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Objective: To assess the economic burden of tyrosine kinase inhibitor (TKI) treatment failure in chronic myeloid leukemia (CML), by assessing all-cause health care resource use (HCRU) and costs in the year after treatment failure by line of therapy (LOT; 1L/2L/3L) using real-world data.Methods: Treatment episodes initiating a TKI of interest (index TKI) during June 2008-December 2011 were identified from the IMS PharMetrics Plus Health Plan Claims Database for adult patients with CML diagnosis (ICD-9-CM 205.1x), 120 days pre-index continuous enrollment (CE) and no clinical trial participation. Episodes experiencing treatment failure, defined as switch to a non-index TKI or discontinuation of index TKI (gap of ≥ 60 days), and with 1 year CE post-failure, were analyzed. LOT was determined by number of unique TKIs used in the pre-index. All-cause HCRU and costs (2012 USD) in the 1 year post-failure were assessed by LOT, and the comparisons between 1L and 2L failures were also adjusted using multivariate generalized linear models (GLMs) to control for underlying differences.Results: A total of 706 episodes were identified (518 1L; 180 2L; 8 3L). Unadjusted HCRU over 1 year post-failure increased significantly. This was accompanied by a significant increase in unadjusted mean costs for 2L failures vs. 1L failures ($99,624 vs. $78,667, p = 0.021, Δ$20,957). Following the adjustment using GLMs, adjusted mean costs were 38% higher (95% CI 1.14-1.68), driven primarily by use of medical services. In adjusted analyses, compared to 1L, 2L failures had: 45% more ambulatory visits (mean 31 vs. 21, 95% CI 1.26-1.66), 75% higher risk of hospitalization (33% vs. 23% hospitalized, 95% CI 1.16-2.64), and 73% higher medical costs (95% CI 1.31-2.29). Medical costs comprised a greater proportion of total costs in 2L vs. 1L (55% vs. 44%); pharmacy costs did not increase significantly.Conclusions: The economic burden over 1 year post TKI failure increased with each sequential line of TKI treatment failure. [ABSTRACT FROM AUTHOR]

Background: Idiopathic pulmonary fibrosis (IPF) is a form of chronic fibrosing interstitial pneumonia characterized by progressive worsening of dyspnea and lung function, with a poor prognosis. The objective of this study was to determine treatment patterns, resource use and costs of managing Spanish patients with IPF.Methods: A three-round Delphi consensus panel of 15 clinical experts was held between December 2012 and June 2013 using questionnaires to describe the management of patients with IPF. A cost analysis based on Delphi panel estimates was made from the Spanish National Health System (NHS) perspective, including the direct costs of IPF diagnosis and management. Unit costs were applied to Delphi panel estimates of health resource use. Univariate sensitivity analyses were made to evaluate uncertainties in parameters.Results: The Delphi panel estimated that 20, 60 and 20% of IPF patients presented with stable disease, slow and rapid disease progression, respectively. The estimated annual cost per patient with stable disease, slow and rapid disease progression was €11,484, €20,978 and €57,759, respectively. This corresponds to a weighted average annual cost of €26,435 with itemized costs of €1,184 (4.5), €7,147 (27.0), €5,950 (22.5), €11,666 (44.1) and €488 (1.9%) for the diagnosis of IPF, treatment, monitoring, management of acute exacerbations and end-of-life care, respectively. The parameter that varied the annual cost per patient the most was resource use associated with acute exacerbations.Conclusions: The management of patients with IPF in Spain, especially patients with rapid disease progression, has a high economic impact on the NHS. [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]

Purpose: The authors evaluated the ability of a fibrin sealant (TISSEEL™: Baxter Healthcare Corp, Deerfield, IL, USA) to reduce the incidence of post-operative seroma following abdominal wall hernia repair.Methods: We performed a 4-year retrospective review of patients undergoing abdominal wall hernia repair, with and without TISSEEL, by a single surgeon (FEE) at The Johns Hopkins Hospital. Demographics, surgical risk factors, operative data and 30-day outcomes, including wound complications and related interventions, were compared. The quantity and cost of Tisseel per case was reviewed.Results: A total of 250 patients were evaluated: 127 in the TISSEEL group and 123 in the non-TISSEEL control group. The average age for both groups was 56.6 years (P = 0.97). The majority of patients were female (TISSEEL 52.8%, non-TISSEEL 56.1%, P = 0.59) and ASA Class III (TISSEEL 56.7%, non-TISSEEL 58.5%, P = 0.40). There was no difference in the average defect size for both groups (TISSEEL 217 ± 187.6 cm(2), non-TISSEEL 161.3 ± 141.5 cm(2), P = 0.36). Surgical site occurrences occurred in 18.1% of the TISSEEL and 13% of the non-TISSEEL group (P = 0.27). There was a trend towards an increased incidence of seroma in the TISSEEL group (TISSEEL 11%, non-TISSEEL 4.9%, P = 0.07). A total of $124,472.50 was spent on TISSEEL, at an average cost of $995.78 per case.Conclusions: In the largest study to date, TISSEEL™ application offered no advantage for the reduction of post-operative seroma formation following complex abdominal hernia repair. Moreover, the use of this sealant was associated with significant costs. [ABSTRACT FROM AUTHOR]

Introduction: Health technology assessment is not required for regulatory submission or approval in either the United States (US) or Japan. This study was designed as a cross-country evaluation of cost analyses conducted in the US and Japan based on the PRONOUNCE phase III lung cancer trial, which compared pemetrexed plus carboplatin followed by pemetrexed (PemC) versus paclitaxel plus carboplatin plus bevacizumab followed by bevacizumab (PCB).Methods: Two cost analyses were conducted in accordance with International Society For Pharmacoeconomics and Outcomes Research good research practice standards. Costs were obtained based on local pricing structures; outcomes were considered equivalent based on the PRONOUNCE trial results. Other inputs were included from the trial data (e.g., toxicity rates) or from local practice sources (e.g., toxicity management). The models were compared across key input and transferability factors.Results: Despite differences in local input data, both models demonstrated a similar direction, with the cost of PemC being consistently lower than the cost of PCB. The variation in individual input parameters did affect some of the specific categories, such as toxicity, and impacted sensitivity analyses, with the cost differential between comparators being greater in Japan than in the US.Conclusion: When economic models are based on clinical trial data, many inputs and outcomes are held consistent. The alterable inputs were not in and of themselves large enough to significantly impact the results between countries, which were directionally consistent with greater variation seen in sensitivity analyses. The factors that vary across jurisdictions, even when minor, can have an impact on trial-based economic analyses.Funding: Eli Lilly and Company. [ABSTRACT FROM AUTHOR]

