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Importance Unprovoked venous thromboembolism (VTE) can be the first manifestation of cancer. It is unclear if extensive screening for occult cancer including a comprehensive computed tomography (CT) scan of the abdomen/pelvis is cost-effective in this patient population. Objective To assess the health care related costs, number of missed cancer cases and health related utility values of a limited screening strategy with and without the addition of a comprehensive CT scan of the abdomen/pelvis and to identify to what extent testing should be done in these circumstances to allow early detection of occult cancers. Participants and setting Cost effectiveness analysis using data that was collected alongside the SOME randomized controlled trial which compared an extensive occult cancer screening including a CT of the abdomen/pelvis to a more limited screening strategy in patients with a first unprovoked VTE, was used for the current analyses. Main outcomes and measures Analyses were conducted with a one-year time horizon from a Canadian health care perspective. Primary analysis was based on complete cases, with sensitivity analysis using appropriate multiple imputation methods to account for missing data. Results Data from a total of 854 patients with a first unprovoked VTE were included in these analyses. The addition of a comprehensive CT scan was associated with higher costs ($551 CDN) with no improvement in utility values or number of missed cancers. Results were consistent when adopting multiple imputation methods. Conclusions and relevance The addition of a comprehensive CT scan of the abdomen/pelvis for the screening of occult cancer in patients with unprovoked VTE is not cost effective, as it is both more costly and not more effective in detecting occult cancer.

Background: The Irbesartan in Reduction of Microalbuminuria trial and the Irbesartan in Diabetic Nephropathy Trial found that irbesartan is renoprotective in patients having hypertension with type 2 diabetes. Objective: The objective of this study was to assess whether treatment with irbesartan is cost-effective in Canada relative to conventional care in this patient population and whether it is more cost-effective to treat patients early rather than later in the development of renal disease from the perspective of the Canadian health and social care system. Methods: The analysis compared 3 alternative strategies for the management of hypertension in patients with type 2 diabetes and early renal disease: (1) conventional hypertensive treatment excluding the use of angiotensin II receptor antagonists (AIIRAs); (2) the early addition of irbesartan (an AIIRA) to conventional treatment; and (3) the late addition of irbesartan to conventional treatment. A Markov model was used to simulate the progression of renal disease (microalbuminuria to death) in hypertensive patients with type 2 diabetes over a 25-year time horizon. Transition probabilities were derived from the 2 randomized controlled trials. A cost-effectiveness analysis was conducted with outcome measured in life-years gained (LYGs). Results: The early addition of irbesartan during microalbuminuria was cost-saving and more effective than both delaying irbesartan treatment until advanced overt nephropathy (AON) (0.45 LYG, Can $54,100 saved) and conventional antihypertensive use (0.62 LYG, $68,400 saved). This was due to the increased drug costs associated with the use of irbesartan being offset by savings arising from delays in the development of overt nephropathy and the subsequent delay to end-stage renal disease (ESRD). Sensitivity analyses confirmed the robustness of the study results. Conclusions: The early use of irbesartan for patients with hypertension and type 2 diabetes who have yet to develop overt nephropathy is both more effective and less costly than delaying irbesartan treatment until AON and conventional antihypertensive use. Analysis suggests that the earlier irbesartan is added to conventional antihypertensive treatment, the greater the delays in the onset of ESRD and the overall savings in health care resource utilization from the perspective of the Canadian health and social care system.

