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Changing treatment patterns for coronary artery revascularization in Canada: the projected impact of drug eluting stents.

https://arctichealth.org/en/permalink/ahliterature177007
Source
BMC Cardiovasc Disord. 2004;4:23
Publication Type
Article
Date
2004
Author
Michael T Halpern
Michael Lacey
Mary Ann Clark
Miguel A Valentin
Author Affiliation
Exponent, Alexandria, VA, USA. mhalpern@exponent.com
Source
BMC Cardiovasc Disord. 2004;4:23
Date
2004
Language
English
Publication Type
Article
Keywords
Adult
Angioplasty, Balloon, Coronary - utilization
Canada
Cardiology
Coronary Artery Bypass - utilization
Coronary Artery Disease - economics - therapy
Device Approval
Humans
Male
Myocardial Revascularization - economics - utilization
Physician's Practice Patterns
Questionnaires
Stents - economics - utilization
Abstract
To evaluate current treatment patterns for coronary artery revascularization in Canada and explore the potential impact of drug eluting stents (DES) on these treatment patterns.
Eleven cardiologists at multiple Canadian academic centers completed a questionnaire on coronary artery revascularization rates and treatment patterns.
Participating physicians indicated slightly higher rates of PTCA, CABG, and stent implantation than reported in CCN publications. Participants estimated that 24% of all patients currently receiving bare metal stents (BMS) would receive DES in the first year following DES approval in Canada, although there was a large range of estimates around this value (5% to 65%). By the fifth year following DES approval, it was estimated that 85% of BMS patients would instead receive DES. Among diabetic patients, estimates ranged from 43% in the first year following approval to 91% in the fifth year. For all patients currently receiving CABG, mean use of DES instead was estimated at 12% in the first year to 42% at five years; rates among diabetic patients currently undergoing CABG were 17% in the first year to 49% in the fifth year.
These results suggest a continued increase in revascularization procedures in Canada. Based on the panel's responses, it is likely that a trend away from CABG towards PTCA will continue in Canada, and will be augmented by the availability of DES as a treatment option. The availability of DES as a treatment option in Canada may change the threshold at which revascularization procedures are considered.
Notes
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PubMed ID
15596004 View in PubMed
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Economic evaluation of drug-eluting stents: a systematic literature review and model-based cost-utility analysis.

https://arctichealth.org/en/permalink/ahliterature160814
Source
Int J Technol Assess Health Care. 2007;23(4):473-9
Publication Type
Article
Date
2007
Author
Pekka Kuukasjärvi
Pirjo Räsänen
Antti Malmivaara
Pasi Aronen
Harri Sintonen
Author Affiliation
Finnish Office for Health Technology Assessment, Stakes, PO Box 220, FIn-00531, Helsinki, Finland. pekka.kuukasjarvi@stakes.fi
Source
Int J Technol Assess Health Care. 2007;23(4):473-9
Date
2007
Language
English
Publication Type
Article
Keywords
Coronary Artery Disease - surgery
Cost-Benefit Analysis
Drug-Eluting Stents - economics
Finland
Humans
Models, Economic
Quality-Adjusted Life Years
Technology Assessment, Biomedical - economics
Abstract
The aim of this study was to systematically review economic analyses comparing drug-eluting stents (DES) to bare metal stents (BMS) in patients who undergo percutaneous coronary intervention to form an overall view about cost-effectiveness of DES and to construct a simple decision analysis model to evaluate the cost-utility of DES.
Electronic databases searched from January 2004 to January 2006 were Cochrane Database of Systematic Reviews; DARE, HTA, EED (NHS CRD); MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE(R). References of the papers identified were checked. We included randomized controlled trials (RCT) or model-based cost-effectiveness analyses comparing DES to BMS in patients with coronary artery disease. The methodological quality of the papers was assessed by Drummond's criteria. Baseline characteristics and results of the studies were extracted and data synthesized descriptively. A decision tree model was constructed to evaluate the cost-utility of DES in comparison to BMS, where health-related quality of life was measured by the 15D.
We identified thirteen good-quality economic evaluations. In two of these based on RCTs, DES was found cost-effective. In six studies, it was concluded that DES might probably be a cost-effective strategy in some circumstances, but not as a single strategy, and four studies concluded that DES is not cost-effective. One study did not draw a clear conclusion. In our analysis, the overall incremental cost-effectiveness ratio was Euros 98,827 per quality-adjusted life-years gained. Avoiding one revascularization with DES would cost Euros 4,794, when revascularization with BMS costs Euros 3,260.
The evidence is inconsistent of whether DES would be a cost-effective treatment compared with BMS in any healthcare system where evaluated. A marked restenosis risk reduction should be achieved before use of DES is justifiable at present prices. When considering adoption of a new health technology with a high incremental cost within a fixed budget, opportunity cost in terms of untreated patients should be seriously considered as a question of collective ethics.
PubMed ID
17937836 View in PubMed
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Economic evaluation of drug-eluting stents compared to bare metal stents using a large prospective study in Ontario.