Rationale: Published studies suggest hospital costs on Day 1 in the intensive care unit (ICU) far exceed those of subsequent days, when costs are relatively stable. Yet, no study stratified patients by ICU type.Objectives: To determine whether daily cost patterns differ by ICU type.Methods: We performed a retrospective study of adults admitted to five ICUs (two surgical: quaternary surgical ICU [SICU quat] and quaternary cardiac surgical ICU [CSICU quat]; two medical: tertiary medical ICU [MICU tertiary] and quaternary medical ICU [MICU quat]; one general: community medical surgical ICU [MSICU comm]) at Montefiore Medical Center in the Bronx, New York during 2013. After excluding costs clearly accrued outside the ICU, daily hospital costs were merged with clinical data. Patterns of daily unadjusted costs were evaluated in each ICU using median regression. Generalized estimating equations with first-order autocorrelation were used to identify factors independently associated with daily costs.Measurements and Main Results: Unadjusted daily costs were higher on Day 1 than on subsequent days only for surgical ICUs-SICU quat (median [interquartile range], $2,636 [$1,834-$4,282] on Day 1 vs. $1,840 [$1,501-$2,332] on Day 2; P < 0.001) and CSICU quat ($5,166 [$3,136-$9,493] on Day 1 vs. $2,060 [$1,336-$2,528] on Day 2; P < 0.001). In nonsurgical ICUs, there was no change (MICU tertiary P = 0.12) or a small increase (MSICU comm P = 0.03; MICU quat P = 0.01) in cost from Days 1 to 2. After multivariate adjustment, there remained a significant decrease in cost from ICU Day 1 to 2 in surgical units with statistically similar Day 1 and 2 costs for other ICUs.Conclusions: Higher Day 1 costs are not seen in patients admitted to medical/nonsurgical ICUs. [ABSTRACT FROM AUTHOR]

Background: Patients with rare and ultra-rare diseases make heavy demands on the resources of both health and social services, but these resources are often used inefficiently due to delays in diagnosis, poor and fragmented care. We analysed the national service for an ultra-rare disease, Alstrom syndrome, and compared the outcome and cost of the service to the standard care.Methods: Between the 9th and 26th of March 2014 we undertook a cross-sectional study of the UK Alstrom syndrome patients and their carers. We developed a semi-structured questionnaire to assess our rare patient need, quality of care and costs incurred to patients and their careers. In the UK all Alstrom syndrome patients are seen in two centres, based in Birmingham, and we systematically evaluated the national service and compared the quality and cost of care with patients' previous standard of care.Results: One quarter of genetically confirmed Alstrom syndrome UK patients were enrolled in this study. Patients that have access to a highly specialised clinical service reported that their care is well organised, personalised, holistic, and that they have a say in their care. All patients reported high level of satisfaction in their care. Patient treatment compliance and clinic attendance was better in multidisciplinary clinic than the usual standard of NHS care. Following a variable costing approach based on personnel and consumables' cost, our valuation of the clinics was just under £700/patient/annum compared to the standard care of £960/patient/annum. Real savings, however, came in terms of patients' quality of life. Furthermore there was found to have been a significant reduction in frequency of clinic visits and ordering of investigations since the establishment of the national service.Conclusions: Our study has shown that organised, multidisciplinary "one stop" clinics are patient centred and individually tailored to the patient need with a better outcome and comparable cost compared with the current standard of care for rare disease. Our proposed care model can be adapted to several other rare and ultra-rare diseases. [ABSTRACT FROM AUTHOR]

Background: Invasive fungal disease (IFD) causes significant morbidity and mortality in hematologic malignancy patients with high-risk febrile neutropenia (FN). These patients therefore often receive empirical antifungal therapy. Diagnostic test-guided pre-emptive antifungal therapy has been evaluated as an alternative treatment strategy in these patients. Methods: We conducted an electronic search for literature comparing empirical versus pre-emptive antifungal strategies in FN among adult hematologic malignancy patients. We systematically reviewed 9 studies, including randomized-controlled trials, cohort studies, and feasibility studies. Random and fixed-effect models were used to generate pooled relative risk estimates of IFD detection, IFD-related mortality, overall mortality, and rates and duration of antifungal therapy. Heterogeneity was measured via Cochran’s Q test, I2 statistic, and between study τ2. Incorporating these parameters and direct costs of drugs and diagnostic testing, we constructed a comparative costing model for the two strategies. We conducted probabilistic sensitivity analysis on pooled estimates and one-way sensitivity analyses on other key parameters with uncertain estimates. Results: Nine published studies met inclusion criteria. Compared to empirical antifungal therapy, pre-emptive strategies were associated with significantly lower antifungal exposure (RR 0.48, 95% CI 0.27–0.85) and duration without an increase in IFD-related mortality (RR 0.82, 95% CI 0.36–1.87) or overall mortality (RR 0.95, 95% CI 0.46–1.99). The pre-emptive strategy cost $324 less (95% credible interval -$291.88 to $418.65 pre-emptive compared to empirical) than the empirical approach per FN episode. However, the cost difference was influenced by relatively small changes in costs of antifungal therapy and diagnostic testing. Conclusions: Compared to empirical antifungal therapy, pre-emptive antifungal therapy in patients with high-risk FN may decrease antifungal use without increasing mortality. We demonstrate a state of economic equipoise between empirical and diagnostic-directed pre-emptive antifungal treatment strategies, influenced by small changes in cost of antifungal therapy and diagnostic testing, in the current literature. This work emphasizes the need for optimization of existing fungal diagnostic strategies, development of more efficient diagnostic strategies, and less toxic and more cost-effective antifungals. [ABSTRACT FROM AUTHOR]

Summary: Scientific interest in vitamin D has greatly risen during the last 10 years. The analysis of the changes in vitamin D prescriptions and related costs in a regional prescription dataset has revealed a profound increase in the period 2006-2013. Further studies on cost-effectiveness of such increase in vitamin D supplementation are needed. Introduction: The aim of this study was to analyze the changes in population-based prescription patterns of vitamin D supplements in the general population in an Italian regional setting during an 8-year period (2006-2013). Methods: Data have been retrieved from the database of reimbursed prescriptions of the Region of Tuscany containing all of the medical reimbursements for the whole regional population (total of 3,619,872 and 3,692,828 inhabitants in 2006 and 2013, respectively). Data referring to adult population (age 20-90+ years) have been considered for this analysis (3,033,530 in 2006 and 3,066,741 in 2013). Two different flows (pharmaceutical distribution dataset and general data flow) were taken into account, using the ATC5 coding system for vitamin D supplements alone or in combination with calcium or alendronate. The number of boxes dispensed was retrieved, the number of patients receiving a specific treatment was calculated, and a cost analysis was performed. Results: An upsurge in the prescriptions of vitamin D compounds was disclosed, mainly sustained by a 75.3-fold increase in cholecalciferol, in all age groups and both sexes. This occurred in parallel to a 4.3-fold rise in prescriptions of oral alendronate in combination with cholecalciferol, a slight decrease in dispensed alendronate alone, and a modest increase in the prescription of the combination of calcium salts and cholecalciferol, and calcium alone. The total cost for reimbursement by the Regional Health System for vitamin D-related compounds rose from €3,242,100 euros in 2006 to €8,155,778 in 2013. Conclusion: The huge increase in vitamin D prescriptions and related costs in the last decade, as revealed by the analysis of a regional pharmaceutical dataset, reflects the increased awareness of the possible consequences of a poor vitamin D status. Further studies on cost-effectiveness of such increase in vitamin D supplementation are needed. [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]