With increasing pressure on health care resources, it is necessary to demonstrate that new treatments are both effective and cost effective. The purpose of this study was to assess the cost effectiveness of pimecrolimus (Elidel) compared to usual therapy in the treatment of both adults and children with atopic eczema in Canada. Analysis was performed using a decision model which estimated the incremental cost per quality adjusted life year (QALY) gained from both a societal and health care perspective. For children, Elidel leads an incremental cost per QALY of $38,000 from a societal perspective. For adults, the incremental cost per QALY was $35,000. Elidel will lead to an overall increase in costs but with an improvement in clinical outcomes. The cost effectiveness ratios for Elidel were consistently below $50,000 per QALY gained. Given previous funding decisions in Canada, Elidel may be considered a cost-effective use of health care resources. Avec la demande accrue pour les ressources en soins de sante, il devient essentiel de prouver aussi bien l'efficacite que la rentabilite de tout nouveau traitement. Evaluer la rentabilite de pimecrolimus (Elidel) par rapport au traitement traditionnel de l'eczema atopique chez les adultes et les enfants au Canada. Des analyses ont ete faites au moyen d'un modele decisionnel qui estime le cout par annee-personne sans invalidite des points de vue societal et de sante. Dans le cas des enfants, le cout par annee-personne sans invalidite du point de vue societal est de 38 000 $. Pour les adultes, le cout est de 35 000 $. Elidel menera a une augmentation generale des couts mais sera accompagne d'une amelioration des resultats cliniques. Les taux de rentabilite de l'Elidel etaient toujours inferieurs a 50 000 $ pour chaque annee-personne additionnelle. En effectuant une comparaison avec les decisions de financement anterieures au Canada, le recours a l'Elidel pourrait etre considere comme usage rentable des ressources en soins de sante.

In probabilistic economic analysis, the uncertainty concerning input parameters is quantified, and determines the level of uncertainty over the optimal decision. Researchers from a wide range of disciplines employ mathematical models to simulate complex processes. Common through many such disciplines is the conduct of importance analysis to determine those input parameters that contribute most to the uncertainty over the optimal decision based on the results of the analysis. In this study, we compare a range of potential importance measures to see how they compare with methods used in economic analysis. Techniques were classified as variance/correlation, information, probability, entropy, or elasticity-based measures. A selection of the most commonly used measures were applied to an economic model of treatment for patients with Parkinson's disease. Techniques were evaluated in terms of their ranking of variables, complexity, and interpretation.

The use of probabilistic analysis as a means for analyzing uncertainty within economic analysis has grown in popularity in recent years as it has been recognized as the most complete method for propagating uncertainty with respect to input parameters in terms of uncertainty about outcomes of interest. The World Health Organization (WHO) in a series of recent reports and publications have recognized the role of probabilistic analysis in what they term generalized cost-effectiveness analysis. However, there are fundamental problems with the analysis and the interpretation of such analysis as proposed by WHO. This study highlights three specific points for concern and offers constructive criticism by recommending more appropriate approaches.

The cost-effectiveness of new health care technologies is conditional upon who receives what therapy and under what circumstances. Understanding this heterogeneity in cost-effectiveness, health care payers often limit reimbursement of therapies to a more restrictive sub-group of patients than that indicated in a product's licensing. Such limits may be based upon clinical or demographic criteria that are prognostic of costs, outcomes or both. However, there is little guidance on how to estimate and interpret stratified cost-effectiveness analysis. In this paper we present a framework for estimating the benefits from stratification that permits consideration of both the opportunity cost resulting from a lack of adherence with criteria and the efficiency loss associated with incorporating equity concerns.

Introduction: The objective of this study was to assess the cost effectiveness of a continuous combined oral preparation of norethisterone (norethindrone) acetate and ethinylestradiol (NA/EE) [FemHRT®] as both a first-line and second-line therapy for menopausal women. Perspective: Third-party payer. Methods: The cost effectiveness of NA/EE was assessed as both a first- and second-line therapy in comparison with conjugated equine oestrogen 0.625mg and medroxyprogesterone acetate 2.5mg (CEE/MPA) and no therapy. Analysis was conducted within a Markov model with states relating to the presence and absence of vaginal bleeding, menopausal symptoms and hip fracture. Analysis forecasted life expectancy, QALYs and lifetime costs for a 50-year-old menopausal woman. Compliance was modelled related to menopausal symptoms and vaginal bleeding. For the base-case analysis, it was assumed that compliant women would take therapy for up to 5 years. Sensitivity analysis assumed therapy was taken only for 1 year. Results: Compared with both CEE/MPA and no therapy, NA/EE led to an increase in both costs and QALYs, both as a first- and second-line therapy. For first-line therapy, the incremental cost per QALY gained for NA/EE was $2200 Canadian dollars ($Can; 1999 values) [compared with no therapy] and was $Can20 300 (compared with CEE/MPA). For second-line therapy, the incremental cost per QALY gained for NA/EE was $Can900 (compared with no therapy) and was $Can16 400 (compared with CEE/MPA). Results were robust to most sensitivity analyses. Conclusions: NA/EE is a cost-effective therapy for women with menopausal symptoms both as a first-line and second-line therapy.

