The costs and effectiveness of asthma action plans for children were evaluated in a cross-sectional economic analysis. Direct health care and indirect costs, nights with symptoms, and asthma attacks were measured in 879 Ontario children with asthma. From a societal perspective, the total annual costs of the asthma action plan and the control groups were CDN$6,948 and CDN$6,140 per patient, respectively. Health outcomes were similar. The difference in cost was attributable to greater medication and health services use in the intervention group. Prospective randomized trials are necessary to measure potential improvements in control of asthma using asthma action plans.
Measuring utility for cost-utility analysis (CUA) is challenging in children. The objectives were to characterize pediatric CUAs, appraise their quality, and identify determinants of higher quality.
Descriptive data were imported from the PEDE database for 305 pediatric CUAs published from 1997 to 2009, and quality was rated using the Pediatric Quality Appraisal Questionnaire (PQAQ) in 213 studies. The impact on quality of publication year, journal type, and whether utility was measured was analyzed using multiple regression.
CUAs increased over time and the largest proportion was from North America (38%). Children aged 1-12 years (39%) and preventative interventions (51%) were studied most frequently. Whereas a societal perspective was most common in papers published before 2007 (49%), a third-party payer perspective was subsequently most frequent (63%). Utility was measured prospectively in 8% of studies. Domains that demonstrated the poorest quality were Perspective, Costs and resource use, Outcomes, Analysis, Incremental analysis and Conflict of interest. Quality increased significantly over time for most domains and was greater in studies published in methods/health economic journals.
The quality of pediatric CUAs is increasing. Few studies ascertain utility prospectively, suggesting the need for better instruments for pediatric health state valuation and measurement.
An increased understanding of the genetic basis of disease creates a demand for personalized medicine and more genetic testing for diagnosis and treatment. The objective was to assess the incremental cost-effectiveness per life-month gained of thiopurine methyltransferase (TPMT) genotyping to guide doses of 6-mercaptopurine (6-MP) in children with acute lymphoblastic leukemia (ALL) compared to enzymatic testing and standard weight-based dosing.
A cost-effectiveness analysis was conducted from a health care system perspective comparing costs and consequences over 3 months. Decision analysis was used to evaluate the impact of TPMT tests on preventing myelosuppression and improving survival in ALL patients receiving 6-MP. Direct medical costs included laboratory tests, medications, physician services, pharmacy and inpatient care. Probabilities were derived from published evidence. Survival was measured in life-months. The robustness of the results to variable uncertainty was tested in one-way sensitivity analyses. Probabilistic sensitivity analysis examined the impact of parameter uncertainty and generated confidence intervals around point estimates.
Neither of the testing interventions showed a benefit in survival compared to weight-based dosing. Both test strategies were more costly compared to weight-based dosing. Incremental costs per child (95% confidence interval) were $277 ($112, $442) and $298 ($392, $421) for the genotyping and phenotyping strategies, respectively, compared to weight-based dosing.
The present analysis suggests that screening for TPMT mutations using either genotype or enzymatic laboratory tests prior to the administration of 6-MP in pediatric ALL patients is not cost-effective.
Comment In: Pediatr Blood Cancer. 2011 Dec 15;57(7):124721796762
Assessment of appendicitis during a weeknight or weekend shift (after-hours period, AHP) might be more costly and less effective than its assessment on a weekday shift (standard hours period, SHP) because of increased costs (staff premium fees) and perforation risk (longer delays and less experience of fellows).
The objectives were to compare the costs and effectiveness of assessing children with suspected appendicitis who required a laparotomy and had US or CT after-hours with those of assessing children during standard hours, and to evaluate the importance of diagnostic imaging (DI) within the overall costs.
We retrospectively microcosted resource use within six areas of a tertiary hospital (emergency [ED], diagnostic imaging (DI), surgery, wards, transport, and pathology) in a tertiary hospital. About 41 children (1.8-17 years) in the AHP and 35 (2.9-16 years) in the SHP were evaluated. Work shift effectiveness was measured with a histological score that assessed the severity of appendicitis (non-perforated appendicitis: scores 1-3; perforated appendicitis: score 4).
The SHP was less costly and more effective regardless of whether the calculation included US or CT costs only. For a salary-based fee schedule, 733 US dollars were saved per case of perforated appendicitis averted in the SHP. For a fee-for-service payment schedule, 847 dollars were saved. Within the overall budget, the highest costs were those incurred on the ward for both shifts. The average cost per patient in DI ranged from 2 to 5% of the total costs in both shifts. Most perforation cases were found in the AHP (31.7%, AHP vs. 17.1%, SHP), which resulted in higher ward costs for patients in the AHP.
A higher proportion of severe cases was seen in the AHP, which led to its higher costs. As a result, the SHP dominated the AHP, being less costly and more effective regardless of the fee schedule applied. The DI costs contributed little to the overall cost of the assessment of appendicitis.
Adverse drug events (ADEs) are common and cause significant morbidity and mortality. Patient safety groups advocate the implementation of electronic medication order entry systems to reduce ADEs. However, these systems are costly, and there are limited data on their effectiveness. We conducted a study to examine the costs of introducing an electronic medication ordering and administration system and its potential impact on reducing ADEs.