Purpose: This paper is to evaluate the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) using unilateral pedicle screws along with contralateral translaminar facet joint screw (UPS+TFS) fixation in comparison with the method using bilateral pedicle screws fixation (BPS) in degenerative lumbar diseases.Methods: Forty patients with single-level lumbar diseases were divided into two groups randomly. One group was treated by TLIF with BPS fixation while the other group was treated by the new technique with UPS+TFS fixation. The preoperative and postoperative ODI, JOA, VAPS scores, mean operation time, mean operation blood loss, fusion rate and complications were collected for comparison under two surgical methods. In terms of complications, only two cases of superficial infection in the BPS group and one case of urinary tract infection in the other group was found.Results: The mean operation time and blood loss was significantly less in UPS+TFS group than in BPS group. The preoperation and postoperative ODI, JOA and VAPS at the intervals of 6 weeks, 3, 6 months and 1 year between the BPS and UPS+TFS group showed no significant disparities. Only one patient in UPS+TFS group was not fused with pseudoarthrosis formation.Conclusions: The clinical efficacy and safety of TLIF with UPS+TFS fixation were comparable to BPS fixation; however, the soft tissue injury and the corresponding operation cost were reduced with unilateral pedicle screw plus translaminar facet screw fixation. [ABSTRACT FROM AUTHOR]

Originator GCSF (Neupogen) has been used to mobilize progenitor stem cells and treat therapy-induced neutropenia in Canadian stem cell transplant settings for years. Although its benefit is not in question, viable alternatives are available. Biosimilar GCSF (Zarzio) is widely in use in Europe since 2009 and was recently approved in the U.S.for the same five indications as Neupogen. Zarzio is reported as safe, equally efficacious, more accessible and cost effective without negatively impacting patient outcomes. This paper summarizes the supporting evidence. [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]

Background/Aims. We aimed to examine the cost-effectiveness of mycophenolate mofetil (MMF) and azathioprine (AZA) as maintenance therapy for patients with Class III and Class IV lupus nephritis (LN), from a United States (US) perspective. Methods. Using a Markov model, we conducted a cost-utility analysis from a societal perspective over a lifetime horizon. The modeled population comprised patients with proliferative LN who received maintenance therapy with MMF (2 gm/day) versus AZA (150 mg/day) for 3 years. Risk estimates of clinical events were based on a Cochrane meta-analysis while costs and utilities were retrieved from other published sources. Outcome measures included costs, quality-adjusted life-years (QALY), incremental cost-effectiveness ratios (ICER), and net monetary benefit. Results. The base-case model showed that, compared with AZA strategy, the ICER for MMF was $2,630,592/QALY at 3 years. Over the patients’ lifetime, however, the ICER of MMF compared to AZA was $6,454/QALY. Overall, the ICER results from various sensitivity and subgroup analyses did not alter the conclusions of the model simulation. Conclusions. In the short term, an AZA-based regimen confers greater value than MMF for the maintenance therapy of proliferative LN. From a lifelong perspective, however, MMF is cost-effective compared to AZA. [ABSTRACT FROM AUTHOR]

Objective: Surgical site infection (SSI) after hip fracture surgery is a well-known complication with serious consequences for both the patient and the medical system. Silver ion treatment is considered an effective antibacterial agent, however, the use of silver dressing (SD) in the primary prevention of SSIs is controversial. The aims of this study were to compare SD with regular dressing (RD) in the prevention of SSI in elderly patients undergoing surgery for hip fractures, and to compare costs. Method: A matched group of 55 patients with hip fractures undergoing surgery with dynamic hip screw, cephalomedullary nail or hemiarthroplasty were randomised to either SD or RD groups. The dressings were applied in the operating theatre, and the patients were followed for one week for clinical signs of infection (discharge, erythema and fever). The RDs were replaced daily. The SDs were not removed for 5-7 days and kept moist. Skin swabs were taken from the wound surface on postoperative day 5-7 for bacterial skin colonisation. Results: The SD (n=31) and RD (n=24) groups were similar in age, sex and comorbidities. Infection signs were seen in two (2/31, 6.4%) of the SD patients compared with 2 (2/24, 8.3%) RD patients (p=1.0). Skin colonisation by bacteria at postoperative day 5-7 was tested in 27 patients: it was higher in the SD group (positive skin swab, 12/19, 63.2%) compared to the RD group (4/8, 50%, p=0.67). The use of SD added ~US$5 (UK ~£3.19) per patient. Conclusion: The use of SD was associated with higher costs than RD, but not superior in preventing SSIs in elderly patients undergoing hemiarthroplasty or fixation of hip fractures. SD was also not effective in reducing bacterial skin colonisation following hip fracture and surgery. Declaration of interest: The authors have no conflict of interest to declare. [ABSTRACT FROM AUTHOR]

Background: Patients with asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) have more rapid disease progression and more exacerbations than do those with either condition alone. Little research has been performed, however, in these patients.Objective: The objective was to summarize the health care utilization, costs, and comorbidities of patients with uncontrolled asthma and patients with ACOS.Methods: This retrospective analysis used medical and pharmacy claims from large commercial health plans. The study included patients 6 years or older with a diagnosis of asthma and one or more asthma exacerbation (index event). Patients were classified as having asthma alone or ACOS, and the two groups were matched for age, sex, region, index year, index month, and health plan type. Outcomes included rates of comorbid disease, health care utilization, and costs during the 12 months before and after the index exacerbation.Results: Among the matched patients with asthma (6,505 ACOS; 26,060 without COPD), mean annual all-cause health care costs were twice as high as for patients with ACOS ($22,393 vs. $11,716; P < 0.0001). Asthma-related costs, representing 29% of total costs, were nearly twice as high among patients with ACOS ($6,319 vs. 3,356; P < 0.0001). Cost differences were driven by large differences in the proportions of patients with an inpatient hospitalization (34.0% vs. 14.6%; P < 0.0001) or emergency department visit (29.6% vs. 19.9%; P < 0.0001). Nearly all prespecified comorbid conditions were more prevalent in the ACOS group.Conclusions: Patients with asthma and COPD had nearly double the health care costs as did patients with asthma without COPD. The overall disease profile of patients with asthma should be considered when managing patients, rather than treating asthma as a solitary condition. [ABSTRACT FROM AUTHOR]

