Standardizing the Response to Category II Tracings during Induction with Oxytocin: A Cost-Effectiveness Analysis

2017 ◽  
Vol 34 (12) ◽  
pp. 1255-1263 ◽  
Author(s):  
Leah Savitsky ◽  
Blake Zwerling ◽  
Justin Williams ◽  
Alison Cahill ◽  
Aaron Caughey ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cost Effectiveness ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Mode Of Delivery ◽  
Cost Effective ◽  
The United States ◽  
Sensitivity Analyses ◽  
Decision Analytic Model ◽  
Cesarean Deliveries

Background Oxytocin is one of the most frequently used medications in obstetrics. It is generally considered to be safe and effective for induction and augmentation of labor but has been implicated in uterine hyperstimulation and adverse fetal outcomes. The management of labor with oxytocin in response to changes in fetal status remains an area of debate. Objective This study sought to assess the cost-effectiveness of reducing or ceasing oxytocin administration in response to Category II fetal heart rate tracings. Study Design A decision-analytic model was built using TreeAge 2016 software (TreeAge Software Inc.) with probabilities, costs, and utilities derived from the literature. Primary outcomes included cerebral palsy (CP), neonatal mortality, and mode of delivery. Secondary outcomes included cost per quality-adjusted life year (QALY; cost-effectiveness threshold set at $100,000/QALY), admission to the neonatal intensive care unit (NICU), and low 5-minute Apgar score (<7). Sensitivity analyses were performed to determine the robustness of our baseline assumptions. Results In a theoretical cohort of 900,000 women (estimated number of women undergoing induction at term in the United States), decreasing or stopping oxytocin in response to Category II tracings prevented 12,510 NICU admissions, 4,410 low Apgar scores, 204 neonatal deaths, and 126 cases of CP. However, there were 81,900 more cesarean deliveries. The strategy cost $356 million more, but was cost-effective with an ICER of $9,881.5 per QALY. Sensitivity analysis revealed that the intervention would be cost-effective up to a cesarean rate of 54%. Conclusion Decreasing or stopping oxytocin in response to Category II fetal heart rate tracings is cost-effective. This intervention increases the rate of cesarean deliveries but reduces neonatal morbidity and mortality. Further work on this guideline should be performed to ascertain how the approach using different aspects of the Category II tracing to guide care might lead to similar improved outcomes without increasing the cesarean delivery rate.

scholarly journals Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus

2020 ◽  
Vol 21 (3) ◽  
pp. 437-449 ◽  
Author(s):  
Alexander Kuhlmann ◽  
Henning Krüger ◽  
Susanne Seidinger ◽  
Andreas Hahn
Keyword(s):  
Diabetes Mellitus ◽  
Cost Effectiveness ◽  
Budget Impact ◽  
Input Parameter ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Decision Analytic Model ◽  
Life Years ◽  
Transfemoral Amputees ◽  
The Impact

Abstract Background The safe use of a prosthesis in activities of daily living is key for transfemoral amputees. However, the number of falls varies significantly between different prosthetic device types. This study aims to compare medical and economic consequences of falls in transfemoral amputees who use the microprocessor-controlled knee joint C-Leg with patients who use non-microprocessor-controlled (mechanical) knee joints (NMPK). The main objectives of the analysis are to investigate the cost-effectiveness and budget impact of C-Legs in transfemoral amputees with diabetes mellitus (DM) and without DM in Germany. Methods A decision-analytic model was developed that took into account the effects of prosthesis type on the risk of falling and fall-related medical events. Cost-effectiveness and budget impact analyses were performed separately for transfemoral amputees with and without DM. The study took the perspective of the statutory health insurance (SHI). Input parameters were derived from the published literature. Univariate and probabilistic sensitivity analyses (PSA) were performed to investigate the impact of changes in individual input parameter values on model outcomes and to explore parameter uncertainty. Results C-Legs reduced the rate of fall-related hospitalizations from 134 to 20 per 1000 person years (PY) in amputees without DM and from 146 to 23 per 1000 PY in amputees with DM. In addition, the C-Leg prevented 15 or 14 fall-related death per 1000 PY. Over a time horizon of 25 years, the incremental cost-effectiveness ratio (ICER) was 16,123 Euro per quality-adjusted life years gained (QALY) for amputees without DM and 20,332 Euro per QALY gained for amputees with DM. For the period of 2020–2024, the model predicted an increase in SHI expenditures of 98 Mio Euro (53 Mio Euro in prosthesis users without DM and 45 Mio Euro in prosthesis users with DM) when all new prosthesis users received C-Legs instead of NMPKs and 50% of NMPK user whose prosthesis wore out switched to C-Legs. Results of the PSA showed moderate uncertainty and a probability of 97–99% that C-Legs are cost-effective at an ICER threshold of 40,000 Euro (≈ German GDP per capita in 2018) per QALY gained. Conclusion Results of the study suggest that the C-Leg provides substantial additional health benefits compared with NMPKs and is likely to be cost-effective in transfemoral amputees with DM as well as in amputees without DM at an ICER threshold of 40,000 Euro per QALY gained.

