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Background: Changes to prescribing policies in England have restricted or stopped access to gluten‐free food on prescription for people with coeliac disease in some geographical areas. The present study aimed to explore the impact of these changes on the affordability and obtainability of gluten‐free foods for adults with coeliac disease. Methods: Semi‐structured qualitative interviews (n = 24) were conducted with people with coeliac disease living in areas where prescriptions for gluten‐free foods were no longer available, were restricted or followed national guidelines. Interviews explored the impact of gluten‐free prescribing changes on the affordability and obtainability of gluten‐free food, as well as dietary adherence. Results: All participants considered gluten‐free substitute foods to be expensive. Participants felt the availability of gluten‐free foods has improved over time, also acknowledging some challenges remain, such as limited local availability. For most, the withdrawal of prescriptions had minimal impact requiring small adjustments such as reducing the quantity of foods obtained. However, greater challenges were faced by those less mobile, permanently sick or disabled and/or on lower incomes. Conclusions: The majority of participants affected by the withdrawal of prescriptions were able to adapt to cope with these changes. However, participants with mobility issues, who are permanently sick or disabled and/or on lower incomes were struggling to afford and obtain gluten‐free substitute foods from elsewhere. The withdrawal of prescriptions may further widen health inequalities. Further research should focus on the long‐term impacts of prescription withdrawal for the vulnerable groups identified. Key points: Prescriptions for gluten‐free substitute foods have been restricted or withdrawn in some areas of England, but the impact of these changes on people with coeliac disease is unknown.The present study found that the majority of people with coeliac disease were able to adapt to cope with prescribing changes, but certain groups (people with mobility issues, who are permanently sick or disabled and/or on lower incomes) were struggling to afford and obtain gluten‐free foods.Future research should focus on the longer‐term impacts of no access or restricted access to gluten‐free substitute foods on prescription, with specific focus on the groups identified above. [ABSTRACT FROM AUTHOR]

Diseases can be interconnected. In the recent years, there has been a surge of multidisease studies. Among them, HDN (human disease network) analysis takes a system perspective, examines the interconnections among diseases along with their individual properties, and has demonstrated great potential. Most of the existing HDN analyses are based on either molecular information (which may be unreliable and have limited clinical relevance) or phenotypic measures (which may have limited implications for disease management and not directly reflect disease severity). In this study, we take advantage of the uniquely valuable Taiwan NHIRD (National Health Insurance Research Database) data and conduct an HDN analysis of disease treatment cost. Complementing the existing literature, treatment cost can serve as a surrogate of disease severity (and hence be clinically highly relevant) and also directly describe the financial burden of illness (and hence be uniquely informative for disease management). With inpatient and outpatient treatment data on close to 1 million randomly selected subjects and collected during the period of 2000 to 2013, the human disease cost network is constructed using a novel copula-based approach and the weighted correlation-based network construction technique. Extensive analysis is conducted, and the results are found to be biomedically sensible. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN: Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING: A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS: Nursing staff and medical care providers in the participating NHs. INTERVENTION: Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS: Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections. RESULTS: Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS: Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46–54, 2019 See related editorial by Furuno et al. in this issue. [ABSTRACT FROM AUTHOR]

Oral sotalol, used in adults for sinus rhythm control, is initiated at 80 mg b.i.d. and titrated to a maximum safe dose. The US Food and Drug Administration recommends monitoring the corrected QT interval (QTc) for at least 3 days, until steady‐state exposure of the drug is reached, before patient discharge, which can significantly impact the total cost of treatment. The objectives of this research were to design an accelerated intravenous sotalol loading and maintenance therapy that will reduce the hospital length of stay and to also evaluate the pharmacoeconomic impact in a hospital setting. Pharmacokinetic simulations of sotalol plasma concentrations vs. times profiles were performed to determine the optimal intravenous/oral transition regimen. A cost minimization analysis from the health sector perspective was conducted to assess the cost savings for these proposed accelerated regimens. For a chosen target dose of 120 mg b.i.d., two infusions of 40 mg over 1 hour and 20 mg over 0.5 hour, each followed up by an evaluation of QTc, can be administered followed immediately by the target oral maintenance dose of 120 mg at the end of the second infusion. Consequently, steady‐state exposure and, therefore, steady‐state QTc are obtained on the first day of therapy, facilitating an earlier hospital discharge. Two and 1‐day mean total cost of −$3,123 (95% confidence interval (CI), −$3,640, −$2,607) −$4,820 (95% CI, −$5,352, −$4,288) were observed for this strategy, respectively. We are proposing an intravenous to oral transition strategy for sotalol that has the potential to significantly reduce cost and increase patient convenience. [ABSTRACT FROM AUTHOR]

Background: The long‐acting oxytocic agent; carbetocin, has been consistently shown to reduce the need for additional uterotonics at caesarean section, but not postpartum haemorrhage (PPH). While promising, current evidence is limited by heterogenicity in study design and findings. Aims: To examine whether carbetocin confers clinical or economic benefit compared to oxytocin at caesarean section in an all‐risk Australian population. Materials and Methods: A retrospective cohort study was undertaken of all singleton caesarean sections at a public tertiary hospital from 2008 to 2010 (n = 2499). From 1 January 2008 to 24 March 2009 all women received prophylactic oxytocin 5–10 units slow push intravenously at delivery, after which all patients received 100 μg intravenous carbetocin. Outcomes were PPH (≥1000 mL) and the requirement of secondary uterotonics. A post hoc cost analysis was also performed. Results: A total of 1467 and 1024 patients received carbetocin and oxytocin, respectively. Incidence of PPH ≥1000 mL was 7.8% for carbetocin compared to and 9.7% for oxytocin (odds ratio (OR) 0.79, 95% CI 0.59–1.05). Moderate blood loss >500 mL was significantly reduced with carbetocin; occurring in 27.3% versus 39.4% (OR 0.57, 95% CI 0.49–0.68). There was a 20.0% reduction in secondary uterotonic treatment with carbetocin (OR 0.42, 95% CI 0.35–0.49). Average drug costs were lower with oxytocin at $4.74 versus $36.42/patient. However, the 1.9% reduction in PPH with carbetocin resulted in a $63.46 reduction in cost per patient, with a cost‐effectiveness ratio of $1667 to prevent one case of PPH ≥1000 mL. Conclusions: Carbetocin reduced moderate blood loss >500 mL, but not PPH ≥1000 mL. Carbetocin conferred a 20% reduction in secondary uterotonic treatment, as well as lowering direct medical costs. [ABSTRACT FROM AUTHOR]

