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Background: In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time.Objective: To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term.Study Design: Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective.Results: The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498).Conclusions: After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs. [ABSTRACT FROM AUTHOR]

Depression is a common disorder in later life that is associated with increased disability and costs, and negative health outcomes over time. Antidepressant treatments in the form of medications or psychotherapy are available, but a large proportion of those treated fail to respond fully, and relapse or recurrence of symptoms is frequent among those who recover. Hence, successful prevention would avoid these negative outcomes. This paper selectively reviews currently available observational and trial data on the prevention of depression. It initially reviews risk factors associated with depression, and then discusses strategies for primary (including universal, selective and indicated), secondary and tertiary prevention. Currently available evidence suggests that selective and indicated preventive interventions are feasible and initial results look promising. Existing trial data indicate that ongoing antidepressant treatments reduce the risk of relapse and recurrence of symptoms, but benefits may not extend beyond two or three years. At this point in time, no interventions have been shown to reduce the long term complications associated with depression. Mental health professionals will need to work collaboratively to develop primary, secondary and tertiary preventive interventions that are effective at targeting relevant risk factors systematically and that can be easily adopted into clinical practice. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Display the cost savings of minimal sterile covers and preparatory time while still maintaining optimal outcomes for sinus procedures. In-office non-sterile endoscopic sinus procedures have not shown a difference in infections and complications. Institutions continue to employ more “traditional” sterile preparation with similar procedures in the operating room. Multiple studies have also shown no significant difference in postoperative course when preoperative antibiotics are administered for sinus procedures. Methods: Endoscopic sinus procedures were selected (58 patients) to analyze itemized sterile costs. Drapes, gloves, gowns, and antibiotics were then tallied and compared to the same items for cochlear implants (14 procedures). The “sterile-prep” time was also analyzed and compared between the two procedures. Cost difference was analyzed. Results: Comparing the supplies used for sinus procedures (56) and cochlear implants, our average sinus cost was $10.19, compared to $34.64, with a difference of $24.45. This equated to a savings of $1418.00 in sinus procedure supplies that year. The difference in draping and scrubbing time showed a difference of 20min between groups, equaling a value of $1760 difference/case. This calculated to a savings of $10,2080 for sinus operating room time. There was no difference in patient outcomes with this surgical preparatory approach. Conclusion: Our analysis showed a large cost savings over a fiscal year in operative time and supplies. This did not compromise any patient outcomes given the already non-sterile nature of endoscopic sinus surgery. This practice can be adopted to greatly enhance efficiency without sacrificing surgical results. [Copyright &y& Elsevier]

Background: Two previous retrospective database analyses compared early combination therapy with an ɑ-blocker (AB) and 5-ɑ reductase inhibitor (5-ARI) to delayed combination therapy and found that patients receiving the delayed combination therapy were more likely to have clinical progression, acute urinary retention (AUR), and surgery. Although these studies indicate the clinical benefits of early treatment, both studies failed to take into account important baseline clinical measures, such as prostate-specific antigen (PSA) values. Objective: This study was designed to compare clinical and cost differences in men with benign prostatic hyperplasia (BPH) who initiated early versus delayed combination therapy with a 5-ARI + an AB, factoring in baseline PSA values. Methods: This retrospective claims data analysis assessed data from >14 million US men with linked medical data, pharmacy data, laboratory results, and enrollment information from January 1, 2000, to December 31, 2009. Men aged 50 or older and treated for BPH with a 5-ARI + an AB were identified. Patients were required to be eligible for services at least 6 months before and 12 months after the index medication date. Patients were assigned to 1 of 2 treatment groups based on therapy (early or delayed) and 3 cohorts based on availability of PSA laboratory values (patients with a PSA value, patients with a PSA value >1.5 and <10, and all patients). Using a logistic model, the likelihood of clinical progression (defined as the occurrence of AUR or prostate surgery) during the 12 months after the date of first prescription fill was compared between BPH patients receiving early versus delayed combination therapy. BPH-related medical costs (excluding pharmacy costs) were assessed using generalized linear models. Results: Among the 13,551 patients identified for study inclusion, the highest risks for clinical progression, AUR, and prostate-related surgery were consistently demonstrated in patients with a PSA >1.5 and <10. Across all 3 cohorts, the delayed combination-treatment group was more likely to have clinical progression, AUR, and prostate-related surgeries versus the early combination- treatment group. The incremental difference in BPH-related costs between the delayed and early combination- treatment groups was $190 per patient overall; the greatest incremental difference ($397) was observed in patients with PSA >1.5 and <10. Conclusions: The results suggest that early initiation of combination therapy with 5-ARI + an AB, compared with delayed initiation, can reduce the risks for clinical progression, AUR, and prostate-related surgeries, as well as BPH-related medical costs, in patients with BPH. [ABSTRACT FROM AUTHOR]