Economic analysis of healthcare interventions is increasingly reliant on decision models to estimate the long- term costs and benefits of new therapies. Models permit analysts to take short-term clinical data to forecast long-term costs and benefits. Models should follow certain basic principles and can be appraised in terms of three broad characteristics: clinical relevance, transparency and analytical ability. The purpose of this paper is to explore the role of modelling in the economic analysis of interventions for type 2 diabetes mellitus. A review of existing models for diabetes identified five complex disease models appropriate for economic analysis. These models were broadly similar in structure and in source of input parameters. However, models did vary according to the coverage of relevant disease complications and the complexity of analysis possible. Models could be enhanced by improving their transparency and by using data relevant to type 2 diabetes. In addition, enhancing clinical knowledge through the provision of long-term data on effectiveness may reduce concern relating to the appropriateness of the assumptions currently required within models. The value of such further information must be weighed against the costs of its acquisition.

Recently published clinical trial results have demonstrated that, in patients with type 2 diabetes mellitus, treatment with pioglitazone hydrochloride as a first-line therapy can lead to significant improvements in glycosylated haemoglobin, total cholesterol, high density lipoprotein cholesterol and triglycerides. Given the results of these trials, we assessed the cost effectiveness of the use of pioglitazone as a first-line therapy in Canada.A Markov model was used to determine the health outcomes and economic impact for patients with type 2 diabetes, from the perspective of a provincial ministry of health. The model incorporated six complications of diabetes: hypoglycaemia, acute myocardial infarction, stroke, lower extremity amputation, nephropathy, and retinopathy. Transition probabilities and costs were taken from published literature. Analysis compared treatment strategies with different first-line therapies: pioglitazone, glibenclamide (glyburide), metformin, and diet and exercise.Compared with other strategies, a pioglitazone-based strategy was estimated to reduce the cumulative incidence of severe clinical events and long-term complications by between 23 and 36% and to increase discounted life expectancy by between 0.13 and 0.35 life-years. The discounted incremental cost per life-year gained of a first-line pioglitazone-based strategy was 54,000 Canadian dollars ($Can) compared with metformin, $Can42,000 compared with glibenclamide and $Can27,000 compared with diet and exercise.When compared with other currently funded chronic therapy, these results demonstrate that a treatment strategy employing pioglitazone as a first-line therapy may be cost effective for certain patient strata.

Objective: To assess the cost effectiveness of nasal calcitonin (Miacalcin®) compared with no therapy, alendronate or etidronate in the treatment of postmenopausal women with previous osteoporotic fracture. Design and setting: Meta-analysis followed by economic analysis. Perspective: A Canadian provincial Ministry of Health. Methods: The meta-analysis of randomised controlled clinical trials was based on the recommendations of the Cochrane Collaboration. Economic analysis was conducted within a Markov model using probabilities and costs derived from Canadian sources. Results: The meta-analysis found evidence of the positive effect of both nasal calcitonin and alendronate in reducing the risks of hip, wrist and vertebral fractures in postmenopausal women. However, there was a lack of evidence of the effect of etidronate on hip and wrist fractures. For a 65-year-old woman, with 5 years’ therapy, the incremental cost per quality-adjusted life-year (QALY) gained for nasal calcitonin was 46 500 Canadian dollars ($Can) compared with no therapy and $Can32 600 compared with etidronate (1998 values). Comparison with alendronate was highly sensitive to the inclusion of one specific trial. Conclusions: Given the results of the analysis, based on current evidence, nasal calcitonin can be considered at themargins of being cost effectiv ewhen compared with no therapy. Compared with active therapy, nasal calcitonin can be considered more cost effective than etidronate, but its cost effectiveness versus alendronate is inconclusive.

