a dynamic process involving a set of interrelated factors. It is suggested that ongoing professional development must be provided for teachers to model the new pedagogies and tools for learning with the aim of enhancing the teaching-learning process. However, it is important for teacher trainers and policy makers to understand the factors affecting effectiveness and cost-effectiveness of different approaches to ICT use in teacher training so training strategies can be appropriately explored to make such changes viable to all.

A comparison of web-based and paper-based survey methods: testing assumptions of survey mode and response cost.

Abstract: Web-based surveys have become more prevalent in areas such as evaluation, research, and marketing research to name a few The proliferation of these online surveys raises the question, how do response rates compare with traditional surveys and at what cost? This research explored response rates and costs for Web-based surveys, paper surveys, and mixed-mode surveys The participants included evaluators from the American Evaluation Association (AEA) Results included that mixed-mode, while more expensive, had higher response rates

Estimates of US influenza-associated deaths made using four different methods

Abstract: Background A wide range of methods have been used for estimating influenza-associated deaths in temperate countries. Direct comparisons of estimates produced by using different models with US mortality data have not been published. Objective Compare estimates of US influenza-associated deaths made by using four models and summarize strengths and weaknesses of each model.

Metabolic engineering of cyanobacteria for ethanol production

Abstract: Development of renewable energy is rapidly being embraced by our society and industry to achieve the nation's economic growth goals and to help address the world's energy and global warming crises. Currently most of the bioethanol production is from the fermentation of agricultural crops and residues. There is much debate concerning the cost effectiveness and energy efficiency of such biomass based ethanol production processes. Here, we report the creation of a Synechocystis sp. PCC 6803 strain that can photoautotrophically convert CO2 to bioethanol. Transformation was performed using a double homologous recombination system to integrate the pyruvate decarboxylase (pdc) and alcohol dehydrogenase II (adh) genes from obligately ethanol producing Zymomonas mobilis into the Synechocystis PCC 6803 chromosome under the control of the strong, light driven psbAII promoter. PCR based assay and ethanol production assay were used to screen for stable transformants. A computerized photobioreactor system was established for the experimental design and data acquisition for the analysis of the cyanobacterial cell cultures and ethanol production. The system described here shows an average yield of 5.2 mmol OD730 unit−1 litre−1 day−1 with no required antibiotic/selective agent.

Using effectiveness and cost-effectiveness to make drug coverage decisions: a comparison of Britain, Australia, and Canada.

Abstract: Context National public insurance for drugs is often based on evidence of comparative effectiveness and cost-effectiveness This study describes how that evidence has been used across 3 jurisdictions (Australia, Canada, and Britain) that have been at the forefront of evidence-based coverage internationally Objectives To describe how clinical and cost-effectiveness evidence is used in coverage decisions both within and across jurisdictions and to identify common issues in the process of evidence-based coverage Design, Setting, and Participants Descriptive analysis of retrospective data from the Common Drug Review (CDR) of Canada, National Institute for Health and Clinical Excellence (NICE) in Britain, and Pharmaceutical Benefits Advisory Committee (PBAC) of Australia All publicly available information as of December 31, 2008, was gathered from each committee's Web site (data set begins in January 2004 [CDR], February 2001 [NICE], and July 2005 [PBAC]) Main Outcome Measure Listing recommendations for each drug by disease indication Results NICE recommended 874% (174/199) of submissions for listing compared with a listing rate of 496% (60/121) and 543% (153/282) for the CDR and PBAC, respectively Significant uncertainty around clinical effectiveness, typically resulting from inadequate study design or the use of inappropriate comparators and unvalidated surrogate end points, was identified as a key issue in coverage decisions Recommendations varied considerably across countries, possibly because of differences in the medications reviewed; different agency processes, including the willingness to negotiate on price; and the approach to “me too” drugs The data suggest that the 3 agencies make recommendations that are consistent with evidence on effectiveness and cost-effectiveness but that other factors are often important Conclusions NICE, PBAC, and CDR face common issues with respect to the quality and strength of the experimental evidence in support of a clinically meaningful effect However, comparative effectiveness and cost-effectiveness, along with other relevant factors, can be used by national agencies to support drug decision making The results of the evaluation process in different countries are influenced by the context, agency processes, ability to engage in price negotiation, and perhaps differences in social values