https://arctichealth.org/en/permalink/ahliterature151781
Source
Int J Technol Assess Health Care. 2009 Apr;25(2):196-207
Publication Type
Article
Date
Apr-2009
Author
Ron Goeree
James M Bowen
Gord Blackhouse
Charles Lazzam
Eric Cohen
Maria Chiu
Rob Hopkins
Jean-Eric Tarride
Jack V Tu
Author Affiliation
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. goereer@mcmaster.ca
Source
Int J Technol Assess Health Care. 2009 Apr;25(2):196-207
Date
Apr-2009
Language
English
Publication Type
Article
Keywords
Aged
Coronary Artery Disease - economics - therapy
Cost-Benefit Analysis
Drug-Eluting Stents - economics
Female
Health Care Costs
Humans
Male
Middle Aged
Ontario
Prospective Studies
Quality-Adjusted Life Years
Risk
Stents - economics
Abstract
To determine the cost-effectiveness (CE) and cost-utility (CU) of drug-eluting stents (DES) compared to bare metal stents (BMS) in Ontario using a large prospective "real-world" cohort study and determine the extent to which results vary by patient risk subgroups.
A field evaluation was conducted based on all stent procedures in the province of Ontario between December 1, 2003, and March 31, 2005, with a minimum subject follow-up of 1 year. Effectiveness data from the study using a propensity-score matched cohort were combined with resource utilization and cost data and quality of life (QOL) data from the published literature in a decision analytic modeling framework to determine 2-year cost-effectiveness (cost per revascularization avoided) and cost-utility (cost per quality-adjusted life-year ([QALY] gained). Stochastic model parameter uncertainty was expressed using probability distributions and analyzed using a probabilistic model. Modeling assumptions were assessed using traditional deterministic sensitivity analysis.
Significant differences in revascularization rates were found for patients with two or more high risk factors. Despite these differences, the CE and CU of DES remained high (e.g., $419,000 per QALY gained in the most favorable patient risk subgroup). In sensitivity analysis, the difference in cost between DES and BMS had an impact on the CE and CU results. For example, at a price differential of $500, the CU of DES was $20,000/QALY for one patient subgroup and DES was dominant (i.e., less costly and more effective) in another.
At current prices, the CE/CU of DES compared with BMS is high even in patient high risk subgroups. As the relative price of DES decrease, the value for money attractiveness of DES increases, especially for selected high risk patients.
PubMed ID
19331710 View in PubMed
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Health economic evaluation of stent or endoluminal brachytherapy as a palliative strategy in patients with incurable cancer of the oesophagus or gastro-oesophageal junction: results of a randomized clinical trial.