Objective: The goal of this study was to examine the cost-effectiveness of fulvestrant 500 mg for the treatment of first progression or recurrence of advanced breast cancer in postmenopausal patients compared with generic nonsteroidal aromatase inhibitors (anastrozole and letrozole) in the United Kingdom. Methods: A cost-utility model based on a time-instate approach was used. Clinical effectiveness estimates used in the model were derived from a network meta-analysis for overall survival and serious adverse events. Overall survival was extrapolated by using a Weibull distribution, and progression-free survival (PFS) estimates were derived from a simultaneous network meta-analysis and extrapolation of PFS curves by using the log-normal distribution. Data on resource use, costs, and utilities were based on various sources, including expert opinion and published data. To explore uncertainty, 1-way and probability sensitivity analyses were conducted. The study was conducted from the perspective of the UK National Health Service, and costs are reported in 2010/2011 British pounds. Results: The base case incremental cost-effectiveness ratio (ICER) for fulvestrant 500 mg versus letrozole was £34,528, with incremental costs of £14,383 and an incremental quality-adjusted life-year (QALY) of 0.417. Extended dominance occurred for anastrozole because the ICER for anastrozole versus letrozole was higher than the ICER for fulvestrant 500 mg versus anastrozole. Based on the probability sensitivity analyses, the probability that fulvestrant 500 mg was the most cost-effective treatment option was 3%, 20%, and 53% at a willingness-to-pay threshold of £20,000, £30,000, and £40,000 per QALY, respectively. According to the 1-way sensitivity analyses, the PFS estimates were the key drivers of the model results. Conclusions: Although fulvestrant 500 mg was found not to be a cost-effective option at a standard UK threshold of £20,000 to £30,000 per QALY, it may be relevant to apply a higher threshold due to the poor prognosis of patients with advanced breast cancer and the limited number of hormonal treatment options available for this stage of treatment. Certain subgroups may also benefit from fulvestrant as a treatment option; however, limited data are currently available to identify these subgroups. [ABSTRACT FROM AUTHOR]

Abstract: Background: The clinical benefits of dual antiplatelet treatment (aspirin + clopidogrel) in the management of acute coronary syndromes (ACS) are well established. However, clopidogrel is a prodrug that requires hepatic activation. Concerns regarding its delayed onset of action, variability in antiplatelet effects, and prolonged recovery of platelet function after discontinuation have prompted the development of P2Y12 receptor antagonists. Ticagrelor is the most recently developed P2Y12 receptor antagonist available in the United States. Ticagrelor is a nonthienopyridine antiplatelet agent and is the first reversible oral antagonist of the P2Y12 receptors. Objective: This article reviews the pharmacology, clinical efficacy, and tolerability of ticagrelor use in management of ACS. Methods: Peer-reviewed clinical trials, review articles, and relevant treatment guidelines published from 1966 to March 15, 2012, were identified from the MEDLINE and Current Content databases using the search terms ticagrelor, ACS, pharmacokinetics, pharmacodynamics, pharmacoeconomics, and cost-effectiveness. Citations from available articles were also reviewed for additional references. Results: Nine pharmacokinetics/pharmacodynamics studies in humans and 1 clinical study were identified. In addition, the findings from 6 subanalyses based on the clinical study were included. Compared with clopidogrel, ticagrelor was associated with a significantly reduced composite rate of death from cardiovascular causes, myocardial infarction, or stroke (ticagrelor, 9.8%; clopidogrel, 11.7%; hazard ratio [HR] = 0.84; 95% CI, 0.77–0.92; P < 0.001). The difference in the rates of major bleeding was not significant (ticagrelor, 11.6%; clopidogrel, 11.2%). Ticagrelor was associated with a higher rate of non–coronary artery bypass graft surgery related major bleeding (4.5% vs 3.8%; P = 0.03), including fatal intracranial bleeding (0.1% vs 0.01%; P = 0.02), and fewer cases of other types of fatal bleeding (0.1% vs 0.3%; P = 0.03). Other adverse events reported with ticagrelor use included dyspnea (13.8%), headache (6.5%), and bradyarrhythmia (5.8%). The effects of ticagrelor have not been compared to those of other antiplatelet agents, including prasugrel. Conclusions: Based on the findings from the present review, ticagrelor provides reversible inhibition of adenosine diphosphate–induced platelet aggregation, with a faster onset of action than clopidogrel, and is effective in the treatment of patients with ACS. More data are required to definitively position ticagrelor with respect to other antiplatelet agents, including prasugrel. [Copyright &y& Elsevier]

Objective: To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued.Design: Prospective cohort study in which women were followed for 18 months.Setting: Eight infertility practices.Patient(s): Three hundred ninety-eight women recruited from infertility practices.Intervention(s): Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used.Main Outcome Measure(s): Per-person and per-successful-outcome costs.Result(s): Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not.Conclusion(s): Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment. [ABSTRACT FROM AUTHOR]