Integrative Medicine and Patient-Centered Care

Abstract: Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies. Additional competencies for primary health partners, including CAM and conventional medical providers, will need to be developed to foster successful integrative practices. Skills include learning to develop appropriate healthcare teams that function well in a medical home, developing an understanding of the diverse healing traditions, and enhancing communication skills. For integrative medicine to flourish in the United States, new providers, new provider models, and a realignment of incentives and a commitment to health promotion and disease management will be required.

Cost-effectiveness of using pharmacogenetic information in warfarin dosing for patients with nonvalvular atrial fibrillation.

Abstract: Eckman and coworkers evaluated the cost-effectiveness of genotype-guided warfarin dosing for patients with nonvalvular atrial fibrillation. For the standard base case (a man age 69 years with no co...

The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model

Abstract: Objectives To investigate whether it is clinically effective and cost-effective to provide (i) a unilateral cochlear implant for severely to profoundly deaf people (using or not using hearing aids), and (ii) a bilateral cochlear implant for severely to profoundly deaf people with a single cochlear implant (unilateral or unilateral plus hearing aid). Data sources Main electronic databases [MEDLINE; EMBASE; Cochrane Database of Systematic Reviews; CENTRAL; NHS EED; DARE; HTA (NHS-CRD); EconLit; National Research Register; and ClinicalTrials.gov] searched in October 2006, updated July 2007. Review methods A systematic review of the literature was undertaken according to standard methods. A state-transition (Markov) model of the main care pathways deaf people might follow and the main complications and device failures was developed. Results The clinical effectiveness review included 33 papers, of which only two were RCTs. They used 62 different outcome measures and overall were of moderate to poor quality. All studies in children comparing one cochlear implant with non-technological support or an acoustic hearing aid reported gains on all outcome measures, some demonstrating greater gain from earlier implantation. The strongest evidence for an advantage from bilateral over unilateral implantation was for understanding speech in noisy conditions (mean improvement 13.2%, p < 0.0001); those receiving their second implant earlier made greater gains. Comparison of bilateral with unilateral cochlear implants plus an acoustic hearing aid was compromised by small sample sizes and poor reporting, but benefits were seen with bilateral implants. Cochlear implants improved children’s quality of life, and those who were implanted before attending school were more likely to do well academically and attend mainstream education than those implanted later. In adults, there was a greater benefit from cochlear implants than from non-technological support in terms of speech perception. Increased age at implantation may reduce effectiveness and there is a negative correlation between duration of deafness and effectiveness. Speech perception measures all showed benefits for cochlear implants over acoustic hearing aids [e.g. mean increase in score of 37 points in noisy conditions (p < 0.001) with BKB sentences]; however, prelingually deafened adults benefited less than those postlingually deafened (mean change scores 20% versus 62%). For unilateral versus bilateral implantation, benefits in speech perception were significant in noisy conditions on all measures [e.g. 76% for HINT sentences (p < 0.0001)]. Quality of life measured with generic and disease-specific instruments or by interview mostly showed significant gains or positive trends from using cochlear implants. The Markov model base-case analysis estimated that, for prelingually profoundly deaf children, the incremental cost-effectiveness ratio (ICER) for unilateral implantation compared with no implantation was £13,413 per quality-adjusted life-year (QALY). Assuming the utility gain for bilateral implantation is the same for adults and children, the ICERs for simultaneous and sequential bilateral implantation versus unilateral implantation were £40,410 and £54,098 per QALY respectively. For postlingually sensorineurally profoundly deaf adults, the corresponding ICERs were £14,163, £49,559 and £60,301 per QALY respectively. Probabilistic threshold analyses suggest that unilateral implants are highly likely to be cost-effective for adults and children at willingness to pay thresholds of £20,000 or £30,000 per QALY. There are likely to be overall additional benefits from bilateral implantation, enabling children and adults to hold conversations more easily in social situations. Conclusions Unilateral cochlear implantation is safe and effective for adults and children and likely to be cost-effective in profoundly deaf adults and profoundly and prelingually deaf children. However, decisions on the cost-effectiveness of bilateral cochlear implants should take into account the high degree of uncertainty within the model regarding the probable utility gain.