Introduction: Cost of illness studies are essential to estimate societal costs of chronic inflammatory demyelinating polyneuropathy (CIDP) and identify cost-driving factors.Methods: In total, 108 patients were recruited from 3 specialized neuroimmunological clinics. Costs were calculated for a 3-month period, including direct and indirect costs. The following outcomes were assessed: inflammatory neuropathy cause and treatment disability scale, Mini-Mental State Examination, Beck Depression Inventory, Charlson comorbidity index, EuroQol-5D, World Health Organization quality of life instrument, and socioeconomic status. Univariate and multivariate analyses were applied to identify cost-driving factors.Results: Total quarterly costs were €11,333. Direct costs contributed to 83% of total costs (€9,423), whereas indirect costs accounted for 17% (€1,910) of total costs. The cost of intravenous immunoglobulin (IVIg) was the main determinant of total costs (67%). Reduced health-related quality of life and depressive symptoms were identified as independent predictors of higher total costs.Discussion: CIDP is associated with high societal costs, mainly resulting from the cost of IVIg treatment. Muscle Nerve 58: 681-687, 2018. [ABSTRACT FROM AUTHOR]

Aims: TECOS, a cardiovascular safety trial ( ClinicalTrials.gov identifier: NCT00790205) involving 14 671 patients with type 2 diabetes and cardiovascular disease, demonstrated that sitagliptin was non‐inferior to placebo for the primary composite cardiovascular outcome when added to best usual care. This study tested hypotheses that medical resource use and costs differed between these 2 treatment strategies. Materials and methods: Information concerning medical resource use was collected on case report forms throughout the trial and was valued using US costs for: Medicare payments for hospitalizations, medical procedures and outpatient visits, and wholesale acquisition costs (WAC) for diabetes‐related medications. Hierarchical generalized linear models were used to compare resource use and US costs, accounting for variable intercountry practice patterns. Sensitivity analyses included resource valuation using English costs for a UK perspective. Results: There were no significant differences in hospitalizations, inpatient days, medical procedures, or outpatient visits during follow‐up (mean and median 3.0 years in both groups). Hospitalization rates appeared to diverge after 2 years, with lower rates among sitagliptin‐treated vs placebo patients after 2.5 years (relative rate, 0.90 [95% CI, 0.83‐0.97]; P = .01). Mean medical costs, exclusive of study medication, were 11 937 USD in the sitagliptin arm and 12 409 USD in the placebo arm (P = .06). Mean sitagliptin costs based on undiscounted WAC were 9978 USD per patient. Differential UK total costs including study drug costs were smaller (911 GBP), primarily because of lower mean costs for sitagliptin (1072 GBP). Conclusions: Lower hospitalization rates across time with sitagliptin slightly offset sitagliptin treatment costs over 3 years in type 2 diabetes patients at high risk for cardiovascular events. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous transluminal angioplasty (PTA) and surgical bypass (BYP) are treatment options for symptomatic peripheral arterial disease (PAD). PTA and BYP have different clinical outcomes and cost implications. This paper aims to compare hospital-related costs of PTA and BYP for PAD of the lower limbs in an Australian health service.Methods: A retrospective cost analysis using clinical and financial data from an urban, tertiary hospital was performed. Patient cohorts were matched to existing published studies and 3-year findings were calculated. Outcomes measured were mean initial admission cost; mean bed stay; mean complication rate; mean cost of re-intervention at 12 months and extrapolated mean cost at 3 years.Results: The mean total admission costs for PTA compared to BYP were $8758 vs. $27,849 (P < 0.001). Patients undergoing BYP were admitted for 10.25 vs. 3.77 nights (P < 0.001). The complication rate was greater in the BYP group for infection only. Re-intervention was required by 13% of the PTA group and 16% of the BYP group, at a mean cost of $11,798 and $14,728, respectively (P = 0.453). The extrapolated total mean cost at 3 years was higher in the BYP group for patients with both intermittent claudication ($26,764 vs. $11,402) and critical limb ischaemia ($27,719 vs. $12,655).Conclusions: In this cohort, PTA is a favourable alternative to BYP for PAD of the lower limbs as it is less costly, does not result in a greater re-intervention rate at 1 year and has been previously demonstrated to have comparable clinical outcomes. Given the limitations of this retrospective analysis, a prospective cost-effectiveness analysis is recommended. [ABSTRACT FROM AUTHOR]

Background: Little progress has been made towards community participation of people with intellectual disability despite it being a policy aim since the 1980s. We aimed to identify the features of programmes designed to support community participation. Method: A scoping review was conducted of peer‐reviewed literature between 2000 and 2015, about interventions to support community participation for adults with intellectual disability. Results: A small body of evidence relates to the design and effectiveness of interventions to enhance community participation. Seventeen studies reported programmes reflecting three conceptualizations of community participation (as social relationships, as convivial encounter and as belonging) that used strategies such as active mentoring, facilitative support worker practice and arts‐based programmes. Conclusions: Studies showed the diverse and person‐centred nature of community participation and demonstrated the need for larger‐scale studies of promising interventions that include details of costs, and strategies to guide implementation of policies to support community participation. [ABSTRACT FROM AUTHOR]

SUMMARY Background International guidelines recommend treatment of anaemia due to chronic kidney disease (CKD) with erythropoiesis-stimulating agents (ESAs). Objective To document the time required and the cost in terms of nursing time to prepare and administer ESAs to patients on facility based haemodialysis (HD) with anaemia due to CKD before and after the introduction of long-acting ESAs. Design A time and motion study was implemented at four HD units in Australia to determine the time and costs associated with preparing and administering ESAs before and after the introduction of long-acting ESAs. Participants This was a prospective, observational study of workplace practices at four HD units in Australia. Measurements Outcome data included the time taken to prepare, and administer ESAs. Results The time costs of preparation and administration per patient per year had a wide variability within each unit and ranged from Australian AUD$55.75 (38 euros) to AUD$90.49 (62 euros) before the introduction of long-acting ESAs. This dropped by 73-80% following the introduction of long-acting ESAs, representing an annual cost savings of between AUD$2,591 and AUD$5,914 if all patients on HD were switched to a long acting ESA. Conclusion Switching from a short-acting to a long-acting ESA in HD units leads to a significant reduction in time costs of health professionals in preparation and administration of ESAs by up to 80%. Practical application: This time and motion study has added further evidence on reduction of human effort by taking advantages of new research development, such as the long acting ESAs. [ABSTRACT FROM AUTHOR]