Introduction Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD). Methods We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained. Results From the hospital payer’s perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses. Discussion The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking.

The clinical and economic burden of osteoporosis is high and has resulted in increasing interest in assessing the costs and benefits associated with strategies to reduce the incidence of fracture. In this article, we aim to summarize the major issues related to conducting economic evaluations of therapies for osteoporosis. We identify the principal data parameters (baseline clinical probabilities, effectiveness, costs, and utilities) and economic model characteristics (patient age, compliance, and duration of therapy). We highlight these issues by referring to previous studies identified in a systematic review and to current work in the area. Further discussion provides an overview of the results of the existing economic evaluations of therapies for osteoporosis and a brief summary of ongoing research in Canada. In conclusion, there appears to be a consensus in the literature that under most circumstances hormone replacement therapy is cost-effective in the treatment of osteoporosis. Further research is required before definitive conclusions on the cost-effectiveness of other therapies can be made. Drug Dev. Res. 49:135–140, 2000. © 2000 Wiley-Liss, Inc.

The increasing number of economic evaluations of healthcare interventions, and of drug therapies in particular, has been well documented. However, surveys have demonstrated that standards of conduct of such studies have not similarly increased. Of particular concern is the lack of development or even consideration of statistical techniques in the reporting of studies. This article addresses issues that must be considered both in the conduct and in the assessment of the quality of studies. Throughout the paper, examples of pharmacoeconomic analyses are used to illustrate the points made. Recommendations for the conduct of future pharmacoeconomic studies are given. Such recommendations specifically relate to the level of testing that is conducted, the choice of statistical tests and the manner in which statistical significance is reported. In addition, existing methods for the statistical analysis of cost-effectiveness ratios and for the determination of sample size in economic evaluations are discussed, and a partial solution to this issue is offered.

The use of economic evaluation to assess the costs and consequences of health care technologies has steadily increased in recent years. However, little is known about the influence economic studies have on health care decision makers or policy at local and national level. This paper reports the results of a survey of economic evaluations in EC countries to identify the impact of the results on decision and policy making in health care. Health service researchers in 10 EC countries were identified and asked to participate in the survey. The researchers were asked to locate economic evaluations in their country and complete a standardised questionnaire for each study. The criteria for inclusion in the survey were first, the studies should have been started or reported since 1987, second, the evaluations should include a comparison of the cost and consequences of the technologies assessed and finally, the appraisals should include a comparison of alternative health care technologies or programmes. A total of 66 studies which met the survey criteria were reported. Of these, 27% were thought to have influenced health care decision makers or policy. The results suggested that method of dissemination, source of funding and purpose of the study may be important determinants of whether an economic evaluation will be used in health care policy or decision making. The results of the survey suggest that economic evaluation currently has a relatively low impact on health care policy or decision making.(ABSTRACT TRUNCATED AT 250 WORDS)

Drugs are becoming a particular target for health care cost containment measures, as part of the increasing pressure to improve the value for money from the use of health care resources. This has led to an exponential growth in the number of economic evaluations of pharmaceuticals, many of which have been funded by pharmaceutical companies. A review of the existing literature on economic evaluation of pharmaceuticals was conducted in order to classify studies and to document their results. The review identified 85 evaluations, published between 1986 and 1991, that were suitable for analysis. In most published studies it was found that in the treatment or prevention of a disease, a drug intervention was more cost-effective than no intervention and, in a number of cases, drug interventions were at least as cost-effective as other forms of intervention. In evaluating the published evidence it is important to note that positive studies are more likely to be published and that the quality of study methods varies. However, the studies can be of use to policy makers with an interest in securing more value for money, although economic assessments should be applied equally to all health technologies.