Evidence-Based Public Policy Options to Reduce Crime and Criminal Justice Costs: Implications in Washington State

Abstract: In 2006, long-term forecasts indicated that Washington faced the need to construct several new prisons in the following two decades. Since new prisons are costly, the Washington legislature directed the Washington State Institute for Public Policy to project whether there are "evidence-based" options that can reduce the future need for prison beds, save money for state and local taxpayers, and contribute to lower crime rates. The institute conducted a systematic review of all research evidence that could be located to determine what works, if anything, to reduce crime. We found and analyzed 545 comparison-group evaluations of adult corrections, juvenile corrections, and prevention programs. We then estimated the benefits and costs of many of these evidence-based options and found that some evidence-based programs produce favorable returns on investment. This paper presents our findings and describes our meta-analytic and economic methods.

Why we should be wary of single-center trials.

Abstract: Objective: To highlight the limitations of single-center trials in critical care, using prominent examples from the recent literature; to explore possible reasons for discrepancies between these studies and subsequent multicenter effectiveness trials; and to suggest how the evidence from single-center trials might be used more appropriately in clinical practice. STUDY SELECTION: Topical and illustrative examples of the concepts discussed including trials of patient positioning, the use of steroids for acute respiratory distress syndrome, the dose of hemofiltration, the control of glycemia, and the targets of resuscitation in sepsis. DATA SYNOPSIS: Many positive single-center trials have been contradicted when tested in other settings and, in one case, the subsequent definitive multicentered trial has found a previously recommended intervention associated with active harm. Problems inherent in the nature of single-center studies make recommendations based on their results ill advised. Single-center studies frequently either lack the scientific rigor or external validity required to support widespread changes in practice, and their premature incorporation into guidelines may make the conduct of definitive studies more difficult. Conclusions: We recommend that practice guidelines should rarely, if ever, be based on evidence from single-center trials. Physicians should apply the findings of single-center trials only after careful evaluation of their methodology, and in particular after comparing the context of the trial with their own situation.

Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study

Abstract: Objectives To assess whether the mortality benefit from screening men aged 65-74 for abdominal aortic aneurysm decreases over time, and to estimate the long term cost effectiveness of screening. Design Randomised trial with 10 years of follow-up. Setting Four centres in the UK. Screening and surveillance was delivered mainly in primary care settings, with follow-up and surgery offered in hospitals. Participants Population based sample of 67 770 men aged 65-74. Interventions Participants were individually allocated to invitation to ultrasound screening (invited group) or to a control group not offered screening. Patients with an abdominal aortic aneurysm detected at screening underwent surveillance and were offered surgery if they met predefined criteria. Main outcome measures Mortality and costs related to abdominal aortic aneurysm, and cost per life year gained. Results Over 10 years 155 deaths related to abdominal aortic aneurysm (absolute risk 0.46%) occurred in the invited group and 296 (0.87%) in the control group (relative risk reduction 48%, 95% confidence interval 37% to 57%). The degree of benefit seen in earlier years of follow-up was maintained in later years. Based on the 10 year trial data, the incremental cost per man invited to screening was £100 (95% confidence interval £82 to £118), leading to an incremental cost effectiveness ratio of £7600 (£5100 to £13 000) per life year gained. However, the incidence of ruptured abdominal aortic aneurysms in those originally screened as normal increased noticeably after eight years. Conclusions The mortality benefit of screening men aged 65-74 for abdominal aortic aneurysm is maintained up to 10 years and cost effectiveness becomes more favourable over time. To maximise the benefit from a screening programme, emphasis should be placed on achieving a high initial rate of attendance and good adherence to clinical follow-up, preventing delays in undertaking surgery, and maintaining a low operative mortality after elective surgery. On the basis of current evidence, rescreening of those originally screened as normal is not justified. Trial registration Current Controlled Trials ISRCTN37381646.