Pressure ulcers represent a major current health problem and cause an important economic impact on the healthcare system. Most studies on the prevention of pressure ulcers have been carried out in hospital contexts, with respect to the use of hyperoxygenated fatty acids (HOFA), and to date no studies have specifically examined the use of olive oil-based treatments. Aim: To evaluate the cost of using extra virgin olive oil, rather than HOFA, in the prevention of pressure ulcers among persons with impaired mobility and receiving home care. Study Design: Cost minimization analysis of the results obtained from a noninferiority, triple-blind, parallel, multicenter, randomized clinical trial. Population attending primary healthcare centers in Andalusia (Spain). Study sample: 831 immobilized patients at risk of suffering pressure ulcers. These persons were included in the study and randomly assigned as follows: 437 to the olive oil group and 394 to the HOFA group. At the end of the follow-up period, the results obtained by the olive oil group were not inferior to those of the HOFA group, and did not exceed the 10% delta limit. The total treatment cost for 16 weeks was €19,758 with HOFAs and €9,566 with olive oil. Overall, the olive oil treatment was €10,192 less costly. It has been concluded the noninferiority of olive oil makes this product an effective alternative for the prevention of pressure ulcers in patients who are immobilized and in a domestic environment. This treatment enables considerable savings in direct costs. Trial registration: Identifier: NCT01595347. Date: 2011-2013 [ABSTRACT FROM AUTHOR]

Introduction: Rapid scale-up of antiretroviral therapy (ART) in the context of financial and health system constraints has resulted in calls to maximize efficiency in ART service delivery. Adopting differentiated care models (DCMs) for ART could potentially be more cost-efficient and improve outcomes. However, no study comprehensively projects the cost savings across countries. We model the potential reduction in facility-level costs and number of health workers needed when implementing two types of DCMs while attempting to reach 90-90-90 targets in 38 sub-Saharan African countries from 2016 to 2020. Methods: We estimated the costs of three service delivery models: (1) undifferentiated care, (2) differentiated care by patient age and stability, and (3) differentiated care by patient age, stability, key vs. general population status, and urban vs. rural location. Frequency of facility visits, type and frequency of laboratory testing, and coverage of community ART support vary by patient subgroup. For each model, we estimated the total costs of antiretroviral drugs, laboratory commodities, and facility-level personnel and overhead. Certain groups under four-criteria differentiation require more intensive inputs. Community-based ART costs were included in the DCMs. We take into account underlying uncertainty in the projected numbers on ART and unit costs. Results: Total five-year facility-based ART costs for undifferentiated care are estimated to be US$23.33 billion (95% confidence interval [CI]: $23.3-$23.5 billion). An estimated 17.5% (95% CI: 17.4%-17.7%) and 16.8% (95% CI: 16.7%-17.0%) could be saved from 2016 to 2020 from implementing the age and stability DCM and four-criteria DCM, respectively, with annual cost savings increasing over time. DCMs decrease the full-time equivalent (FTE) health workforce requirements for ART. An estimated 46.4% (95% CI: 46.1%-46.7%) fewer FTE health workers are needed in 2020 for the age and stability DCM compared with undifferentiated care. Conclusions: Adopting DCMs can result in significant efficiency gains in terms of reduced costs and health workforce needs, even with the costs of scaling up community-based ART support under DCMs. Efficiency gains remained flat with increased differentiation. More evidence is needed on how to translate analyzed efficiency gains into implemented cost reductions at the facility level. [ABSTRACT FROM AUTHOR]

The objective of this systematic review is to identify current computer-assisted technologies used for managing patients with a need to re-establish craniofacial appearance, subjective discomfort and stomatognathic function, and the extent of their clinical documentation. Electronic search strategies were used for locating clinical studies in MEDLINE through PubMed and in the Cochrane library, and in the grey literature through searches on Google Scholar. The searches for commercial digital products for use in oral rehabilitation resulted in identifying 225 products per November 2016, used for patient diagnostics, communication and therapy purposes, and for other computer-assisted applications in context with oral rehabilitation. About one-third of these products were described in about 350 papers reporting from clinical human studies. The great majority of digital products for use in oral rehabilitation has no clinical documentation at all, while the products from a distinct minority of manufacturers have frequently appeared in more or less scientific reports. Moore's law apply also to digital dentistry, which predicts that the capacity of microprocessors will continue to become faster and with lower cost per performance unit, and innovative software programs will harness these improvements in performance. The net effect is the noticeable short product life cycle of digital products developed for use in oral rehabilitation and often lack of supportive clinical documentation. Nonetheless, clinicians must request clinically meaningful information about new digital products to assess net benefits for the patients or the dental professionals and not accept only technological verbiage as a basis for product purchases. [ABSTRACT FROM AUTHOR]

Background In the UK, people with intellectual disabilities who exhibit aggressive behaviour often receive community-based specialist health services from a community learning disability team ( CLDT). Our aim was to estimate costs associated with this provision and to identify predictors of higher costs. Method Costs were estimated for 60 adults with intellectual disabilities and aggressive behaviour who attended specialist psychiatric outpatient clinics in the West Midlands region of the UK, including contact time with members of the CLDT and use of psychotropic medication over a 12-month period. Results Mean total cost of 12-month service provision was £418 (95% confidence interval [ CI] £299-557). Mean total cost of 12-month psychotropic medication was £369 (95% CI £256-492). Amongst individual members of the CLDT, mean costs were highest for psychiatrists (£181) and relatively lower for community nurses (£70) and clinical psychologists (£30), and lowest for physiotherapists (£13). Male sex, presence of expressive verbal communication and presence of epilepsy were independently associated with 12-month medication and service use costs, accounting for 23% of the variance in cost. Conclusions It seems that in terms of costs, there is an overreliance on medication and psychiatrists and a relatively lesser reliance on other CLDT members such as community nurses and clinical psychologists for the management of aggressive behaviour in adults with intellectual disabilities within community settings. Health commissioners may wish to explore this relative cost discrepancy further and try to redress the balance where appropriate. [ABSTRACT FROM AUTHOR]

This study, conducted from a government program perspective, compared the incremental cost-effectiveness of oral health interventions, in particular their delivery to underserved populations in whom dental sealants constitute an important, high-yielding complement to toothbrushing in dental-caries prevention. The study data concern the relative cost-effectiveness of three sealant materials in four approaches to prevent cavitated dentine carious lesions in permanent molars in a community intervention trial among school-age children in Wuhan, China. The four approaches were high-viscosity glass-ionomer cement without heat application ( HVGIC); high-viscosity glass-ionomer cement with heat application [light-emitting diode ( LED) thermocured HVGIC]; glass-carbomer; and composite resin. The costs studied were: cost of sealing permanent molars; adverse event costs for restoring cavitated dentine carious lesions developing within 4 yr in study data; and projections of 1,000 sealants per group. Preventing one more cavitated dentine carious lesion cost US$105 for the study data when comparing HVGIC ( n = 405) with composite resin ( n = 396) and US$59 per 1,000 sealants in the projections; LED thermocured HVGIC compared with composite resin cost US$115 for one more cavitated lesion and US$52 per 1,000 sealants, respectively. Although more expensive than composite resin, LED thermocured HVGIC was identified as the most cost-effective among the sealant materials studied. Ease of application, minimal technical and infrastructure requirements, and cost-effectiveness make glass-ionomers a practicable option for governments making decisions under economic constraints. [ABSTRACT FROM AUTHOR]