https://arctichealth.org/en/permalink/ahliterature83099
Source
Eur J Gastroenterol Hepatol. 2005 Dec;17(12):1369-77
Publication Type
Article
Date
Dec-2005
Author
Wenger Urs
Johnsson Erik
Bergquist Henrik
Nyman Jan
Ejnell Hans
Lagergren Jesper
Ruth Magnus
Lundell Lars
Author Affiliation
Department of Surgery, Karolinska University Hospital, Stockholm, Sweden. urs.wenger@karolinska.se
Source
Eur J Gastroenterol Hepatol. 2005 Dec;17(12):1369-77
Date
Dec-2005
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Brachytherapy - economics
Cost-Benefit Analysis
Deglutition Disorders - economics - radiotherapy - therapy
Esophageal Neoplasms - radiotherapy - therapy
Esophagogastric Junction
Female
Health Care Costs - statistics & numerical data
Hospital Costs - statistics & numerical data
Humans
Male
Middle Aged
Palliative Care - economics - methods
Prospective Studies
Severity of Illness Index
Stents - economics
Survival Analysis
Sweden
Treatment Outcome
Abstract
OBJECTIVE: To relieve dysphagia is the main goal in palliative treatment of patients with incurable cancer of the oesophagus or the gastro-oesophageal junction. The aim of this prospective, randomized multicentre study was to compare stent placement and brachytherapy regarding health economy and clinical outcomes. METHODS: Patients with incurable cancer of the oesophagus or gastro-oesophageal junction were randomized to receive a self-expandable metallic stent or 3 x 7 Gy brachytherapy. At clinical follow-up visits, dysphagia was scored and health care consumptions were recorded. Costs were based on hospital debits. Total lifetime healthcare consumption costs and costs for the initial treatments were calculated and a sensitivity analysis was conducted. RESULTS: Thirty patients were randomized to each treatment group. There was no difference in survival or complication rates between the two treatment strategies. There was a significant difference in the change of dysphagia scores between the time of inclusion and the 1-month follow-up visit, in favour of the stented group (P = 0.03). This difference had disappeared at 3 months. Median total lifetime costs were 17,690 for the stented group compared with 33 171 for the brachytherapy group (P = 0.005). This difference was due to higher costs for the initial treatment (4615 versus 23 857, P
PubMed ID
16292092 View in PubMed
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Hospitalization costs of primary stenting versus thrombolysis in acute myocardial infarction: cost analysis of the Canadian STAT Study.

https://arctichealth.org/en/permalink/ahliterature183003
Source
Circulation. 2003 Nov 25;108(21):2624-30
Publication Type
Article
Date
Nov-25-2003
Author
Michel R Le May
Richard F Davies
Marino Labinaz
Heather Sherrard
Jean-François Marquis
Louise A Laramée
Edward R O'Brien
William L Williams
Rob S Beanlands
Graham Nichol
Lyall A Higginson
Author Affiliation
Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada. mlemay@ottawaheart.ca
Source
Circulation. 2003 Nov 25;108(21):2624-30
Date
Nov-25-2003
Language
English
Publication Type
Article
Keywords
Canada
Cardiac Catheterization - statistics & numerical data
Cost-Benefit Analysis
Follow-Up Studies
Hospital Costs - statistics & numerical data
Hospitalization - economics - statistics & numerical data
Humans
Length of Stay - statistics & numerical data
Middle Aged
Multivariate Analysis
Myocardial Infarction - economics - therapy
Outcome Assessment (Health Care)
Patient Readmission - statistics & numerical data
Stents - economics - statistics & numerical data
Thrombolytic Therapy - economics - statistics & numerical data
Tissue Plasminogen Activator - economics - therapeutic use
Abstract
We previously showed that primary stenting was more effective than accelerated tPA in reducing the 6-month composite of death, reinfarction, stroke, or repeat revascularization for ischemia. This study looks at the hospitalization costs of primary stenting compared with accelerated tPA.
Initial and 6-month hospitalization costs were computed for all patients randomly assigned to primary stenting (n=62) or accelerated tPA (n=61) in the Stenting versus Thrombolysis in Acute myocardial infarction Trial (STAT). Costs and resource usage were collected in detail for each patient. Physician fees were obtained directly from billings to the Ontario Health Insurance Plan. The length of initial hospitalization was 6.7+/-11.3 days in the stent group and 8.7+/-6.7 days in the tPA group (P
PubMed ID
14597591 View in PubMed
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Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties.