OBJECTIVE: Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis. METHODS: An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping. RESULTS: The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919–1325) for the combination therapy, $1210 (95% CI: 1004–1441) for no active treatment, $1322 (95% CI: 1093–1571) for epinephrine alone, and $1360 (95% CI: 1124–1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11–13) for the combination therapy, 12.7 days (95% CI: 12–13) for no active treatment, 13.0 days (95% CI: 12–14) for epinephrine alone, and 12.6 days (95% CI: 12–13) for dexamethasone alone. CONCLUSION: Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.

Irbesartan has been shown to reduce the doubling of serum creatinine (a strong predictor of progression to end-stage renal disease), the onset of end-stage renal disease and all-cause mortality in patients with type 2 diabetes when compared with standard care and amlodipine.The present study assessed the cost effectiveness of irbesartan, an angiotensin II receptor antagonist, and amlodipine, a calcium channel blocker, in the treatment of Canadian patients with diabetic nephropathy and hypertension.The analysis was conducted based on a Markov model using Monte Carlo simulation analysis to estimate the expected values for outcomes of interest. Transition probabilities were obtained from a comparative trial of amlodipine, irbesartan and standard care (antihypertensive treatment excluding other angiotensin II receptor antagonists or calcium channel blockers) in patients with overt diabetic nephropathy and hypertension. Canadian costs for the health states studied were obtained from published data.Based on the results of the Monte Carlo simulation, irbesartan was dominant over standard care and amlodipine because it both reduces costs and leads to greater life expectancy. The incremental cost-effectiveness ratio for amlodipine in comparison with standard care was 102,000 dollars. Estimates of net benefit were correlated with transition probabilities relating to progression from the initial health state. The results were insensitive to univariate sensitivity analysis.Irbesartan use would lead to a reduction in medical costs and an increase in life expectancy when compared with amlodipine or standard care.

Rising health care costs, expensive new health care technologies and increasing patient expectations are placing huge pressures on the publicly funded health care system in Canada. As a result, policy makers need information on the cost and cost-effectiveness of new therapies in addition to their clinical benefits. In response to this need, the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) established a Working Group on Economic Analysis (WGEA) to provide advice on the economic evaluation of new cancer therapies. This article describes the WGEA's recommendations on which trials should be considered for concurrent analysis of economic, as well as related issues, such as the number of patients required for an economic analysis within a prospective clinical trial and the selection of participating centres. The recommendations in this document are meant to be pragmatic, as the WGEA recognizes that both the research funds and human resource capacity for this type of research in Canada are limited. These recommendations are currently guiding priority setting with regard to trials for economic evaluation in NCIC trials. Examples of how these recommendations have been applied to actual trials are presented.

To determine whether statins are underprescribed in the Canadian military. The cost effectiveness of statin therapy in patients identified by the 1998 Canadian cholesterol interim guidelines was also explored.Charts of 1424 Canadian military personnel (age 45 or older) were reviewed at 11 Canadian bases. Risk factors and cholesterol values were used to identify drug therapy candidates. Cost effectiveness ratios and health benefits in terms of years of life saved for statin therapy were estimated for the candidates using a validated cardiovascular disease life expectancy model.Of the 1313 personnel not on lipid lowering medication, 172 were identified as drug therapy candidates. An average of 2.89 years of life saved was forecast for the identified personnel, at an average cost of less than 10,000 dollars per year of life saved.The health benefits of statin therapy in this population are substantial and the cost effectiveness is acceptable. Statin therapy warrants greater attention as a preventive strategy for coronary artery disease.