This observational case series in 65 premenopausal women with abnormal uterine bleeding evaluated whether transvaginal ultrasound followed by saline infusion sonohysterography ( SIS) prevented unnecessary hysteroscopy. Although SIS indicated that hysteroscopy was unnecessary in eight women, this benefit was offset by the invasive nature of the scan, the number of endometrial abnormalities falsely detected by SIS and the cost of the additional investigation. [ABSTRACT FROM AUTHOR]

Objectives To examine potentially inappropriate medication ( PIM) use in older adults initiating an antimuscarinic medication for the treatment of overactive bladder ( OAB). Design Retrospective database analysis. Setting Medical and pharmacy claims data. Participants Medicare Advantage Prescription Drug Plan members aged 65 and older newly initiated on an antimuscarinic OAB treatment were identified and assigned to PIM and non- PIM comparison groups based on 2012 American Geriatrics Society Beers Criteria and/or the presence of an anticholinergic medication interaction at the time of initiation of treatment (N = 66,275). Measurements Healthcare costs and OAB medication use. Results Of members initiated on an antimuscarinic OAB medication, 31.1% had a drug-drug or drug-disease or syndrome interaction. Dementia was the most common disease or syndrome interaction (11.3%), followed by constipation (8.6%) and delirium (2.9%). Paroxetine (2.6%), amitriptyline (2.2%), cyclobenzaprine (1.7%), and meclizine (1.6%) were the most common interacting medications. Subjects in the PIM group had greater healthcare costs over 12 months of follow-up ($12,001) than those in the non- PIM group ($9,373) after controlling for baseline characteristics ( P < .001). There was no difference between the PIM and the non- PIM groups in odds of discontinuing OAB treatment at 12 months after controlling for baseline characteristics (odds ratio = 0.98, 95% confidence interval = 0.89-1.07, P = .63). Conclusion Potentially inappropriate medication use was highly prevalent and was associated with greater total healthcare costs. Providers should carefully consider medical history and concurrent medication use when initiating antimuscarinic medication for the treatment of OAB. Development of interventions to reduce potentially inappropriate use of antimuscarinics in individuals with OAB is warranted. [ABSTRACT FROM AUTHOR]

Objectives: To undertake a cost-effectiveness analysis of outpatient uterine polypectomy compared with standard inpatient treatment under general anaesthesia.Design: Economic evaluation carried out alongside the multi-centre, pragmatic, non-inferiority, randomised controlled Outpatient Polyp Treatment (OPT) trial. The UK National Health Service (NHS) perspective was used in the estimation of costs and the interpretation of results.Setting: Thirty-one secondary care UK NHS hospitals between April 2008 and July 2011.Participants: Five hundred and seven women with abnormal uterine bleeding and hysteroscopically diagnosed endometrial polyps.Interventions: Outpatient uterine polypectomy versus standard inpatient treatment. Clinicians were free to choose the technique for polypectomy within the allocated setting.Main Outcome Measures: Patient-reported effectiveness of the procedure determined by the women's self-assessment of bleeding at 6 months, and QALY gains at 6 and 12 months.Results: Inpatient treatment was slightly more effective but more expensive than outpatient treatment, resulting in relatively high incremental cost-effectiveness ratios. Intention-to-treat analysis of the base case at 6 months revealed that it cost an additional £9421 per successfully treated patient in the inpatient group and £ 1,099,167 per additional QALY gained, when compared with outpatient treatment. At 12 months, these costs were £22,293 per additional effectively treated patient and £445,867 per additional QALY gained, respectively.Conclusions: Outpatient treatment of uterine polyps associated with abnormal uterine bleeding appears to be more cost-effective than inpatient treatment at willingness-to-pay thresholds acceptable to the NHS.Tweetable Abstract: HTA-funded OPT trial concluded that outpatient uterine polypectomy is cost-effective compared with inpatient polypectomy. [ABSTRACT FROM AUTHOR]

Objectives: Situational analysis of lymphatic filariasis (LF) morbidity and its management in Ahanta West, Ghana, to identify potential barrier to healthcare for LF patients.Methods: Lymphoedema and hydrocoele patients were identified by community health workers from a subset of villages, and were interviewed and participated in focus group discussions to determine their attitudes and practices towards managing their morbidity, and their perceived barriers to accessing care. Local health professionals were also interviewed to obtain their views on the availability of morbidity management services in the district.Results: Sixty-two patients (34 lymphoedema and 28 hydrocoeles) and 13 local health professionals were included in the study. Lymphoedema patients predominantly self-managed their conditions, which included washing with soap and water (61.8%), and exercising the affected area (52.9%). Almost 65% of patients had sought medical assistance at some stage, but support was generally limited to receiving tablets (91%). Local health professionals reported rarely seeing lymphoedema patients, citing stigma and lack of provisions to assist patients as a reason for this. Almost half of hydrocoele patients (44%) chose not to seek medical assistance despite the negative impact it had on their lives. Whilst surgery itself is free with national health insurance, 63% those who had not sought treatment stated that indirect costs of surgery (travel costs, loss of earnings, etc.) were the most prohibitive factor to seeking treatment.Conclusions: The information obtained from this study should now be used to guide future morbidity strategies in building a stronger relationship between the local health services and LF patients, to ultimately improve patients' physical, psychological and economic wellbeing. [ABSTRACT FROM AUTHOR]

Background Results of a previously published study demonstrated a significant decrease in transfusion requirements and calculated blood loss for pediatric major craniosynostosis surgery, if a ROTEM® FIBTEM trigger of <13 mm (early substitution group) was applied as compared to a trigger of <8 mm (conventional group). The aim of this study was a posthoc analysis of the costs for this coagulation management. Methods The total volume as well as the number of units or bags for all transfused blood products and coagulation factors were recorded for each case. The number of laboratory and point-of-care coagulation tests was also analyzed. Total blood product costs were calculated according to the local prices per unit. Results The total cost for all transfused/administered blood products/coagulation factors per patient was a median of 1023 EUR ( IQR 850 EUR-1058 EUR) in the early substitution group as compared to a median of 910 EUR ( IQR 719 EUR-1351 EUR) in the conventional group ( P = 0.81). No difference in the number of coagulation tests performed was observed. Conclusion In this study, the use of a higher fibrinogen trigger was not linked to a significant increase in total costs for transfused blood products and coagulation factors, and may offer an economically equivalent approach to coagulation management. [ABSTRACT FROM AUTHOR]