https://arctichealth.org/en/permalink/ahliterature155638
Source
J Urol. 2008 Oct;180(4 Suppl):1693-8; discussion1698-9
Publication Type
Article
Date
Oct-2008
Author
Luis H P Braga
Armando J Lorenzo
Walid A Farhat
Darius J Bägli
Antoine E Khoury
Joao L Pippi Salle
Author Affiliation
Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario Canada.
Source
J Urol. 2008 Oct;180(4 Suppl):1693-8; discussion1698-9
Date
Oct-2008
Language
English
Publication Type
Article
Keywords
Adult
Anesthesia, General
Decision Trees
Drainage - economics - instrumentation
Female
Hospital Costs
Humans
Kidney Pelvis - surgery
Length of Stay
Male
Ontario
Operating Rooms - economics
Retrospective Studies
Stents - economics
Treatment Outcome
Ureteral Obstruction - surgery
Urologic Surgical Procedures - economics - instrumentation - methods
Abstract
Despite the widespread use of ureteral stents for pyeloplasty by pediatric urologists there is ongoing controversy regarding the most advantageous type of transanastomotic drainage. We compared patients who underwent placement of an externalized pyeloureteral Salle intraoperative pyeloplasty stent (Cook Urological, Spencer, Indiana) to those who had a standard Double-J ureteral stent placed to assess the benefits, drawbacks and costs of each modality during open pyeloplasty.
Our study sample comprised 470 age matched children who underwent primary open pyeloplasty in an 11-year period. A total of 242 patients (51.5%) underwent Double-J ureteral stent insertion and 228 (48.5%) underwent placement of a Salle intraoperative pyeloplasty stent at surgery. Operative time, hospital stay, overall complication and success rates, type of complications and hospital costs were compared between the 2 groups.
Median age was 18 months and median followup was 39 months. Mean hospital stay was 3.0 and 3.1 days in children with a Double-J ureteral and a Salle intraoperative pyeloplasty stent, respectively (p = 0.7). The overall complication rate was 9.9% (24 of 242 patients) for the Double-J ureteral stent vs 8.3% (19 of 228) for the Salle intraoperative pyeloplasty stent (p = 0.6). Complications in patients with a Double-J ureteral stent consisted of urinoma in 3, return visits due to bladder spasms in 7 or catheter obstruction in 6 and readmission due to pyelonephritis in 5. Complications in children with a Salle intraoperative pyeloplasty stent involved urinoma in 1, prolonged drainage through the Penrose drain in 5 and readmission due to pyelonephritis in 1. Recurrent ureteropelvic junction obstruction developed in 12 cases per group. The success rate was 95.0% (230 of 242 cases) and 94.7% (216 of 228) for the Double-J ureteral and the Salle intraoperative pyeloplasty stent, respectively (p = 0.2). Hospital charges, including the surgical procedure, postoperative hospitalization and cystoscopy or a clinical visit for catheter removal, in patients with a Double-J ureteral and a Salle intraoperative pyeloplasty stent were $9,825 and $9,260, respectively.
The 2 ureteral stents are equivalent in regard to overall complication and success rates after pyeloplasty. However, Salle intraoperative pyeloplasty stent insertion was associated with a Canadian $565 cost decrease per patient and most importantly the preclusion of a second general anesthesia for catheter removal.
Notes
Comment In: J Urol. 2009 Jul;182(1):399-40019467676
PubMed ID
18708220 View in PubMed
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Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation.

