Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, McMaster University Medical Centre, 1200 Main Street West, HSC-2C, Hamilton, Ontario, Canada L8N 3Z5; Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph's Healthcare Hamilton, 2000-25 Main Street West, Hamilton, Ontario, Canada L8P 1H1. Electronic address: email@example.com.
A systems analysis perspective was undertaken to evaluate access to surgery for children with medically refractory epilepsy (MRE) in Ontario, the largest province in Canada. The analysis focused on the assessment of referral patterns, healthcare utilization, time intervals and patient flow to determine surgical candidacy in children with MRE. The purpose of this systems analysis study was to identify rate limiting steps that may lead to delayed surgical candidacy decision and surgery.
Prolonged video electroencephalography (vEEG) is the common entry point into the process for all potential epilepsy surgery candidates. Therefore, a single centre retrospective chart review of children and adolescents referred to the epilepsy monitoring unit (EMU) for vEEG monitoring at the primary referral centre for paediatric epilepsy surgery in the province. Basic demographic and referral data were abstracted for all screened cases. Included cases were: (1) age 8h). Forty five percent (n=160) of patients came to seizure conference for discussion of their data, of whom 40% (64/160) were considered surgical candidates. Time from first seizure to EMU referral was approximately 4.6 years. Time from referral to admission and admission to first seizure conference were approximately 103 days and 71 days, respectively. From initial EMU referral to surgery ranged from 1.6 to 1.1 years depending on whether the patient required invasive monitoring with intracranial EEG. Overall, 95% of surgical patients had a reduction in seizure frequency, 74% were seizure free after one year post-surgery.
Referral rates for surgical assessment are low relative to the estimated number of children living with MRE in Ontario, less than 2%. Hence, only a limited number of children with this disorder in the province of Ontario who could benefit from epilepsy surgery are being assessed for surgical candidacy. The majority of Ontario children with MRE are not being provided the potential opportunity to be seizure free and live without functional limitations following surgical intervention. These data document the critical need for health system redesign in Ontario, the goal of which should be to provide more consistent and just access to evidence-based medical and surgical care for those citizens of the province who suffer from epilepsy.
To use data from a randomized controlled trial and update an earlier economic evaluation of surgery versus collagen injection for the treatment of female stress urinary incontinence (SUI).
A decision tree model was developed using probabilities of success and complications from a randomized controlled trial. Resource use and cost data were taken from the earlier economic evaluation. The primary outcome was treatment success, which was defined as a negative 24 hour PAD test given 1 year post-treatment. The evaluation was conducted from the 'healthcare system' perspective and separate analyses were undertaken for Ontario and Québec. Sensitivity analyses were used to examine uncertainty in probabilities and costs.
Surgery was generally more costly and more successful than collagen injection. Incremental cost effectiveness ratios indicated that the healthcare system would incur an additional cost of $121.08 to $341.35 per additional patient that was successfully treated with surgery. Sensitivity analyses showed that surgery would be less costly and more successful than collagen injection if the postoperative length of hospital stay was reduced to 1 day. Surgery might also be more cost effective than collagen injection if the number of injections used to treat patients were to increase beyond two for treatment successes and four for treatment failures.
Collagen injection is an outpatient procedure without risk of significant morbidity or complications. However, this does not readily translate into a clear cost effective advantage relative to surgery. In some cases, surgery may be more cost effective than collagen injection in the treatment of female SUI.
Atrial fibrillation (AF) is a common disease that frequently requires acute hospital care; however, the cost of hospital care in Canada has not been reported. The purpose of this study was to estimate the cost of AF related to hospital-based care in Canada.
Analyses were conducted with 2 national administrative databases for the fiscal year 2007-2008. Databases included information for hospital admissions, day operations, and ambulatory care. Records with a most responsible diagnosis of AF, atrial flutter, or a diagnosis related to AF with a concomitant comorbidity of AF were included. Hospital costs were estimated, in 2010 Canadian dollars, by applying an average cost per weighted case to the resource intensity weight for each admission or visit and then adding the separate billable fee for admissions, surgical procedures, and interventions.
In 2007-2008, the number of acute care admissions with AF as the most responsible diagnosis was 22,823, same-day surgical procedures was 5707, and emergency department visits was 58,066. The hospital costs attributable to AF were $815 million in 2010 Canadian dollars: $710 million for hospitalizations; $32 million for same-day surgical procedures; and $73 million for emergency department visits. Most of the acute care costs were for hospitalizations when AF was listed as a comorbidity ($558 million, or 69%).