Background: A health utility value represents an individual's preference for living in a specific health state and is used in cost-utility analyses. This study investigates the impact of continuing medical therapy on health utility outcomes in patients with chronic rhinosinusitis (CRS). Methods: The Medical Outcomes Study Short Form- 6D (SF-6D) questionnaire was administered to patients prospectively enrolled in a longitudinal study examining treatment outcomes for CRS. Patients were prescribed robust, initial medical therapy and then elected to continue with medical therapy (n = 40) or undergo endoscopic sinus surgery (ESS), followed by medical therapy (n = 152). Patients observed through treatment crossover to ESS were also evaluated (n = 20). Health utility values (SF-6D) were generated at baseline, 6-months, and 12-months follow-up for both cohorts and evaluated using repeated measures analysis of variance (ANOVA). Results: Treatment crossover patients were found to have a significantly higher prevalence of previous sinus surgery compared to medical management (χ² = 6.91; p = 0.009) and surgical intervention (χ² = 8.11; p = 0.004) subgroups. Mean baseline utility value for the medical therapy cohort was significantly better compared to the ESS cohort (mean ± standard deviation; 0.76 ± 0.12 vs 0.70 ± 0.15; p = 0.023). Significant improvement in health utility was reported in the ESS cohort (F(2) = 37.69; p < 0.001), whereas values remained stable, without significant improvement, in both themedical therapy cohort (F(2) =0.03; p=0.967) and treatment crossover cohort (F(2) = 2.36; p = 0.115). Conclusion: Patients electing continued medical management report better baseline health utility compared to patients electing ESS. Patients electing ESS show signifi- cant improvement in health utility, whereas those electing continuedmedical management demonstrate stable health utility over 12 months. [ABSTRACT FROM AUTHOR]

Background Initial rehabilitation in juvenile patients with oligodontia is a major challenge for the dentist. Conventional permanent prosthetic and/or implantological treatment options alongside permanent natural teeth are contraindicated in growing patients, because their skeletal development is still in progress. Case Report A non-invasive temporary-fixed treatment option for an adolescent patient is presented by the use of adhesively cemented (non-prep) all-ceramic onlays of primary teeth. The outcome of treatment was monitored over a period of 4 years. Conclusion Long-term preservation of persistent primary teeth may be a meaningful alternative to removable dentures in growing patients with oligodontia. Intermediate rehabilitation should cause no more than mild psychological stress for the patient and improve quality of life, especially when extensive orthodontic and/or implantological treatment is planned at the end of the patient's skeletal growth. [ABSTRACT FROM AUTHOR]

Aim The study aimed to compare the rate of success and cost of anal fistula plug ( AFP) insertion and endorectal advancement flap ( ERAF) for anal fistula. Method Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost. Results Seventy-one patients ( AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group ( P = 1.00). The median length of stay was 1.23 and 2.0 days ( P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 ( P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost ( P = 0.023). Conclusion Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay. [ABSTRACT FROM AUTHOR]

Objectives Gingival overgrowth ( GO) is an adverse drug reaction in patients using calcium channel blockers ( CCBs). Little is known about the effects of CCBs on the management of periodontal diseases. The aim of this study was to assess how the use of CCBs affects the long-term supportive treatment and outcomes in patients undergoing periodontal therapy. Methods All patients using CCBs during the initial treatment and/or the supportive periodontal therapy ( SPT) were selected from a periodontal practice. Patients were scored using a Gingival Overgrowth Index ( GOI). The effects of CCB types and dosages were assessed in terms of the frequency and the severity of GO, treatment responses, substitutions and extra treatment costs. Mean values, Standard Deviation ( SD) and range were calculated. The Mann-Whitney test was used to assess statistically significant differences ( p < 0.05) for GO between patients with good and poor oral hygiene, differences between before and after terminating or replacing the CCBs, possible differences between drug dosages (Dihydropyridine 5 mg and 10 mg) and differences between three drug combinations ( CCB and inhibitors of the renin-angiotensin system ( IRAS), CCB and non- IRAS, CCB and statins). Results One hundred and twenty-four patients (58 females, 66 males, 4.6% of the patient population) were using CCBs. 103 patients were assessed. Average age was 66.53 years ( SD. 9.89, range 42-88) and the observation time was 11.30 years ( SD 8.06, range 1-27). Eighty-nine patients had GO, 75 of these required treatment for GO. Terminating or replacing with alternatives to CCBs resulted in significant decreases in GO ( p = 0.00016, p = 0.00068) respectively. No differences were found between good and poor oral hygiene ( p = 0.074), drug dosages or the various drug combinations. Surgical treatment was more effective than non-surgical treatment in controlling the GO. Long-term tooth loss was 0.11 teeth per patient per year. Forty-two patients needed re-treatments for GO, resulting in an extra life cost per patient of €13471 (discounted €4177). Conclusion The majority of patients (86.4%) using CCBs experienced GO. 47.2% of these experienced recurrence(s) of GO during the SPT and needed re-treatments with resulting added costs. The long-term tooth loss was considerably higher for patients using CCBs than for other patients groups from the same practice setting. [ABSTRACT FROM AUTHOR]