Rheumatoid arthritis is one of the most common chronic systemic inflammatory diseases, affecting approximately 1% of the adult population. Disease-modifying antirheumatic drugs (DMARDs) have been the mainstay of treatment for rheumatoid arthritis when combined with physical therapy and aspirin (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs. Recently, a number of new biological therapies have been introduced for the treatment of this condition and will have a major impact on the future management of this disabling disease. In this review, we summarise data on the efficacy and tolerability of the currently available DMARDs, including gold compounds, antimalarials, penicillamine, cytotoxic drugs (azathioprine and cyclophosphamide), sulfasalazine, methotrexate, leflunomide, cyclosporin, anti-tumour necrosis factor agents, combination therapy and apheresis. A literature review and quality assessment of economic evaluations of DMARDs is presented, illustrating that there has been a paucity of economic evaluations on these agents and showing the variable quality of those studies that are available. The manuscript also addresses the pharmacoeconomic implications of the new agents for rheumatoid arthritis; the need for formal long term economic evaluations in order to determine the cost effectiveness of these costly, but highly effective, new treatments is emphasised.

Objective.To examine the effectiveness of a home visit program to improve home safety and decrease the frequency of injury in children. We examined the effects of the program on 1) parental injury awareness and knowledge; 2) the extent that families used home safety measures; 3) the rate of injury; and 4) the cost effectiveness of the intervention.Design.A randomized, controlled trial.Setting.A multicenter trial conducted at 5 hospitals in 4 Canadian urban centers.Participants.Children Intervention.Subsequent to a home inspection conducted to determine baseline hazard rates for both groups, participants in the intervention group received a single home visit that included the provision of an information package, discount coupons, and specific instruction regarding home safety measures.Main Results.The median age was 2 years, with males comprising ∼60% of participants. The experimental groups were comparable at outset in terms of case-control status, age, gender, and socioeconomic status. Parental injury awareness and knowledge was high; 73% correctly identified injury as the leading cause of death in children, and an intervention effect was not demonstrated. The adjusted odds ratios (ORs) for the home inspection items indicated that significant safety modifications only occurred in the number of homes having hot water not exceeding 54°C (OR: 1.31, 95% confidence interval [CI]: 1.14, 1.50) or the presence of a smoke detector (OR: 1.45, 95% CI: 0.94, 2.22). However, the intervention group reported home safety modifications of 62% at 4 months and significantly less injury visits to the doctor compared with the nonintervention group (rate ratio: 0.75; 95% CI: 0.58, 0.96). The total costs of care for injuries were significantly lower in the intervention group compared with the nonintervention group with a cost of $372 per injury prevented.Conclusions.An intervention using a single home visit to improve the extent to which families use safety measures was found to be insufficient to influence the long-term adoption of home safety measures, but was effective to decrease the overall occurrence of injuries. Future programs should target a few, well-focused, evidence-based areas including the evaluation of high-risk groups and the effect of repeated visits on outcome.

Objective: The objective of this study was to assess the cost effectiveness of using epoetin-α (erythropoietin) to augment preoperative autologous donation (PAD) of blood prior to elective cardiac surgery. Design and setting: We designed a decision-analytic model incorporating the risk of receiving allogeneic blood, the costs of blood products, the likelihood of developing transfusion-related diseases, the costs of transfusion-related diseases and their impact on life expectancy, and the effect of epoetin-α on the probability of transfusion. Interventions: The efficacy of epoetin-α was derived from data from a meta-analysis of published randomised trials comparing the use of epoetin-α to augment PAD with the use of PAD alone. Estimates for the other parameters were obtained by a systematic review of the literature. Main outcome measures and results: The use of epoetin-α reduced the proportion of patients receiving allogeneic transfusions by 60% (from 31.6 to 12.7%). However, this led to only a modest benefit of 0.000035 life years gained per patient and an incremental cost per life year gained of $Can44.6 million (1998 Canadian dollars). A detailed sensitivity analysis confirmed that the cost-effectiveness ratio was larger than that which is generally considered acceptable. Conclusions: Our study indicates that the use of epoetin-α to reduce perioperative allogeneic transfusions in cardiac surgery is not cost effective.