Background: Multiple techniques have been suggested for the treatment of isolated knee articular cartilage injuries. For smaller lesions (<2-5 cm2), microfracture and osteochondral autograft transplantation (OAT) are commonly used options. With an increasing focus on health care efficiency, analyzing the cost-effectiveness of treatment modalities has become increasingly important. Purpose/Hypothesis: The purpose of this study was to analyze the costs and outcomes of microfracture and OAT to compare their cost-effectiveness. The hypothesis was that microfracture would be more cost-effective. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A literature search was performed to identify studies comparing microfracture and OAT for the treatment of articular cartilage lesions of the distal femur in an adult population. Data from these studies including surgical time, failure rates, revision surgeries, outcome scores, and return to athletics were then incorporated into a constructed cost model using standard accounting methodology. The model was based on actual 2013 cost figures (in US dollars) for all procedure, operating room, and instrumentation costs. Results: Three studies, with a mean follow-up of 8.7 years, met the inclusion criteria of having evidence level 1 or 2 comparing microfracture and OAT. There was a cumulative 28.6% reoperation rate among patients undergoing microfracture compared with 12.5% among patients undergoing OAT. While both groups demonstrated significant improvements compared with preoperative levels, the only significant differences in any outcome score reported between the 2 procedures were the International Cartilage Repair Society (ICRS) score and patient-reported return to their previous sports activity level. While microfracture had a lower initial cost ($3100), these savings lessened over 1 year ($1843) and 10 years ($996). Microfracture was more cost-effective when comparing Lysholm and Hospital for Special Surgery scores, whereas OAT was more cost-effective when comparing Tegner and ICRS scores. There was a significantly lower cost for return to play in athletes after OAT versus microfracture at 1 year ($11,428 vs $16,953, respectively), 3 years ($12,856 vs $38,000, respectively), and 10 years ($32,141 vs $60,799, respectively). Conclusion: Published level 1 and 2 clinical studies with a 10-year follow-up demonstrated that the net cost and cost-effectiveness of microfracture and OAT are comparable for the treatment of isolated articular cartilage lesions of the distal femur. Clinical Relevance: Given similar clinical outcomes, microfracture and OAT are both viable, cost-effective first-line treatment options for these injuries. [ABSTRACT FROM AUTHOR]

We estimated the frequency and direct medical cost from the provider perspective of U.S. hospital visits for pediatric abusive head trauma (AHT). We identified treat-and-release hospital emergency department (ED) visits and admissions for AHT among patients aged 0-4 years in the Nationwide Emergency Department Sample and Nationwide Inpatient Sample (NIS), 2006-2011. We applied cost-to-charge ratios and estimated professional fee ratios from Truven Health MarketScan[sup ®] to estimate per-visit and total population costs of AHT ED visits and admissions. Regression models assessed cost differences associated with selected patient and hospital characteristics. AHT was diagnosed during 6,827 (95% confidence interval [CI] [6,072, 7,582]) ED visits and 12,533 (95% CI [10,395, 14,671]) admissions (28% originating in the same hospital's ED) nationwide over the study period. The average medical cost per ED visit and admission were US$2,612 (error bound: 1,644-3,581) and US$31,901 (error bound: 29,266-34,536), respectively (2012 USD). The average total annual nationwide medical cost of AHT hospital visits was US$69.6 million (error bound: 56.9-82.3 million) over the study period. Factors associated with higher per-visit costs included patient age <1 year, males, coexisting chronic conditions, discharge to another facility, death, higher household income, public insurance payer, hospital trauma level, and teaching hospitals in urban locations. Study findings emphasize the importance of focused interventions to reduce this type of high-cost child abuse. [ABSTRACT FROM AUTHOR]

Purpose Evidence suggests that clinical outcomes for people with type 2 diabetes mellitus can be improved through multifactorial treatment. The key challenges in the successful treatment of type 2 diabetes include maintaining tight glycemic control, minimizing the risk of hypoglycemia, controlling cardiovascular risk factors, and reducing or controlling weight. The aim of the present analysis was to evaluate the cost per patient achieving a composite clinical end point (glycosylated hemoglobin <7%, with no weight gain and no hypoglycemic events) in patients with type 2 diabetes in Quebec, Quebec, Canada, receiving liraglutide 1.2 mg, liraglutide 1.8 mg, thiazolidinedione, sulfonylurea, insulin glargine, sitagliptin, or exenatide. Methods The proportion of patients achieving control was taken from a meta-analysis that was based on the Phase III trial program of liraglutide. Treatment costs, estimated from a health care payer perspective, were calculated on the basis of the trials included in the meta-analysis and captured the study drug, needles, self-monitoring of blood glucose (SMBG) test strips, SMBG lancets, and other antidiabetes medications received. Cost-effectiveness in terms of cost per patient achieving the composite end point (cost of control) was evaluated with an economic model developed in Microsoft Excel. No discounting was applied to cost or clinical outcomes because these were not projected beyond a 1-year time horizon. Sensitivity analyses were performed. Findings Liraglutide 1.8 mg was associated with the lowest number needed to treat, with 3 patients needing to be treated to bring 1 patient to the composite end point. Pioglitazone was associated with the highest number needed to treat, with 17 patients requiring treatment to bring 1 patient to the composite end point. Evaluation of only annual pharmacy costs indicated that liraglutide 1.8 mg was the most costly treatment at Can$2780 per patient per year. Pioglitazone and glimepiride were associated with the lowest direct annual costs. Combining the clinical efficacy data with the annual cost of medications produced cost of control values of Can$6070 (liraglutide 1.2 mg), Can$6949 (liraglutide 1.8 mg), Can$7237 (glimepiride), Can$7704 (exenatide), Can$8297 (insulin glargine), Can$8741 (pioglitazone), and Can$9270 (sitagliptin) per patient achieving the composite end point. Implications Liraglutide 1.2 mg and 1.8 mg were associated with the lowest cost of control values, driven by the high proportion of patients achieving the composite end point, which offset the higher medication costs. A relatively low cost of control value was achieved for glimepiride, driven by low acquisition costs, despite relatively few patients achieving the composite end point. [ABSTRACT FROM AUTHOR]

Background: Tiotropium (TIO) is a well-established bronchodilator, LAMA (long-acting anticholinergic), for the treatment of moderate to very severe chronic obstructive pulmonary disease (COPD). Clinical evidence suggests that tiotropium is superior to usual non-LAMA care (UC) but may also have benefits compared to other LAMAs in preventing and limiting the effects of severe exacerbations. The primary objective of this study was to undertake a cost-effectiveness analysis of adding tiotropium to usual care versus usual care alone. A secondary objective was to assess the cost-effectiveness of tiotropium compared to glycopyrronium (GLY), another LAMA. The study was conducted with a Swedish setting in mind. Methods: A Markov cohort model, incorporating the effects of exacerbations, was populated with efficacy data from the UPLIFT and SPARK trials and epidemiological data relevant for a Swedish patient population. Treatment efficacy of tiotropium was modelled as a lowering of the risk of exacerbations and as a slow-down of overall disease progression. The model followed patients over their remaining life-time. Results: The base case analysis showed that patients treated with tiotropium gained 0.07 quality-adjusted life years (QALYs) compared to usual care alone at an incremental cost of SEK 15,041, resulting in a cost per QALY gained of SEK 224,850. Compared to glycopyrronium the QALY gained was estimated to 0.23 QALYs in favour of tiotropium at an incremental cost of SEK 2423, yielding a cost per QALY gained of SEK 10,456. The results were mainly driven by differences in the risk of severe exacerbations. Conclusion: At the current implicit willingness-to-pay (WTP) per QALY threshold in Sweden, the results from this study indicate that tiotropium is a highly cost-effective intervention when added to usual non-LAMA care in the treatment of moderate to very severe COPD in Sweden. In addition, tiotropium is a highly cost-effective intervention when compared to glycopyrronium monotherapy. [ABSTRACT FROM AUTHOR]