Objective To determine whether the utilization of healthcare resources is reduced after chronic migraine patients are treated for 6 months with onabotulinumtoxin A. Background Onabotulinumtoxin A is indicated for headache prophylaxis in patients with chronic migraine, but its effect on healthcare resource use is unknown. Methods We analyzed data from an open-label study of 230 chronic migraine patients refractory to ≥2 oral prophylactics who presented to a headache specialty clinic and who were treated with two cycles of onabotulinumtoxin A. Frequency and cost of migraine-related healthcare resource use, including visits to emergency departments, urgent care, or hospitalization, were compared for the 6 months before and after initial treatment. Costs were based on publicly available sources. Results Compared with the 6 months predating initial treatment, patients had 55% fewer emergency department visits (174 vs 385), 59% fewer urgent care visits (61 vs 150), and 57% fewer hospitalizations (19 vs 45) during the 6-month treatment period ( P < .01 for all). Analysis of treatment-related costs yielded an average reduction of $1219.33/patient, off-setting 49.7% of the total estimated cost for 6 months of treatment with onabotulinumtoxin A. Conclusions Although we are unable to distinguish onabotulinumtoxin A's treatment effect from other potential confounding variables, our analysis showed that severely afflicted, treatment-refractory patients with chronic migraine experienced a significant cost-offset through reduced migraine-related emergency department visits, urgent care visits, and hospitalizations in the 6 months following treatment initiation of onabotulinumtoxin A. Future analyses will assess the longer-term effect of onabotulinumtoxin A treatment and the potential contribution of regression to the mean. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Rapid response systems ( RRSs) are recommended by the Institute for Healthcare Improvement and implemented worldwide. Our study on the effects of an RRS showed a non-significant decrease in cardiac arrest and/or unexpected death from 0.5% to 0.25%. Unplanned intensive care unit ( ICU) admissions increased significantly from 2.5% to 4.2% without a decrease in APACHE II scores. In this study, we estimated the mean costs of an RRS per patient day and tested the hypothesis that admitting less severely ill patients to the ICU reduces costs. Methods A cost analysis of an RRS on a surgical ward, including costs for implementation, a 1-day training programme for nurses, nursing time for extra vital signs observation, medical emergency team ( MET) consults and differences in unplanned ICU days before and after RRS implementation. To test the hypothesis, we performed a scenario analysis with a mean APACHE II score of 14 points instead of the empirical 17.6 points for the unplanned ICU admissions, including 33% extra MET consults and 22% extra unplanned ICU admissions. Results Mean RRS costs were €26.87 per patient-day: implementation €0.33 (1%), training €0.90 (3%), nursing time spent on extended observation of vital signs €2.20 (8%), MET consults €0.57 (2%) and increased number of unplanned ICU days after RRS implementation €22.87 (85%). In the scenario analysis mean costs per patient-day were €10.18. Conclusions The costs for extra unplanned ICU days were relatively high but the remaining RRS costs were relatively low. The ' APACHE II 14' scenario confirmed the hypothesis that costs for the number of unplanned ICU days can be reduced if less severely ill patients are referred to the ICU. Based upon these findings, our hospital stimulates earlier referral to the ICU, although further implementation strategies are needed to achieve these aims. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that somatostatin reduces the occurrence of postoperative pancreatic fistula. However, no study to date has analyzed the cost effectiveness of this treatment. The purpose of this study was to analyze the cost effectiveness of prophylactic somatostatin use with respect to pancreatectomy. Methods: Review of prospectively collected 2002 patient hepato-pancreatico-biliary database from January 2007 to May 2012. Patients received somatostatin prophylactically at the discretion of their surgeon. Data were analyzed using univariate analysis to determine if somatostatin had an effect on imaging costs, lab costs, 'other' costs, PT/OT costs, surgery costs, room and board costs, and total hospital costs. Results: A total of 179 patients underwent pancreatectomy at a single teaching institution. Median total hospital costs were 90,673.50 (59,979-743,667) for patients who developed a postoperative pancreatic fistula versus 86,563 (39,190-463,601) for those who did not ( p = 0.004). Median total hospital costs were 89,369 (39,190-743,667) for patients who were administered somatostatin versus 85,291 (40,092-463,601) for patients who did not ( p = 0.821). Conclusions: Pancreatic fistulas significantly increase hospital costs, and somatostatin has been shown to decrease the rate of pancreatic fistula formation. Somatostatin has no significant effect on hospital costs. [ABSTRACT FROM AUTHOR]

Objective To present the results of a large series of patients with ovarian hyperstimulation syndrome treated with a conservative medical approach and to compare the cost of this treatment with outpatient management with paracentesis according to published data. Design Retrospective case series and cost analysis study using a decision-tree model. Setting University hospital. Population 496 consecutive patients with ovarian hyperstimulation syndrome treated in our center from 1991 to 2010. Methods All patients were treated with a conservative medical approach: (a) conservative outpatient approach: bed rest and a low-sodium diet or (b) hospitalized patients: bed rest, low-sodium diet, 20% albumin (60 g/day) and furosemide (20 mg/8 h). Main outcome measures Percentage of admissions, length of hospital stay and readmissions. Total cost of each therapeutic approach. Results (a) Conservative outpatient approach ( n = 377): all cases solved without admission. (b) Hospitalized patients with conservative medical treatment ( n = 119): 2.8 days of mean hospital stay, no patient required paracentesis or admission to intensive care unit. Readmissions: Five patients (4.2%) resolved on restarting medical treatment. (c) Cost-analysis comparison: Cost of the outpatient approach with paracentesis: US$980 (range US$519-3557). Cost of conservative medical treatment: US$570 (range US$232-1640). Conclusions Ovarian hyperstimulation syndrome can be safely managed with a conservative medical approach, which was not found to be more expensive than outpatient management with paracentesis. [ABSTRACT FROM AUTHOR]

Objective To explore the incremental effects of patient dependence and function on costs of care for patients with Alzheimer's disease (AD) and amnestic mild cognitive impairment (MCI) in Ireland. Methods Cost analysis based on reported resource use for a cross-section of 100 community-based people with AD and MCI. Formal care included general practice visits, hospitalizations, outpatient clinic consultations, accident and emergency visits, respite care, meals on wheels services and other health and social care professional consultations. Informal care included time input provided by caregivers. Resource unit costs were applied to value formal care and the opportunity cost method was used to value informal care. Patient dependence on others was measured using the Dependence Scale and patient functional capacity using the Disability Assessment for Dementia scale. Multivariate regression analysis was used to model the cost of care. Results Both dependence and function were independently and significantly associated with total formal and informal care cost: a one point increase in dependence was associated with a €796 increase in total cost and a one point improvement in function with a €417 reduction in total cost over 6 months. Patient function was significantly associated with formal care costs, whereas patient function and dependence were both significantly associated with informal care costs. Conclusion The costs of care for patients with AD and MCI in Ireland are substantial. Interventions that reduce patient dependence on others and functional decline may be associated with important economic benefits. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Laparoscopic inguinal hernia repair has been widely adopted. While the clinical advantages and disadvantages are well-quantified, the economic cost is less well-studied. Methods A retrospective audit and case review of a single-centre public hospital consecutive case series was performed using data captured from real-time stock usage tracking technology and review of electronic medical records. Results Laparoscopic inguinal hernia repair requires 11-min (21%) extra theatre time and costs $1268 (370%) more for single-use disposable equipment and prostheses. Conclusions Laparoscopic inguinal hernia repair does not require significantly more theatre time, but has a higher short-term in-hospital cost. Repair technique should be tailored according to patient factors. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the changes in pain severity and associated costs resulting from resource utilization and reduced productivity in patients with gabapentin-refractory peripheral neuropathic pain who switched to pregabalin therapy in primary care settings in Spain. Patients and Methods: This is a post hoc analysis of a 12-week, multicentre, noninterventional cost-of-illness study. Patients were included in the study if they were over 18 years of age and had a diagnosis of chronic, treatment-refractory peripheral neuropathic pain. The analysis included all pregabalin-naïve patients who had previously shown an inadequate response to gabapentin and switched to pregabalin. Severity of pain before and after treatment with pregabalin, alone or as an add-on therapy, was assessed using the Short-Form McGill Pain Questionnaire (SF-MPQ) and its related visual analogue scale (VA). Healthcare resource utilization, productivity (including lost-workday equivalents [LWDE]), and related costs were assessed at baseline and after pregabalin treatment. Results: A total of 174 patients switched to pregabalin had significant and clinically relevant reductions in pain severity (mean [SD] change on SF-MPQ VA scale, −31.9 [22.1]; P < 0.05 vs. baseline; effect size, 1.87). Reduction in pain was similar with both pregabalin monotherapy and add-on therapy. Significant reductions in healthcare resource utilization (concomitant drug use [in pregabalin add-on group], ancillary tests, and unscheduled medical visits) were observed at the end of trial. Additionally, there were substantial improvements in productivity, including a reduction in the number of LWDE following pregabalin treatment (−18.9 [26.0]; P < 0.0001). These changes correlated with substantial reductions in both direct (−652.9 ± 1622.4 €; P < 0.0001) and indirect healthcare costs (−851.6 [1259.6] €; P < 0.0001). Conclusions: The cost of care in patients with gabapentin-refractory peripheral neuropathic pain appeared to be significantly reduced after switching to pregabalin treatment, alone or in combination with other analgesic drugs, in a real-life setting. [ABSTRACT FROM AUTHOR]