Comparing Price and Non-price Approaches to Urban Water Conservation

Abstract: [1] Urban water conservation is typically achieved through prescriptive regulations, including the rationing of water for particular uses and requirements for the installation of particular technologies. A significant shift has occurred in pollution control regulations toward market-based policies in recent decades. We offer an analysis of the relative merits of market-based and prescriptive approaches to water conservation, where prices have rarely been used to allocate scarce supplies. The analysis emphasizes the emerging theoretical and empirical evidence that using prices to manage water demand is more cost effective than implementing nonprice conservation programs, similar to results for pollution control in earlier decades. Price-based approaches may also compare favorably to prescriptive approaches in terms of monitoring and enforcement. Neither policy instrument has an inherent advantage over the other in terms of predictability and equity. As in any policy context, political considerations are also important.

Original research article Cost effectiveness of contraceptives in the United States

Abstract: Background: The study was conducted to estimate the relative cost effectiveness of contraceptives in the United States from a payer's perspective. Methods: A Markov model was constructed to simulate costs for 16 contraceptive methods and no method over a 5-year period. Failure rates, adverse event rates and resource utilization were derived from the literature. Sensitivity analyses were performed on costs and failure rates. Results: Any contraceptive method is superior to “no method”. The three least expensive methods were the copper-T intrauterine device (IUD) (US$647), vasectomy (US$713) and levonorgestrel (LNG)-20 intrauterine system (IUS) (US$930). Results were sensitive to the cost of contraceptive methods, the cost of an unintended pregnancy and plan disenrollment rates. Conclusion: The copper-T IUD, vasectomy and the LNG-20 IUS are the most cost-effective contraceptive methods available in the United States. Differences in method costs, the cost of an unintended pregnancy and time horizon are influential factors that determine the overall value of a contraceptive method.

HIV Preexposure Prophylaxis in the United States: Impact on Lifetime Infection Risk, Clinical Outcomes, and Cost-Effectiveness

Abstract: Background The combination of tenofovir and emtricitabine shows promise as HIV preexposure prophylaxis (PrEP). We sought to forecast clinical, epidemiologic, and economic outcomes of PrEP, taking into account uncertainties regarding efficacy, the risks of developing drug resistance and toxicity, behavioral disinhibition, and drug costs. Methods We adapted a computer simulation of HIV acquisition, detection, and care to model PrEP among men who have sex with men and are at high risk of HIV infection (i.e., 1.6% mean annual incidence of HIV infection) in the United States. Base-case assumptions included 50% PrEP efficacy and monthly tenofovir-emtricitabine costs of $753. We used sensitivity analyses to examine the stability of results and to identify critical input parameters. Results In a cohort with a mean age of 34 years, PrEP reduced lifetime HIV infection risk from 44% to 25% and increased mean life expectancy from 39.9 to 40.7 years (21.7 to 22.2 discounted quality-adjusted life-years). Discounted mean lifetime treatment costs increased from $81,100 to $232,700 per person, indicating an incremental cost-effectiveness ratio of $298,000 per quality-adjusted life-year gained. Markedly larger reductions in lifetime infection risk (from 44% to 6%) were observed with the assumption of greater (90%) PrEP efficacy. More-favorable incremental cost-effectiveness ratios were obtained by targeting younger populations with a higher incidence of infection and by improvements in the efficacy and cost of PrEP. Conclusions PrEP could substantially reduce the incidence of HIV transmission in populations at high risk of HIV infection in the United States. Although it is unlikely to confer sufficient benefits to justify the current costs of tenofovir-emtricitabine, price reductions and/or increases in efficacy could make PrEP a cost-effective option in younger populations or populations at higher risk of infection. Given recent disappointments in HIV infection prevention and vaccine development, additional study of PrEP-based HIV prevention is warranted.

Cost Effectiveness of Internet Interventions: Review and Recommendations

Abstract: Background Internet interventions have a large potential for public health impact, and their efficacy has been established over the past 10–15 years. Cost effectiveness of Internet interventions is one of the most frequently cited reasons for developing such treatments.