Nebivolol is a highly selective β-adrenergic receptor antagonist with a pharmacologic profile that differs from those of other drugs in its class. In addition to cardioselectivity mediated via β receptor blockade, nebivolol induces nitric oxide-mediated vasodilation by stimulating endothelial nitric oxide synthase via β agonism. This vasodilatory mechanism is distinct from those of other vasodilatory β-blockers (carvedilol, labetalol), which are mediated via α-adrenergic receptor blockade. Nebivolol is approved for the treatment of hypertension in the US, and for hypertension and heart failure in Europe. While β-blockers are not recommended within the current US guidelines as first-line therapy for treatment of essential hypertension, nebivolol has shown comparable efficacy to currently recommended therapies in lowering peripheral blood pressure in adults with hypertension with a very low rate of side effects. Nebivolol also has beneficial effects on central blood pressure compared with other β-blockers. Clinical data also suggest that nebivolol may be useful in patients who have experienced erectile dysfunction while on other β-blockers. Here we review the pharmacological profile of nebivolol, the clinical evidence supporting its use in hypertension as monotherapy, add-on, and combination therapy, and the data demonstrating its positive effects on heart failure and endothelial dysfunction. [ABSTRACT FROM AUTHOR]

Objective: To assess the clinical success and costs of computed tomography (CT)-guided radiofrequency ablation (RFA) of osteoblastoma (OB) and spinal osteoid osteoma (OO). Materials and methods: Nineteen patients with OB and eight patients with spinal OO were treated with CT-guided RFA. The OBs were localized in the extremities ( n = 10), the vertebral column ( n = 2), and (juxta-)articular ( n = 7). Dedicated procedural techniques included three-dimensional CT-guided access planning in all cases, overlapping RFA needle positions (median, two positions; range, 1-6 RF-electrode positions) within the OB nidus (multiple ablation technique, n = 15), and thermal protection in case of adjacent neural structure in four spinal OO. The data of eight operated OB and ten operated spinal OO patients were used for comparison. Long-term success was assessed by clinical examination and using a questionnaire sent to all operated and RFA-treated patients including visual analogue scales (VAS) regarding the effect of RFA on severity of pain and limitations of daily activities (0-10, with 0 = no pain/limitation up to 10 = maximum or most imaginable pain/limitation). Results: All patients had a clear and persistent pain reduction until the end of follow-up. The mean VAS score for all spinal OO patients and all OB patients treated either with RFA or with surgical excision significantly decreased for severity of pain at night, severity of pain during the day, and both for limitations of daily and of sports activities. Conclusions: RFA is an efficient method for treating OB and spinal OO and should be regarded as the first-line therapy after interdisciplinary individual case discussion. [ABSTRACT FROM AUTHOR]

Purpose: The American Society of Clinical Oncology (ASCO)/ American Board of Internal Medicine (ABIM) Choosing Wisely (CW) measures aim to reduce the use of interventions that lack evidence of benefit in cancer care. The study presented here characterized adherence to the 2012 ASCO/ABIM CW recommendations by linking health plan claims data with a regional cancer registry and sought to identify areas for research interventions to improve adherence. Methods: SEER records for patients diagnosed with cancer in Western Washington State between 2007 and 2014 were linked with enrollment and claims from a large regional commercial insurance plan. Using claims and SEER records, algorithms were developed to characterize adherence to each CW measure. In addition, we calculated differences in total reimbursements and procedure-specific reimbursements for patients receiving adherent and nonadherent care. [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]

Background: Intracameral cefuroxime is recommended as prophylaxis against postoperative endophthalmitis (POE) following cataract surgery. Aprokam is the only licensed product for prophylaxis of POE, although unlicensed intracameral cefuroxime may be administered using pre-filled syringes (PFS), either prepared in hospital by reconstituting cefuroxime via serial dilution (prepared PFS), or commercially purchased (purchased PFS). This study aimed to estimate the potential budget impact of using Aprokam over unlicensed cefuroxime for intracameral administration. Methods: A budget impact model (BIM) was developed from UK NHS hospital perspective to estimate the economic impact of adopting Aprokam compared with purchased PFS or prepared PFS for the prophylaxis of POE following cataract surgery over a 5-year time horizon. The BIM incorporated direct costs only, associated with the acquisition, delivery, storage, preparation, and administration of cefuroxime. Resource utilisation costs were also incorporated; resource utilisation was sourced from a panel survey of hospital pharmacists, surgeons, and theatre nurses who are involved in the delivery, storage, preparation, quality assurance, or administration of cefuroxime formulations. Unit costs were sourced from NHS sources; drug acquisition costs were sourced from BNF. The model base case used a hypothetical cohort comprising of 1000 surgeries in the first year and followed a 5.2 % annual increase each year. Results: The model predicts Aprokam is cost saving compared with purchased PFS, with a modest increase compared prepared PFS over 5 years. There are total savings of £3490 with Aprokam compared with purchased PFS, driven by savings in staff costs that offset greater drug acquisition costs. Compared with prepared PFS, there are greater drug acquisition costs which drive an increased total cost over 5 years of £13,177 with Aprokam, although there are substantial savings in staff costs as well as consumables and equipment costs. Conclusions: The lower direct costs of using Aprokam compared with purchased PFS presents a strong argument for the adoption of Aprokam where purchased PFS is administered. The additional benefits of Aprokam include increased liability coverage and possible reduction in dilution errors and contaminations; as such, in hospitals where unlicensed prepared PFS is used, modest additional resources should be allocated to adoption of Aprokam. [ABSTRACT FROM AUTHOR]

Background: The Dietary Approaches to Stop Hypertension (DASH) diet is a proven way to prevent and control hypertension and other chronic disease. Because the DASH diet emphasizes plant-based foods, including vegetables and grains, adhering to this diet might also bring about environmental benefits, including lower associated production of greenhouse gases (GHGs). Objective: The objective was to examine the interrelation between dietary accordance with the DASH diet and associated GHGs. A secondary aim was to examine the retail cost of diets by level of DASH accordance. Design: In this cross-sectional study of adults aged 39-79 y from the European Prospective Investigation into Cancer and Nutrition-Norfolk, United Kingdom cohort (n = 24,293), dietary intakes estimated from food-frequency questionnaires were analyzed for their accordance with the 8 DASH food and nutrient-based targets. Associations between DASH accordance, GHGs, and dietary costs were evaluated in regression analyses. Dietary GHGs were estimated with United Kingdom-specific data on carbon dioxide equivalents associated with commodities and foods. Dietary costs were estimated by using national food prices from a United Kingdom-based supermarket comparison website. Results: Greater accordance with the DASH dietary targets was associated with lower GHGs. Diets in the highest quintile of accordance had a GHG impact of 5.60 compared with 6.71 kg carbon dioxide equivalents/d for least-accordant diets (P < 0.0001). Among the DASH food groups, GHGs were most strongly and positively associated with meat consumption and negatively with whole-grain consumption. In addition, higher accordance with the DASH diet was associated with higher dietary costs, with the mean cost of diets in the top quintile of DASH scores 18% higher than that of diets in the lowest quintile (P < 0.0001). Conclusions: Promoting wider uptake of the DASH diet in the United Kingdom may improve population health and reduce diet-related GHGs. However, to make the DASH diet more accessible, food affordability, particularly for lower income groups, will have to be addressed. [ABSTRACT FROM AUTHOR]