Objective: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. Methods: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. Results: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) ( p¼0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. Conclusion: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Appropriate use of diagnostic and treatment modalities are essential for rational use of resources. The aim of this study is to evaluate the use of diagnostic modalities and different treatment options and their economic impacts following an acute ankle distortion resulting from an occupational accident. We evaluated the type-of-treatment impact on the victims' course of recovery as well as its impact on the associated accident costs. Research was carried out in Belgium. Methods An ankle distortion victims' database consisting of 200 cases of (Belgian) occupational accidents during the period 2005–2007 was analysed. Results Patients who were prescribed immobilization or the use of adjuvant support or physical therapy (118 cases) were not employed during a period of 37 days on average, with a mean total cost of 3140.14 Euros caused by the ankle sprain. Patients without any adjuvant therapy (82 cases) were characterized by an unemployment rate of 15 days on average, and a total cost of 1077.86 Euros. Cast immobilization, although its application is not supported by evidence-based literature, was still applied in 36% of the population studied and resulted in the longest average absence of work of 42 days with an obvious significant increase in medical and total costs. Conclusions Our results show a high rate of inappropriate use of cast immobilizations for ankle distortions. From an economic point of view and for the same clinical endpoint (being full resumption of the occupational activities), simple conventional treatment, consisting of rest, ice, compression and elevation at diagnosis with allowance of early weight bearing in the further clinical course, leads to the quickest full resumption of activities in combination with the lowest medical costs, if compared with any other kind of treatment. [ABSTRACT FROM AUTHOR]

Title. Search and destroy policy for methicillin-resistant Staphylococcus aureus: cost-benefit analysis.Aim. This paper is a report of a cost-benefit analysis of a 'search and destroy' policy as compared with the absence of such a policy for methicillin-resistant Staphylococcus aureus from a hospital perspective, including the impact of nurses on the costs and benefits of this policy.Background. The 'search and destroy' policy involved screening, isolation, decontamination and antimicrobial treatment of methicillin-resistant Staphylococcus aureus.Methods. A prospective analysis was carried out in one intensive care unit and one gerontology unit of a university hospital in 2007. A benefit-cost ratio was calculated by dividing the benefits of the 'search and destroy' policy by its costs related to screening and quarantine. Benefits consisted of hospital savings through avoidance of isolation, decontamination, antimicrobial therapy and extended hospital stay of affected patients. Resource utilization data were gathered from a time-and-motion study of nurses, patient medical records, hospital databases and the literature. Unit costs pertained to 2005.Results. The benefit-cost ratio of the 'search and destroy' policy as compared with the absence of such a policy was 1·17 in the intensive care unit and 1·16 in the gerontology unit. Nurses accounted for 23% of costs and 16% of benefits of the policy as compared with the absence of such a policy in the intensive care unit, and 19% of costs and 28% of benefits in the gerontology unit.Conclusion. Hospital managers should consider implementing a 'search and destroy' policy for methicillin-resistant Staphylococcus aureus and to support the contribution of nurses and other healthcare workers to such a policy. [ABSTRACT FROM AUTHOR]

Rationale Depressive disorders generate severe personal burden and high economic costs. Cost-utility analyses of the different therapeutical options are crucial to policy-makers and clinicians. Previous cost-utility studies, comparing selective serotonin reuptake inhibitors and tricyclic antidepressants, have used modelling techniques or have not included indirect costs in the economic analyses. Objective To determine the cost-utility of fluoxetine compared with imipramine for treating depressive disorders in primary care. Methods A 6-month randomized prospective naturalistic study comparing fluoxetine with imipramine was conducted in three primary care centres in Spain. One hundred and three patients requiring antidepressant treatment for a DSM-IV depressive disorder were included in the study. Patients were randomized either to fluoxetine (53 patients) or to imipramine (50 patients) treatment. Patients were treated with antidepressants according to their general practitioner's usual clinical practice. Outcome measures were the quality of life tariff of the European Quality of Life Questionnaire: EuroQoL-5D (five domains), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and after 1, 3 and 6 months. Incremental cost-utility ratios (ICUR) were obtained. To address uncertainty in the ICUR's sampling distribution, non-parametric bootstrapping was carried out. Results Taking into account adjusted total costs and incremental quality of life gained, imipramine dominated fluoxetine with 81.5% of the bootstrap replications in the dominance quadrant. Conclusion Imipramine seems to be a better cost-utility antidepressant option for treating depressive disorders in primary care. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of a decision aid for menorrhagia on treatment outcomes and costs over a 12-month follow-up. Design: Randomized trial and pre-trial prospective cohort study. Setting and participants: Gynaecology outpatient clinics in 14 Finnish hospitals, 363 (randomized trial) plus 206 (cohort study) patients with menorrhagia. Intervention: A decision aid booklet explaining menorrhagia and treatment options, mailed to patients before their first clinic appointment. Main outcome measures: Health related quality of life, psycho- logical well-being, menstrual symptoms, satisfaction with treatment outcome, use and cost of health care services. Results: All study groups experienced overall improvement in health- related quality of life, anxiety, and psychosomatic and menstrual symptoms, but not in sexual life. Treatment in the intervention group was more active than in the control group, with more frequent course of medication and less undecided treatments. However, there were no marked disparities in health outcomes, satisfaction with treatment outcome and costs. Total costs (including productivity loss) per woman because of menorrhagia over the I 2-month follow-up were 2760€ and 3094€ in the intervention and control group, respectively (P = 0.1). The pre-trial group also had a significantly lower rate of uterus saving surgery compared with the control group, but no difference in costs because of menorrhagia treatment. Conclusion: Despite some differences in treatment courses, a decision aid for menorrhagia in booklet form did not increase the use of health services or treatment costs, nor had it impact on health outcomes or satisfaction with outcome of treatment. [ABSTRACT FROM AUTHOR]