scholarly journals Cost-Effectiveness Analysis of Biomarker-Guided Treatment for Metastatic Gastric Cancer in the Second-Line Setting

2020 ◽  
Vol 2020 ◽  
pp. 1-10 ◽  
Author(s):  
Brianna Lauren ◽  
Sassan Ostvar ◽  
Elisabeth Silver ◽  
Myles Ingram ◽  
Aaron Oh ◽  
...  
Keyword(s):  
Gastric Cancer ◽  
Cost Effectiveness ◽  
Targeted Therapies ◽  
Cost Effective ◽  
Metastatic Gastric Cancer ◽  
Sensitivity Analyses ◽  
Decision Analytic Model ◽  
Effective Strategy ◽  
Second Line ◽  
Life Years

Background. The 5-year survival rate of patients with metastatic gastric cancer (GC) is only 5%. However, trials have demonstrated promising antitumor activity for targeted therapies/immunotherapies among chemorefractory metastatic GC patients. Pembrolizumab has shown particular efficacy among patients with programmed death ligand-1 (PD-L1) expression and high microsatellite instability (MSI-H). The aim of this study was to assess the effectiveness and cost-effectiveness of biomarker-guided second-line GC treatment. Methods. We constructed a Markov decision-analytic model using clinical trial data. Our model compared pembrolizumab monotherapy and ramucirumab/paclitaxel combination therapy for all patients and pembrolizumab for patients based on MSI status or PD-L1 expression. Paclitaxel monotherapy and best supportive care for all patients were additional comparators. Costs of drugs, treatment administration, follow-up, and management of adverse events were estimated from a US payer perspective. The primary outcomes were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100,000/QALY over 60 months. Secondary outcomes were unadjusted life years (survival) and costs. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty. Results. The most effective strategy was pembrolizumab for MSI-H patients and ramucirumab/paclitaxel for all other patients, adding 3.8 months or 2.0 quality-adjusted months compared to paclitaxel. However, this strategy resulted in a prohibitively high ICER of $1,074,620/QALY. The only cost-effective strategy was paclitaxel monotherapy for all patients, with an ICER of $53,705/QALY. Conclusion. Biomarker-based treatments with targeted therapies/immunotherapies for second-line metastatic GC patients substantially improve unadjusted and quality-adjusted survival but are not cost-effective at current drug prices.

Cost-effectiveness of once weekly carfilzomib 70 mg/m2 plus dexamethasone in patients with relapsed and refractory multiple myeloma in the United States.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18356-e18356
Author(s):  
Shaji Kumar ◽  
Istvan Majer ◽  
Sumeet Panjabi ◽  
Jean Malacan ◽  
Rohan Medhekar ◽  
...  
Keyword(s):  
Health Care ◽  
Multiple Myeloma ◽  
Cost Effectiveness ◽  
Progression Free Survival ◽  
Cost Effective ◽  
The United States ◽  
Sensitivity Analyses ◽  
Refractory Multiple Myeloma ◽  
Life Years ◽  
Lifetime Costs

e18356 Background: Carfilzomib plus dexamethasone (Kd) dosed once weekly at 70 mg/m2 (QW Kd70) was recently approved in the US for treating patients with relapsed and refractory multiple myeloma (RRMM). To assess the cost-effectiveness (CE) of QW Kd70 vs twice weekly Kd dosed at 27 mg/m2 (BIW Kd27), data from the phase 3 ARROW trial, which directly compared these regimens in patients with 2-3 prior lines of therapy were used. Methods: A partitioned survival model was developed for the CE analysis. Time to treatment discontinuation, progression-free survival, and overall survival (OS) were estimated from the ARROW trial. Long-term OS was extrapolated using Surveillance Epidemiology and End Results registry data after matching characteristics of patients in the registry and ARROW trial. Direct costs were estimated from a US health care payer perspective. Utilities collected in the ARROW trial using the five-level version of the EuroQol questionnaire (EQ-5D-5L) were applied to estimate the quality-adjusted life years (QALYs). Uncertainty was explored using sensitivity analyses. Two subgroups of patients refractory to lenalidomide or bortezomib were assessed. Main outcomes were mean life-years (LYs), QALYs, lifetime costs, and incremental cost-effectiveness ratios (ICERs). Results: For QW Kd70 and BIW Kd27, the model predicted mean LYs of 4.17 and 3.07 years, QALYs of 2.98 and 2.03 years, and mean total lifetime costs of $444,563 and $373,364, respectively. The incremental LYs gain, QALY gain, and incremental costs of QW Kd70 vs BIW Kd27 were estimated to be 1.10 years, 0.95 year, and $71,199, respectively, resulting in an ICER of $64,595 per LY gained and $75,204 per QALY gained. For patients refractory to lenalidomide and bortezomib, similar results were found with ICERs of $79,988 and $76,793, respectively. Conclusions: In line with ARROW trial results, this CE analysis showed that QW Kd70 is expected to provide considerable additional benefit in terms of LYs and QALYs gained compared with BIW Kd27. In the RRMM setting, QW Kd70 is cost-effective with ICERs below accepted willingness to pay thresholds in US and represents an efficient utilization of the health care budget.