Dengue fever, a mosquito-borne virus, is an ongoing public health issue in North Queensland. Importation of dengue fever by travellers visiting or returning to Australia can lead to epidemics. The mosquito can acquire the virus in the symptomatic viraemic phase, so timely recognition of cases is important to prevent epidemics. There is a gap in the literature about backpackers' knowledge of dengue fever and the decision-making process they use when considering utilising the Australian health-care system. This study uses grounded theory methods to construct a theory that explains the process backpackers use when seeking health care. Fifty semi-structured interviews with backpackers, hostel receptionists, travel agents and pharmacists were analysed, resulting in identification of a core category: 'weighing up the costs of seeking health care'. This core category has three subcategories: 'self-assessment of health status', 'wait-and-see' and 'seek direction'. Findings from this study identified key areas where health promotion material and increased access to health-care professionals could reduce the risk of backpackers spreading dengue fever. [ABSTRACT FROM AUTHOR]

Background and purpose - Fractures of the scaphoid are often not detected on initial plain radiographs. Conventional management of clinically suspected scaphoid fractures is cast immobilization for 2 weeks and then reassessment. Early MRI is a diagnostic alternative. We compared the cost and usefulness of the early MRI diagnostic strategy with that of conventional management. Patients and methods - This prospective pseudo-randomized study included patients between 18 and 49 years of age who attended Bergen Accident and Emergency Department, Bergen, Norway during 1 year in 2009-2010, after sustaining an acute wrist trauma in the previous week and with a clinically suspected scaphoid fracture. 61 patients were investigated with acute MRI, while 63 patients received standard treatment as a control group. We used cost-minimization analysis to estimate the cost of the 2 patient groups. Results - Concerning cost, there were no statistically significant differences in the total direct medical costs or in indirect costs between the groups. Concerning usefulness, patients in the MRI group without a fracture (n = 35) used a cast for fewer days (mean 1 day) than patients in the control group with no fractures (n = 52) (mean 14 days; p < 0.001). They had less than half the number of days on sick leave than patients in the control group (mean 7 days vs. 15 days; p = 0.002). Interpretation - In a Norwegian setting, an early MRI was of value in patients with clinically suspected scaphoid fracture and normal plain radiographs. [ABSTRACT FROM AUTHOR]

Background: Few studies have addressed the cost patterns of patients with multiple myeloma (MM) before and after first relapse. This US claims analysis evaluated, from a US health plan perspective, patterns of total direct costs of care from treatment initiation to progression for patients with MM treated with novel agents, using time to next therapy (TTNT) as a proxy measure for progression. Methods: A retrospective study was conducted using a large US claims database, evaluating patients with claims for MM between 2006 and 2013. Patients with claims for stem cell transplant (SCT) were excluded. The analysis focused on patients receiving lenalidomide (LEN) or bortezomib (BORT) based treatment, for whom complete claim history was available through initiation of subsequent treatment. Average patient monthly direct costs were determined, including medical and pharmacy costs, and total cost patterns over quarterly time periods were calculated. Results: The study population comprised 2843 patients with newly diagnosed MM (NDMM) and 1361 with relapsed MM. Total monthly cost for patients with NDMM declined steadily, from $15,734 initially to $5082 at 18+ months after therapy. Upon initiation of second-line therapy, total monthly costs rose to $13,876 and declined to $6446 18 months later. Although NDMM cost levels for individual ordinal months were similar between the LEN and BORT groups, TTNT was longer for LEN-based treatments (37 months). The BORTtreated cohort had higher average monthly total costs for NDMM and for the common time period through 37 months after initiation of therapy ($7534 vs $10,763 for LEN and BORT, respectively). Key limitations of this study, in addition to the lack of mortality and staging information available from claims data, include the definition of TTNT based on change in treatment or a defined gap in therapy prior to retreatment, which may differ from actual time of progression in some patients. Conclusions: For patients with NDMM receiving either LEN- or BORT-based treatment without SCT, followed until TTNT, total direct monthly costs (drug+medical) declined steadily over time. Monthly costs returned to near initial levels when patients began second-line therapy and then followed a similar pattern of decline. Due to the longer TTNT for patients initiated on LEN and the associated longer period of below-average costs, patients initiated with LEN-based treatments had mean monthly total costs4$3200 lower than total costs for patients initiated on BORT during the first 3 years after starting treatment, cumulating to nearly $120,000 in lower costs for patients initiated on LEN. [ABSTRACT FROM AUTHOR]

BackgroundElectroconvulsive therapy (ECT) is widely applied to treat severe depression resistant to standard treatment. Results from previous studies comparing the cost-effectiveness of this technique with treatment alternatives such as repetitive transcranial magnetic stimulation (rTMS) are conflicting.MethodWe conducted a cost-effectiveness analysis comparing ECT alone, rTMS alone and rTMS followed by ECT when rTMS fails under the perspective of the Spanish National Health Service. The analysis is based on a Markov model which simulates the costs and health outcomes of individuals treated under these alternatives over a 12-month period. Data to populate this model were extracted and synthesized from a series of randomized controlled trials and other studies that have compared these techniques on the patient group of interest. We measure effectiveness using quality-adjusted life years (QALYs) and characterize the uncertainty using probabilistic sensitivity analyses.ResultsECT alone was found to be less costly and more effective than rTMS alone, while the strategy of providing rTMS followed by ECT when rTMS fails is the most expensive and effective option. The incremental cost per QALY gained of this latter strategy was found to be above the reference willingness-to-pay threshold used in these types of studies in Spain and other countries. The probability that ECT alone is the most cost-effective alternative was estimated to be around 70%.ConclusionsECT is likely to be the most cost-effective option in the treatment of resistant severe depression for a willingness to pay of €30 000 per QALY. [ABSTRACT FROM AUTHOR]

The article focuses on a study which evaluates and characterizes the use of fixed, low-dose rasburicase, a recombinant urate oxidase enzyme, for the treatment of hyperuricemia in adult patients. Topics discussed include the baseline demographics and laboratory characteristics of patients, change in uric acid level post rasburicase dose of the patients and revised Scott & White algorithm for the management and prevention of hyperuricemia in oncology patients with tumor lysis syndrome.