An incremental cost-effectiveness analysis was performed comparing an electronic medication ordering and administration system to the standard system used at a large health care institution over a 10-year time horizon. Estimates of effect were obtained from the literature. Cost data were obtained from a health care institution in Toronto, Canada.
The incremental cost-effectiveness of the new system was $12,700 (USD) per ADE prevented. The cost-effectiveness was found to be sensitive to the ADE rate, to the effectiveness of the new system, the cost of the system, and costs due to possible increase in doctor workload.
An electronic medication order entry and administration system could improve care by reducing adverse events. Unfortunately there are limited data on effectiveness of these systems at reducing ADEs. Further research is required to determine more precisely the potential economic benefit of this technology.
Cost-utility of laparoscopic Nissen fundoplication versus proton pump inhibitors for chronic and controlled gastroesophageal reflux disease: a 3-year prospective randomized controlled trial and economic evaluation.
Very few randomized controlled trials (RCTs) have compared laparoscopic Nissen fundoplication (LNF) to proton pump inhibitors (PPI) medical management for patients with chronic gastroesophageal reflux disease (GERD). Larger RCTs have been relatively short in duration, and have reported mixed results regarding symptom control and effect on quality of life (QOL). Economic evaluations have reported conflicting results.
To determine the incremental cost-utility of LNF versus PPI for treating patients with chronic and controlled GERD over 3 years from the societal perspective.
Economic evaluation was conducted alongside a RCT that enrolled 104 patients from October 2000 to September 2004. Primary study outcome was GERD symptoms (secondary outcomes included QOL and cost-utility). Resource utilization and QOL data collected at regular follow-up intervals determined incremental cost/QALY gained. Stochastic uncertainty was assessed using bootstrapping and methodologic assumptions were assessed using sensitivity analysis.
No statistically significant differences in GERD symptom scores, but LNF did result in fewer heartburn days and improved QOL. Costs were higher for LNF patients by $3205/patient over 3 years but QOL was also higher as measured by either QOL instrument. Based on total costs, incremental cost-utility of LNF was $29,404/QALY gained using the Health Utility Index 3. Cost-utility results were sensitive to the utility instrument used ($29,404/QALY for Health Utility Index 3, $31,117/QALY for the Short Form 6D, and $76,310/QALY for EuroQol 5D) and if current lower prices for PPIs were used in the analysis.
Results varied depending on resource use/costs included in the analysis, the QOL instrument used, and the cost of PPIs; however, LNF was generally found to be a cost-effective treatment for patients with symptomatic controlled GERD requiring long-term management.
Although rarely life-threatening, postoperative vomiting (POV) is a distressing complication. The incidence of POV ranges from 34 to 90% in children undergoing strabismus surgery when antiemetics are not administered prophylactically.
In this study, a cost-consequence analysis (CCA) is used to estimate the economic benefit of ondansetron and dimenhydrinate as antiemetics administered prophylactically in children undergoing strabismus surgery. This retrospective study was conducted at The Hospital for Sick Children based on a review of 70 charts.
Ondansetron was more effective with 45.3 POV-free patients (PFP) in an adjusted cohort of 100, while dimenhydrinate resulted in 38.2 PFP in an adjusted cohort of 100. The costs were significantly different between the two groups, CAD dollars 185.90 (+/-26.37, 95% CI, CAD dollars 173,89; CAD dollars 197.90) and CAD dollars 232.90 (+/-CAD dollars 66.84, 95% CI, CAD dollars 198.53; CAD dollars 267.27) per patient for ondansetron and dimenhydrinate, respectively. The length of stay in the postanesthetic care unit (PACU) represented over 97% of total costs, and the mean lengths of stay in the PACU for ondansetron and dimenhydrinate were significantly different, 3.43 and 4.41 h, respectively.
This study should serve as a pilot for a large-scale investigation on the correlation between the length of stay in the PACU and the antiemetic agent used.
Currently there is no tool available to adequately appraise the quality of the pediatric health economics literature. A comprehensive pediatric-specific instrument would be valuable in informing allocation decisions related to pediatric interventions and services. The goal of this study was to develop the Pediatric Quality Appraisal Questionnaire (PQAQ).
A draft instrument was constructed from published checklists and questionnaires. New questions pertaining to the pediatric population were incorporated. An expert panel reviewed the draft instrument and the proposed scoring scheme for face and content validity. A revised version was pilot tested by three independent appraisers. After addressing discrepancies in scores, a final version was created and subjected to interrater and test-retest reliability assessment.
The 57 items in the final PQAQ were mapped onto 14 domains: economic evaluation, comparators, target population, time horizon, perspective, costs and resource use, outcomes, quality of life, analysis, discounting, incremental analysis, sensitivity analysis, conflict of interest, and conclusions. Among the 57 items, 46 have response options that are scored from 0 to 1. Interrater reliability was 0.75 (95% confidence interval [CI] 0.66-0.81) and test-retest reliability was 0.92 (95% CI 0.71-0.98).
The PQAQ is a comprehensive instrument demonstrating face and content validity and strong interrater and test-retest reliability in the appraisal of pediatric economic evaluations. This tool will be valuable to health economists, methods researchers, and policy decision makers involved in allocation decisions for pediatric health care.