https://arctichealth.org/en/permalink/ahliterature17457
Source
World J Surg. 2004 Aug;28(8):812-7
Publication Type
Article
Date
Aug-2004
Author
Erik Johnsson
Anders Thune
Bengt Liedman
Author Affiliation
Department of Surgery and Transplantation, Sahlgrenska University Hospital/Sahlgrenska, 413 45, Göteborg, Sweden.
Source
World J Surg. 2004 Aug;28(8):812-7
Date
Aug-2004
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Comparative Study
Cost Savings - economics
Digestive System Neoplasms - economics - mortality - surgery
Duodenoscopy - economics
Female
Gastric Outlet Obstruction - economics - mortality - surgery
Gastroenterostomy - economics
Hospital Charges - statistics & numerical data
Humans
Length of Stay - economics
Male
Middle Aged
Palliative Care - economics
Prospective Studies
Stents - economics
Survival Rate
Sweden
Treatment Outcome
Abstract
Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p
PubMed ID
15457364 View in PubMed
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Potential shift from coronary bypass surgery to percutaneous coronary intervention for multivessel disease and its economic impact in the drug-eluting stent era.

https://arctichealth.org/en/permalink/ahliterature159946
Source
Can J Cardiol. 2007 Dec;23(14):1139-45
Publication Type
Article
Date
Dec-2007
Author
Frédéric Poulin
Stéphane Rinfret
François Gobeil
Author Affiliation
Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
Source
Can J Cardiol. 2007 Dec;23(14):1139-45
Date
Dec-2007
Language
English
Publication Type
Article
Keywords
Aged
Blood Vessel Prosthesis Implantation - economics - methods - statistics & numerical data
Coated Materials, Biocompatible - economics
Coronary Angiography
Coronary Artery Bypass - economics - methods - statistics & numerical data
Coronary Disease - economics - radiography - surgery
Costs and Cost Analysis
Female
Follow-Up Studies
Humans
Male
Middle Aged
Quebec
Retrospective Studies
Stents - economics
Treatment Outcome
Abstract
Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money.
The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences.
Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l'Université de Montréal's Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations.
The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients.
Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.
Notes
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PubMed ID
18060100 View in PubMed
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Resource allocation among cardiovascular specialists and trainees: a pilot survey.

https://arctichealth.org/en/permalink/ahliterature158806
Source
Can J Cardiol. 2008 Feb;24(2):118-20
Publication Type
Article
Date
Feb-2008
Author
James M Brophy
Author Affiliation
Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada. james.brophy@mcgill.ca
Source
Can J Cardiol. 2008 Feb;24(2):118-20
Date
Feb-2008
Language
English
Publication Type
Article
Keywords
Antibodies, Monoclonal - economics
Anticoagulants - economics
Attitude of Health Personnel
Biomedical Technology - economics
Budgets
Cardiac Pacing, Artificial - economics
Cardiology
Defibrillators - economics
Equipment and Supplies, Hospital - economics
Heart-Assist Devices - economics
Humans
Immunoglobulin Fab Fragments - economics
Internship and Residency
Pilot Projects
Quebec
Questionnaires
Resource Allocation
Stents - economics
Abstract
To assess the relative importance that cardiovascular specialists assign to new technologies.
A pilot survey of practising cardiologists in one tertiary hospital and cardiology trainees from two university programs. Respondents were asked to distribute a hypothetical budget among several new technologies.
A total of 28 responses (response rate of 62%) were analyzed. In the hypothetical situation described, doctors appeared willing to spend approximately equal amounts on implantable cardiac defibrillators (median 25%, interquartile range 5% to 30%) and bare metal coronary stents (median 28%, interquartile range 20% to 40%). Physicians were more restrained in their allocation for refinements of these two technologies, including drug-eluting stents and biventricular pacing. Wide individual variations in technology use were noted.
There is considerable uncertainty among cardiovascular specialists regarding the relative value of new technologies. Further work is required to better quantify this uncertainty and its determinants.
Notes
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PubMed ID
18273484 View in PubMed
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14 records – page 1 of 2.