Background and Objective. Hematopoietic stem cell transplantation (HSCT) in developing countries is cost-limited. Our primary goal was to determine the cost structure for the HSCT program model developed over the last decade at our public university hospital and to assess its clinical outcomes. Materials and Methods. Adults and children receiving an allogeneic hematopoietic stem cell transplant from January 2010 to February 2011 at our hematology regional reference center were included. Laboratory tests, medical procedures, chemotherapy drugs, other drugs, and hospitalization costs were scrutinized to calculate the total cost for each patient and the median cost for the procedure. Data regarding clinical evolution were incorporated into the analysis. Physician fees are not charged at the institution and therefore were not included. Results. Fifty patients were evaluated over a 1-year period. The total estimated cost for an allogeneic HSCT was $12,504. The two most expensive diseases to allograft were non-Hodgkin lymphoma ($11,760 ± $2,236) for the malignant group and thalassemia ($12,915 ± $5,170) for the nonmalignant group. Acute lymphoblastic leukemia ($11,053 ± 2,817) and acute myeloblastic leukemia ($10,251 ± $1,538) were the most frequent indications for HSCT, with 11 cases each. Median out-of-pocket expenses were $1,605, and 1-year follow-up costs amounted to $1,640, adding up to a total cost of $15,749 for the first year. The most expensive components were drugs and laboratory tests. Conclusion. Applying the cost structure described, HSCT is an affordable option for hematological patients living in a developing country. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that pharmaceutical care can result in favorable clinical outcomes in human immunodeficiency virus (HIV)-infected patients, however, few studies have assessed the economic impact. The objective of this study was to evaluate the clinical and economic impact of pharmaceutical care of HIV-infected patients. Methods: A controlled ambispective study was conducted in Brazil from January 2009 to June 2012. Patients were allocated to either intervention or control group. The control group was followed according to standard care while the intervention group was also followed by a pharmacist at each physician appointment for one year. Effectiveness outcomes included CD4+ count, viral load, absence of co-infections and optimal immune response, and economic outcomes included expenses of physician and pharmaceutical appointments, laboratory tests, procedures, and hospitalizations, at six months and one year. Results: Intervention and control groups included 51 patients each. We observed significant decreases in total pharmacotherapy problems during the study. At six months, the intervention group contained higher percentages of patients without co-infections and of patients with CD4+ >500 cells/mm³. None of the differences between intervention and control group considering clinical outcomes and costs were statistically significant. However, at one year, the intervention group showed higher percentage of better clinical outcomes and generated lower spending (not to procedures). An additional health care system daily investment of US$1.45, 1.09, 2.13, 4.35, 1.09, and 0.87 would be required for each additional outcome of viral load <50 copies/ml, absence of co-infection, CD4+ >200, 350, and 500 cells/mm3, and optimal immune response, respectively. Conclusion: This work demonstrated that pharmaceutical care of HIV-infected patients, for a one-year period, was able to decrease the number of pharmacotherapy problems. However, the clinical outcomes and the costs did not have statistical difference but showed higher percentage of better clinical outcomes and lower costs for some items. [ABSTRACT FROM AUTHOR]

Purpose: To calculate the costs to the US healthcare system of transition from single-row (SR) to double-row (DR) rotator cuff repair (RCR) and to calculate the decrease in re-operations for re-tear that DR RCR would need to accomplish in order to render the transition cost-neutral. Methods: Standard accounting methods were used to determine the cost of a single RCR, the annual cost to the US healthcare system of rotator cuff surgery, the cost of a single-revision RCR, and the decrease in revision for re-tear rate necessary to make DR or suture bridge (SB) methods cost-neutral in comparison with SR methods. We varied tear size, operating room cost, time required for implant placement, annual tear size distribution, and repair method. Results: The cost of RCR ranged from $7,572 (SR, <1 cm tear) to $12,979 (DR, >5 cm tear). Complete conversion from SR RCR to a DR technique without an associated decrease in revision surgeries would increase the annual US healthcare cost between $80 million and $262 million per year. To obtain cost neutrality, use of DR or SB methods would need to result in one fewer revision in every 17 primary repairs (for tears <1 cm) to one fewer in every four primary repairs (for tears >5 cm). Conclusions: Conversion from SR to DR or SB RCR techniques would result in considerable increases in healthcare expenditures. Since the large decreases in revision surgery rates necessary to justify DR or SB repairs purely on a cost basis may not be realistic or even possible, the use of these methods should be supported by evidence of improved structural healing rates and quality-adjusted life years in comparison with SR methods. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

The article presents a study on the most efficient strategy for the diagnosis of meniscus tears. Topics covered include patient history and physical examination (H&P), magnetic resonance imaging (MRI) as part of the diagnostic strategy, and decision analysis. Also mentioned is diagnostic imaging as the fastest rising segment of costs in the health care system in the U.S.

Background This study is done to compare the effect of adjunctive therapy with pregabalin versus usual care (UC) on health-care costs and clinical and patients consequences in generalized anxiety disorder (GAD) subjects with partial response (PR) to a previous selective serotonin reuptake inhibitor (SSRI) course in medical practice in Spain. Methods Post hoc analysis of patients with PR to SSRI monotherapy enrolled in a prospective 6-month naturalistic study was done. PR was defined as a Clinical Global Impression (CGI) scale score ≥3 and insufficient response with persistence of anxiety symptoms ≥16 in the Hamilton Anxiety Rating Scale (HAM-A). Two groups were analyzed: 1) adjunctive therapy (AT) with pregabalin (150–600 mg/day) to existing therapy and 2) UC (switching to a different SSRI or adding another anxiolytic different than pregabalin). Costs included GAD-related health-care resources utilization. Consequences were a combination of psychiatrist-based measurements [HAM-A, CGI, and Montgomery-Asberg Depression Rating Scale (MADRS)] and patientreported outcomes [Medical Outcomes Study Sleep (MOS-sleep) scale, disability (World Health Organization Disability Assessment Schedule II (WHO-DAS II) and quality-of-life (Euro Qol-5D (EQ-5D)]. Changes in both health-care costs and scale scores were compared separately at end-of-trial visit by a general linear model with covariates. Results Four hundred eighty-six newly prescribed pregabalin and 239 UC GAD patients [mean (SD) HAM-A 26.7 (6.9) and CGI 4.1 (0.5)] were analyzed. Adding pregabalin was associated with significantly higher mean (95% CI) score reductions vs. UC in HAM-A [–14.9 (–15.6; –14.2) vs. –11.2 (–12.2; –10.2), p < 0.001] and MADRS [–11.6 (–12.2; –10.9) vs. –7.8 (–8.7; –6.8), p < 0.001]. Changes in all patient-reported outcomes favored significantly patients receiving pregabalin, including quality-of-life gain; 26.4 (24.7; 28.1) vs. 19.4 (17.1; 21.6) in the EQ-VAS, p < 0.001. Health-care costs were significantly reduced in both cohorts yielding similar 6-month costs; €1,565 (1,426; 1,703) pregabalin and €1,406 (1,200; 1,611) UC, p = 0.777. The effect of sex on costs and consequences were negligible. Conclusion In medical practice, GAD patients with PR to SSRI experienced greater consequence improvements with adjunctive therapy with pregabalin versus UC, without increasing healthcare cost. The effect of pregabalin was independent of patient gender. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of a new, next-generation antimicrobial dressing (AQUACEL Ag+ dressing) in facilitating healing in a variety of hard-to-heal wounds that may have been compromised by infection and/or biofilm. Method: This was an international, multi-centred, real-life, non-randomised evaluation involving patients with a wide variety of slow-, non-healing or deteriorating chronic and acute wounds. There were no strict inclusion or exclusion criteria and the clinicians were asked to use their discretion in the selection of patients. The clinicians continued to use their standard protocol of care but replaced their existing primary wound-contact dressing with the next-generation antimicrobial dressing (NGAD) for up to 4 weeks. Clinicians could extend the treatment period if this was deemed clinically appropriate. Baseline assessments included wound bed characteristics, exudate level, indicators of wound biofilm, and signs and symptoms of infection. At the final assessment, the investigators reported the wound size, wound bed characteristics, and exudate level. Results: A total of 121 patients were recruited into the original evaluation, of which eight were excluded for incomplete data sets. Most wounds (73; 64%) were either venous leg ulcers (59; 52%) or diabetic foot ulcers (14; 12%). At baseline, the wounds of (26; 23%) patients were slowly improving, 65 were stagnant (58%) and 22 (19%) were deteriorating. Just under three-quarters (74%) of the wounds had suspected biofilm (criteria including failure of a wound to heal, lack of response to topical and systemic antimicrobial agents, or the presence of slimy substances on the wound surface). Following the evaluations, the average wound closure achieved for all wounds was 72.6%, 19 (17%) wounds healed, 47 (42%) achieved at least 90% wound closure, and 71 (63%) achieved at least 75% closure. The average treatment period was 4.1 weeks; 35 wounds were treated with the dressing for more than 4 weeks. Cost analysis indicated that potential antimicrobial dressing cost reductions of approximately 30% were realised using the NGAD. Conclusion: This real-life, non-randomised evaluation provides encouraging evidence that the NGAD may have a role to play in facilitating wound progression towards healing by helping to eliminate the biofilm barrier. [ABSTRACT FROM AUTHOR]