Background: Best supportive care has long been considered to be the standard therapy for metastatic non-small-cell lung cancer (NSCLC). There is now evidence from randomized trials that a number of chemotherapy regimens can palliate cancer-related symptoms and modestly improve survival. We show how cost-effectiveness analyses can be used to make choices between different (ambulatory) chemotherapy regimens. Methods: Clinical algorithms describing the diagnosis, staging, and treatment of metastatic NSCLC were incorporated into Statistics Canada’s Population Health Model. Using consistent methodology, we assessed the costeffectiveness of several chemotherapeutic interventions: a combination of vindesine (VDS) plus cisplatin, etoposide (VP-16) plus cisplatin, vinblastine (VLB) plus cisplatin, vinorelbine (Navelbine; NVB) plus cisplatin, paclitaxel (Taxol) plus cisplatin, and gemcitabine (GEM) and NVB alone. We calculated the total chemotherapy costs in 1995 Canadian dollars, the cost per case, the average life-years saved, and the cost per life-year saved. Using the Population Health Model, we then constructed an advanced decision framework that rank-ordered the various treatment regimens so as to optimize benefit below various cost-effectiveness thresholds. Results: One regimen (VLB plus cisplatin) appears to result in better survival and lower health care expenditures than best supportive care. By use of costeffectiveness thresholds of $25 000 and $50 000 per life-year gained, NVB plus cisplatin is the preferred regimen. When quality of life is considered, however, GEM is preferred to NVB plus cisplatin at a threshold value of $50 000. At thresholds of $75 000 and $100 000, paclitaxel plus cisplatin at a dose of 135 mg/m 2 is the preferred regimen. At thresholds of $50 000 and above, best supportive care is the least preferred regimen. Conclusions: This decision framework allows the comparison of different treatment regimens based on various cost-effectiveness thresholds. Our analysis also supports the use of chemotherapy regimens and the abandonment of best supportive care as the standard of care for patients with advanced NSCLC. [J Natl Cancer Inst 2000;92:1321–9].

Background: The objective was to determine the average cost per quality-adjusted life year (QALY) gained of treating trauma victims at a tertiary trauma hospital and to determine the cost-effectiveness of trauma care at this center. The setting was a tertiary trauma center in the province of Ontario, Canada. The study population consisted of consecutive trauma admissions with ISS > 12 from April, 1994 to April, 1996. The study was of a retrospective cohort design with a cross-sectional survey. Methods: The hospital perspective was taken. Costs were determined from a retrospective cohort using a hospital-based case-costing system. Utility estimates for calculation of QALYs gained were obtained using a cross-sectional survey design. Cost-effectiveness was determined by estimating the incremental cost/QALY attributable to treatment at the trauma center. Sensitivity analysis was employed to vary assumptions about the proportion of costs and increased survival. Results: 484 patients with a median age of 39 years and a median ISS of 22 were studied. The average cost per QALY was $1,721, with a maximum value of $3,861. The increase in cost per QALY gained for treatment in a tertiary care center as opposed to a nontrauma center was $4,303, assuming a 20% increase in survival and assuming that the existence of the center increased the cost of care by 50%. The incremental cost/QALY ranged from $191 to $15,492 in the sensitivity analysis varying assumptions about the increased proportion of costs and survival attributable to care at the tertiary trauma center. Conclusions: This is the first economic evaluation of tertiary trauma care which includes both costs as opposed to charges as well as estimates of the QALYs gained. The results suggest that tertiary trauma care is cost-effective and less costly than treatment programs for other disease conditions when the quality-adjusted life years gained are included in the evaluation.