: Patients diagnosed with irritable bowel syndrome may have coeliac disease. : To evaluate the cost-effectiveness of coeliac disease testing in suspected irritable bowel syndrome. : We used decision analysis to estimate the number of coeliac disease cases detected, quality-adjusted life-years gained, and costs resulting from testing suspected irritable bowel syndrome patients for tissue transglutaminase antibody or an antibody panel (tissue transglutaminase, gliadin, total immunoglobulin A). Positive tests prompted endoscopic biopsy. A gluten-free diet improved quality of life in coeliac disease. : Assuming a coeliac disease prevalence of 3%, tissue transglutaminase detected 28 and the panel detected 29 of 30 coeliac disease cases among 1000 suspected irritable bowel syndrome patients. The cost/case detected was $4600 with tissue transglutaminase and $8800 with the panel. The cost/quality-adjusted life-year gained with tissue transglutaminase was $7400, and the incremental cost/quality-adjusted life-year gained for the panel vs. tissue transglutaminase was $287 000. Tissue transglutaminase cost under $100 000/quality-adjusted life-year gained at a coeliac disease prevalence ≥1.1%, assuming a modest utility gain of 0.005 with coeliac disease diagnosis. : Testing for coeliac disease in patients with suspected irritable bowel syndrome is likely to be cost-effective even at a relatively low coeliac disease prevalence and with small improvements in quality of life with a gluten-free diet. [ABSTRACT FROM AUTHOR]

Summary. Participants in an international conference on prophylactic therapy for severe haemophilia developed a consensus summary of the findings and conclusions of the conference. In the consensus, participants agreed upon revised definitions for primary and secondary prophylaxis and also made recommendations concerning the need for an international system of pharmacovigilance. Considerations on starting prophylaxis, monitoring outcomes, and individualizing treatment regimens were discussed. Several research questions were identified as needing further investigation, including when to start and when to stop prophylaxis, optimal dosing and dose interval, and methods for assessment of long-term treatment effects. Such studies should include carefully defined cohorts, validated orthopaedic and quality-of-life assessment instruments, and cost-benefit analyses. [ABSTRACT FROM AUTHOR]

ObjectiveThis study was carried out to assess both the efficacy and the economic advantages of two different surgical techniques in the treatment of ovarian cysts in women of reproductive age. DesignA prospective randomized clinical study. SettingEndocrinological Gynaecology Department of the Catholic University of S. Cuore, Rome. SubjectsThese were 68 women of reproductive age (16–39 years) who were hospitalized for ovarian cysts which had persisted for at least 3 months, or who were noted to have an increase in ovarian volume detected by consecutive ultrasound investigations. InterventionsOf these patients, 34 received laparotomic treatment using a Pfannewstiel incision and traditional techniques. The other 34 patients underwent a laparoscopic stripping of the capsule of the cyst with no sutures on the ovary. ResultsThe two techniques showed similar levels of safety and efficacy. The comparison of direct and indirect costs for the two procedures showed an average total cost of $4940 for laparotomic surgery and $3543 for laparoscopy. ConclusionsThe present study demonstrates that ovarian cysts can be as well treated using laparoscopic access as with laparotomy, but with an average cost reduction of 28% for the former. [ABSTRACT FROM AUTHOR]

Background. Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using the clinical literature, claims databases, and a panel of experienced practitioners, the relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study. Methods. We reviewed the clinical literature for the following genital wart therapies: podofilox, podophyllin, trichloroacetic acid, cryotherapy, and laser therapy, focusing on their relative efficacy. Physicians experienced in treating genital warts defined standard treatment protocols for men and women patients with moderate wart burdens. Using national claims data and protocols developed by physicians, we derived three economic models based on provider charges, third-party payments, and a resource- based relative value scale, respectively. Results. The literature review demonstrated highly variable success and recurrence rates among treatment methods and failed to show that one treatment provides consistently superior efficacy. In the economic models, treating women generally proved more costly than treating men per episode of care. This was due to the need for more extensive follow-up visits in the treatment of women. Total costs were highest for cryotherapy and lowest for a patient- applied therapy that reduced the need for follow-up visits. Conclusions. Clinicians should consider both clinical and cost issues when choosing the appropriate treatment for patients with genital warts. [ABSTRACT FROM AUTHOR]

Objective: To evaluate institutional experiences regarding laparoscopic salpingo-oophorectomy in breast cancer patients and to compare the technique with gonadotropin-releasing hormone (GnRH) analogs among premenopausal women with hormone-sensitive breast cancer.Methods: Between 2004 and 2009, 103 women with breast cancer underwent laparoscopic salpingo-oophorectomy at Addenbrooke's Hospital, Cambridge, UK. All relevant medical records-including reasons for salpingo-oophorectomy, peri-operative events, and subsequent follow-up-were reviewed.Results: In the study period, 3 (2.9%) women experienced a recurrence of breast cancer but none had primary peritoneal/ovarian cancer within a median follow-up interval of 34 months (range, 0-70 months). No operative complications were noted among these women and all of them went home on the day of their operation.Conclusion: Laparoscopic salpingo-oophorectomy seems to be a safe, permanent, and cost-effective method of ovarian ablation compared with the use of GnRH analogs. Salpingo-oophorectomy also considerably reduces the risk of subsequent ovarian/fallopian tube malignancy in this high-risk population. [ABSTRACT FROM AUTHOR]

Focuses on the consideration of cost in treating benign prostatic hyperplasia. Decision of patients in their preference of maintaining cost-efficiency and the best treatment at the same time; Evaluation of newer invasive treatments based on outcome data from randomized controlled trials; Comparison on the cost analysis with established therapies.

More money The government has announced £48 million in funding for research as part of the Biomedical Catalyst initiative, operated jointly by the Medical Research Council and the Technology Strategy Board to support academic research and small and medium enterprises with innovative solutions to health care challenges. Projects benefiting from the new money include a blood test that could be used to assist the diagnosis of Alzheimer's disease and a new gene therapy for Parkinson's disease. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Why should American headache and migraine patients still be treated with butalbital containing medicine?" by P. C. Tfelt-Hansen PC and H-C Diener in the April 2012 issue.

Summary Objective In 2009, a random survey was conducted in Muzaffarpur district to document the clinical outcomes of visceral leishmaniasis patients (VL) treated by the public health care system in 2008, to assess the effectiveness of miltefosine against VL. We analysed the operational feasibility and cost of such periodic random surveys as compared with health facility-based routine monitoring. Methods A random sample of 150 patients was drawn from registers kept at Primary Health Care centres. Patient records were examined, and the patients were located at their residence. Patients and physicians were interviewed with the help of two specifically designed questionnaires by a team of one supervisor, one physician and one field worker. Costs incurred during this survey were properly documented, and vehicle log books maintained for analysis. Results Hundred and 39 (76.7%) of the patients could be located. Eleven patients were not traceable. Per patient, follow-up cost was US$ 15.51 and on average 2.27 patients could be visited per team-day. Human resource involvement constituted 75% of the total cost whereas involvement of physician costs 51% of the total cost. Conclusion A random survey to document clinical outcomes is costly and labour intensive but gives probably the most accurate information on drug effectiveness. A health service-based retrospective cohort reporting system modelled on the monitoring system developed by tuberculosis programmes could be a better alternative. Involvement of community health workers in such monitoring would offer the additional advantage of treatment supervision and support. [ABSTRACT FROM AUTHOR]