Subcutaneous liraglutide (Victoza), a glucagon-like peptide 1 receptor agonist, is approved for the treatment of adult patients with type 2 diabetes mellitus. Once-daily liraglutide, as monotherapy or add-on therapy to other antidiabetic agents (including basal insulin), was an effective and generally well tolerated treatment in adult patients with type 2 diabetes in several well-designed phase III trials and in the real world clinical practice setting. In addition to improving glycaemic control, liraglutide had beneficial effects on bodyweight, systolic blood pressure and surrogate measures of β-cell function in clinical trials, with these benefits maintained during long-term treatment (≤2 years). Liraglutide has a convenient once-daily administration regimen, a low potential for drug-drug interactions and low propensity to cause hypoglycaemia. Thus, liraglutide continues to be a useful option for the management of type 2 diabetes. This article reviews the therapeutic use of liraglutide in adult patients with type 2 diabetes and summarizes its pharmacological properties. [ABSTRACT FROM AUTHOR]

Berlin- Frankfurt- Munster ( BFM) and Dana- Farber Cancer Institute ( DFCI) consortia's treatment strategies for acute lymphoblastic leukaemia ( ALL) in children are widely used. We compared the health effects and monetary costs of hospital treatments for these two strategies. Parents of children treated at seven centres in Canada, Italy and the USA completed health-related quality of life ( HRQL) assessments during four active treatment phases and at 2 years after treatment. Mean HRQL scores were used to calculate quality-adjusted life years ( QALYs) for a period of 5 years following diagnosis. Total costs of treatment were determined from variables in administrative databases in a universally accessible and publicly funded healthcare system. Valid HRQL assessments ( n = 1200) were collected for 307 BFM and 317 DFCI patients, with costs measured for 66 BFM and 28 DFCI patients. QALYs per patient were <1.0% greater for BFM than DFCI. Median HRQL scores revealed no difference in QALYs. The difference in mean total costs for BFM ( US$88 480) and DFCI ( US$93 026) was not significant ( P = 0.600). This study provides no evidence of superiority for one treatment strategy over the other. Current BFM or DFCI strategies should represent conventional management for the next economic evaluation of treatments for ALL in childhood. [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]

Hemophilias are the most known inherited bleeding disorders. The challenges in the management of hemophilic children are different from those in adults: prophylaxis regimen removed the hallmark of crippling disease with lifelong disabilities; individualized regimens are being implemented in order to overcome venous access problems. Presently, at least in high-income countries, advances in treatment of hemophilia resulted in continuous improvement of the patients' quality of life and life expectancy. Inhibitors remain the most severe complication of hemophilia therapy. The treatment' compliance is the key to achieve a successful management. The patient, his family, the medical and psychological team are the players of a comprehensive care system. The current management of hemophilic children is the example of huge resource investments enabling long-term benefits in particular quality of life as a primary objective of the healthcare process. [ABSTRACT FROM AUTHOR]

The article discusses the proper way for physicians to deal with psychiatric patients with the use of right circumstances. The author mentions his experiences of dealing with a certain Ms. M. who was brought to the hospital because of suicidal tendency. It discusses the importance unexpected or surprising utterances on the psychocatalytic effects for the patients.

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]

Aim: To carry out a cost-minimization analysis including a comparison of the costs arising from first-line treatment by trastuzumab plus docetaxel versus trastuzumab plus paclitaxel in patients with metastatic breast cancer. Methods: All consecutive patients with human epidermal growth receptor 2-postive metastatic breast cancer who were treated at Besanc¸on University Hospital and Saint Vincent private hospital between 2001 and 2010 by first-line therapy containing trastuzumab plus taxane were retrospectively studied. Economic analysis took into account costs related to drugs, hospitalization, and healthcare travel. Results: Progression-free survival difference between the two treatments was not significant (p¼0.65). First-line treatment by trastuzumab plus taxane was estimated at approximately E68,000 (p¼0.74). The drug costs represented around 70–75% of the total cost, mainly related to the use of trastuzumab. Conclusion: Our economic analysis shows that although the costs of the two trastuzumab plus taxane regimens are similar, they may contribute to the on-going debate about the availability and use of innovative chemotherapy drugs, in particular in human epidermal growth factor receptor 2-positive metastatic breast cancer with new therapies such as trastuzumab-DM1 and pertuzumab. [ABSTRACT FROM AUTHOR]

As yet, no evidence is available about the cost-effectiveness of positive psychological interventions. When offered via the Internet, these interventions may be particularly cost-effective, because they are highly scalable and do not rely on scant resources such as therapists’ time. Alongside a randomized controlled trial of an online positive psychological intervention, a health-economic evaluation was conducted. Mild to moderately depressed adults seeking self-help and recruited in the general population were randomly assigned to the intervention group (n?=?143) and a waitlisted usual care group (n?=?141). Improved clinical outcomes were achieved in the intervention group (at least for depression) at higher costs. When outliers (the top 2.5%,n?=?5 in intervention group,n?=?2 in control group) were removed, cost-effectiveness was increased considerably. For positive psychology, economic evaluations may be a means to nudge policy decision-makers towards placing positive psychological interventions on the health agenda. [ABSTRACT FROM PUBLISHER]