In most economic evaluations, future monetary costs and benefits and future health benefits are discounted at the same rate. The purpose of this article is to question such current practice. The primary reason behind discounting costs and benefits is to allow for individuals' preferences over the timing of such events, i.e. to represent social time preference. We argue that the social time preference rate for health benefits is unlikely to be the same as that for monetary costs and benefits. The results of a sensitivity analysis of pharmacoeconomic analyses of drug treatments for hypertension illustrate how the choice of discount rate can affect the conclusions. As no definite conclusions can be drawn regarding the magnitude of the discount rate for health benefits, we recommend that analysts conduct sensitivity analyses employing differential discount rates for health benefits as well as monetary costs and benefits.

© 2012 Lazo-Langner et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: To demonstrate the use of risk-benefit analysis for comparing multiple competing interventions in the absence of randomized trials, we applied this approach to the evaluation of five anticoagulants to prevent thrombosis in patients undergoing orthopedic surgery. Methods. Using a cost-effectiveness approach from a clinical perspective (i.e. risk benefit analysis) we compared thromboprophylaxis with warfarin, low molecular weight heparin, unfractionated heparin, fondaparinux or ximelagatran in patients undergoing major orthopedic surgery, with sub-analyses according to surgery type. Proportions and variances of events defining risk (major bleeding) and benefit (thrombosis averted) were obtained through a meta-analysis and used to define beta distributions. Monte Carlo simulations were conducted and used to calculate incremental risks, benefits, and risk-benefit ratios. Finally, net clinical benefit was calculated for all replications across a range of risk-benefit acceptability thresholds, with a reference range obtained by estimating the case fatality rate - ratio of thrombosis to bleeding. Results: The analysis showed that compared to placebo ximelagatran was superior to other options but final results were influenced by type of surgery, since ximelagatran was superior in total knee replacement but not in total hip replacement. Conclusions: Using simulation and economic techniques we demonstrate a method that allows comparing multiple competing interventions in the absence of randomized trials with multiple arms by determining the option with the best risk-benefit profile. It can be helpful in clinical decision making since it incorporates risk, benefit, and personal risk acceptance. During the conduction of this work Dr. Alejandro Lazo-Langner was supported by a Graduate Scholarship from Consejo Nacional de Ciencia y Tecnología (CONACyT), México, an International Fellowship awarded by the University of Ottawa and by Program Grant PRG 5513 of the Heart and Stroke Foundation of Ontario. Dr. Marc A. Rodger is supported by a Career Scientist Research award from the Heart and Stroke Foundation of Ontario. Dr. Philip S. Wells is supported by the Canada Research Chairs Program.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: The prevalence of physician-diagnosed-asthma has risen over the past three decades and misdiagnosis of asthma is potentially common. Objective: to determine whether a secondary-screening-program to establish a correct diagnosis of asthma in those who report a physician diagnosis of asthma is cost effective.Method: Randomly selected physician-diagnosed-asthmatic subjects from 8 Canadian cities were studied with an extensive diagnostic algorithm to rule-in, or rule-out, a correct diagnosis of asthma. Subjects in whom the diagnosis of asthma was excluded were followed up for 6-months and data on asthma medications and heath care utilization was obtained. Economic analysis was performed to estimate the incremental lifetime costs associated with secondary screening of previously diagnosed asthmatic subjects. Analysis was from the perspective of the Canadian healthcare system and is reported in Canadian dollars.Results: Of 540 randomly selected patients with physician diagnosed asthma 150 (28%; 95%CI 19-37%) did not have asthma when objectively studied. 71% of these misdiagnosed patients were on some asthma medications. Incorporating the incremental cost of secondary-screening for the diagnosis of asthma, we found that the average cost savings per 100 individuals screened was $35,141 (95%CI $4,588-$69,278).Conclusion: Cost savings primarily resulted from lifetime costs of medication use averted in those who had been misdiagnosed. This work was funded by the Canadian Institute of Health Research, Canada and the University Of Ottawa Division Of Respiratory Medicine.