AF results in a substantial cost burden to the acute care hospital sector. Current hospital costs in AF patients are driven by the consequences of AF, while the costs for specific treatments for AF are relatively low.
There is a dearth of information about the burden of osteoporosis in Canadian men. To fill this gap, we conducted a burden of illness study aimed at estimating the economic burden attributable to osteoporosis in Canadian men aged 50 years and older. Five national data sources were used to estimate health care resource utilization and costs (in 2010 Canadian dollars) associated with osteoporosis in men. Any information gap was supplemented by using data from provincial and community sources. Direct medical costs included costs associated with hospitalizations, same day surgeries, emergency room visits, rehabilitation, chronic care, long-term care, home care, physician visits, and prescribed medications. The value of lost productivity from patients and informal caregivers was also determined to provide a societal perspective. Sensitivity analyses were conducted to evaluate the impact of key assumptions on the results. In fiscal year 2007/2008, the total economic burden of treating and rehabilitating male osteoporotic fractures was estimated at $570 million per year, where direct medical costs accounted for 86%. Acute care utilization was responsible for 70% of all direct costs. About 51% of all hospitalizations were for hip fractures and hip fractures alone accounted for 54% of the acute care spending. If a proportion of Canadian men were assumed to live in long-term care facilities due to osteoporosis, the overall annual cost of osteoporosis would increase from $570 million to $910 million. Male osteoporosis has a substantial economic burden on the Canadian society.
Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract. Symptoms include but are not limited to abdominal pain, nausea, emesis, and diarrhea. Anti-TNF-a drugs are increasingly being used in patients with CD who have inadequate response to conventional therapy. However, these medications are quite expensive. The objective of this study is to evaluate the cost-utility of two anti-TNF-a drugs (infliximab, adalimumab) for refractory CD.
A Markov model was used to estimate the costs and QALYs of three treatments (usual care, infliximab, adalimumab) over a 5 year time horizon. After initial treatment, patients achieve remission, achieve treatment response or remain in the drug refractory health state. Patients who achieve remission or treatment response are at risk of relapse each 3 month model cycle. Patients in the drug refractory health state either remain in the health state or have surgery in each cycle. Different costs and utility values were assigned to the various model health states. Model input parameters including initial response rates, relapse rates, utility values were derived from published literature.
Usual care had both the lowest expected costs ($17,017) and QALYs (2.555), while infliximab had both the highest expected costs ($54,084) and QALYs (2.721). The incremental cost per QALY moving from usual care to adalimumab and from adalimumab to infliximab was estimated to be to be $193,305 and $451,165, respectively.
Based on common willingness to pay thresholds, ant-TNF-a drugs would not be perceived as a cost effective treatment for refractory CD.
Idiopathic thrombocytopenic purpura (ITP) is a hematological disorder and can be classified as acute or chronic. The main goal of treatment for acute childhood ITP is the prevention of potentially fatal bleeding complications, the most serious of which is intracranial hemorrhage (ICH). Treatment options for acute childhood ITP include splenectomy, corticosteroids, and blood products such as intravenous immunoglobulin.
The objective was to evaluate, from a Canadian perspective, the cost-effectiveness of intravenous immunoglobulin (IVIG) compared to alternative inpatient treatments for acute childhood idiopathic thrombocytopenic purpura (ITP).
A Markov model with a lifelong time horizon was used to evaluate the costs and quality-adjusted life years (QALYs) for 5 treatments for children hospitalized for ITP: 1) no treatment; 2) IVIG; 3) Anti-D; 4) prednisone; and 5) methylprednisolone. The model predicted the probability of intracranial hemorrhage for each treatment strategy based on the time children spent with platelet counts
The importance of patient instructions, designed to optimize therapy with phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction (ED), has recently been demonstrated.
To evaluate the impact of an educational program for new sildenafil users against usual ED management in Canadian primary care practices.
This multicenter, 6-month cluster randomized prospective study was conducted across Canada in general practitioners' offices where sites were randomized to receive a treatment optimization program (TOP) tool at visit 1 (TOP sites) or not to receive the TOP tool (non-TOP sites) while continuing with usual practice. Study participants were men seeking medical attention for ED and who were sildenafil naïve. The TOP tool consisted of a tear-off sheet, a brochure, and a video. Study drug was not provided to the patients. Sildenafil samples and prescriptions were dispensed as per usual care practices.
The Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire was used to determine treatment satisfaction at visit 2 (month 3) and visit 3 (month 6). Patient and physician satisfaction with the TOP tool was assessed using self-reported questionnaires.
The intent-to-treat (ITT) population consisted of 2,573 patients from 231 primary care sites. At visits 2 and 3, treatment satisfaction with sildenafil was high with almost 9 patients out of 10 satisfied with treatment. No significant statistical differences were observed in the EDITS scores between the TOP and the non-TOP groups at visits 2 and 3. More than 80% of the participants were satisfied or very satisfied with the video and the brochure. More than 8 out of 10 participating physicians (84%) would use the TOP tool in their current practice if available.
TOP is a valuable and time-efficient ED management tool providing benefits to newly diagnosed ED patients and to their physicians.
Department of Clinical Epidemiology & Biostatistics, McMaster University & Programs for Assessment of Technology in Health (PATH) Research Institute, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada. firstname.lastname@example.org
Cost-effectiveness analysis of elective endovascular repair compared with open surgical repair of abdominal aortic aneurysms for patients at a high surgical risk: A 1-year patient-level analysis conducted in Ontario, Canada.
Abdominal aortic aneurysm (AAA) is a prevalent health condition affecting up to 14% of men and 6% of women. The objective of this study was to estimate the cost-effectiveness and cost-utility of elective endovascular aneurysm repair (EVAR) compared with open surgical repair (OSR) in patients at a high risk of surgical complications.
Patient-level cost and outcome data from a 1-year prospective observational study conducted at London Health Sciences Centre, London, Ontario, Canada, was used to determine the incremental cost per life-year gained and the incremental cost per quality-adjusted life year (QALY) gained of EVAR compared with OSR in patients with an AAA >5.5 cm and a high risk of surgical complications. The analysis was taken from a societal perspective and the time horizon was 1 year. To measure sampling uncertainty on costs and effects, nonparametric bootstrap techniques were applied. Uncertainty results were expressed using cost-effectiveness acceptability curves. Extrapolations of the 1-year results to a 5-year time horizon were conducted in sensitivity analyses.
Between August 11, 2003, and April 3, 2005, 192 patients at a high risk of surgical complications were enrolled: 140 received EVAR and 52 OSR. Point estimates during a 1-year period showed that EVAR dominated OSR for high-risk patients in terms of incremental cost per life-year gained and incremental cost per QALYs. However, bootstrap estimates for the two cost-effectiveness measures indicated there was a great deal of uncertainty regarding the costs and the QALYs and less uncertainty regarding life-years gained. If society was willing to pay $50,000 per life-year gained or per QALY gained, the probability of EVAR being cost-effective was found to be 0.76 and 0.55, respectively. Five-year extrapolations indicated that EVAR was cost-effective compared with OSR.
According to this 1-year observational study, EVAR may be a cost-effective strategy compared with OSR for high-risk patients. Longer-term data are needed to decrease the uncertainty associated with the results.
The primary risk of abdominal aortic aneurysms (AAAs) is rupture, which is associated with a high mortality rate. Elective surgical options for AAA include open repair (OR) and endovascular aneurysm repair (EVAR). EVAR is less invasive than OR, and therefore may have less surgical risk than OR. However, the graft used for EVAR is much more expensive then the graft used for OR.
A decision model with a 10-year time horizon was used to assess the cost-effectiveness of EVAR versus OR. The primary outcome measure was quality-adjusted life-years (QALYs). The model incorporated the costs and benefits of both perioperative outcomes and postoperative outcomes. A systematic review was conducted to derive clinical outcome rates. Cost and utility model variables were based on various literature sources and data from a recent Canadian observational study. Parameter uncertainty was assessed using probabilistic sensitivity analysis.
In the base-case model, the incremental cost per QALY of EVAR was estimated to be $268,337, whereas the incremental cost per life-year was found to be $444,129. The incremental cost per QALY of EVAR remained above $295,715 under different assumptions of cohort age and model time horizon.
Based on commonly quoted willingness-to-pay thresholds, EVAR was not found to be cost-effective compared to OR.