Baseline Fetal Heart Rate at Term in Obese and Diabetic Women and Mode of Delivery [23J]

2018 ◽  
Vol 131 ◽  
pp. 114S
Author(s):  
Jennifer Kidd ◽  
Martin Larry Gimovsky ◽  
Munir Nazir ◽  
Karen Koscica
Keyword(s):  
Heart Rate ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Mode Of Delivery

COST-EFFECTIVENESS OF ALEMTUZUMAB FOR T-CELL PROLYMPHOCYTIC LEUKEMIA

2012 ◽  
Vol 28 (3) ◽  
pp. 241-248 ◽  
Author(s):  
Lanting Lu ◽  
Jaime Peters ◽  
Chris Roome ◽  
Ken Stein
Keyword(s):  
Cost Effectiveness ◽  
T Cell ◽  
Cost Effective ◽  
Perfect Information ◽  
Sensitivity Analyses ◽  
Future Research ◽  
Decision Analytic Model ◽  
Prolymphocytic Leukemia ◽  
The Cost ◽  
The Impact

Objectives:The aim of this study was to evaluate the cost-effectiveness of alemtuzumab (CAMPATH-1H) compared with conventional chemotherapy in people with T-cell prolymphocytic leukemia (T-PLL).Methods:We developed a decision-analytic model to assess the costs and benefits of alemtuzumab or conventional therapy based on their effects on quality of life of patients. The main outcome was the incremental cost-effectiveness ratio incorporating costs per additional quality-adjusted life-year (QALY) gained over lifetime. Due to the limited data available, a large number of assumptions had to be made to construct the cost-utility model. One-way, multi-way, and probabilistic sensitivity analyses (PSA) were conducted to explore the impact of these uncertainties. Expected values of perfect information were also calculated for four specific scenarios.Results:Depending on different key assumptions made, the PSA suggested distinct conclusions using a willingness-to-pay threshold of 30,000 GBP per QALY gained. Using this threshold, the probability that alemtuzumab would be cost-effective varies from 0 percent to 53 percent for the four modeled scenarios. Population expected value of perfect information analysis suggests that resolving the parameter uncertainty in the analysis for people with T-PLL in the United Kingdom would have considerable value—up to 5.3 million euro.Conclusions:Alemtuzumab appears more likely to be cost-effective if used earlier in the course of T-PLL and where it replaces the use of multiple alternative therapies. However, cost-effectiveness is highly uncertain and future research is clearly justified. Nevertheless, our analysis demonstrates the feasibility of considering the cost-effectiveness of an agent despite the presence of significant uncertainty to provide appropriate assessment information to policy makers.

scholarly journals Cost-effectiveness of cryptococcal antigen screening at CD4 counts of 101–200 cells/µL in Botswana

2021 ◽  
Vol 6 ◽  
pp. 55
Author(s):  
Mark W. Tenforde ◽  
Charles Muthoga ◽  
Ponego Ponatshego ◽  
Julia Ngidi ◽  
Madisa Mine ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Treatment Costs ◽  
World Health ◽  
Sensitivity Analyses ◽  
Decision Analytic Model ◽  
High Coverage ◽  
Cd4 Counts ◽  
Cryptococcal Antigen ◽  
Health Organization

Background: Cryptococcal antigen (CrAg) screening in individuals with advanced HIV reduces cryptococcal meningitis (CM) cases and deaths. The World Health Organization recently recommended increasing screening thresholds from CD4 ≤100 cells/µL to ≤200 cells/µL. CrAg screening at CD4 ≤100 cells/µL is cost-effective; however, the cost-effectiveness of screening patients with CD4 101–200 cells/µL requires evaluation. Methods: Using a decision analytic model with Botswana-specific cost and clinical estimates, we evaluated CrAg screening and treatment among individuals with CD4 counts of 101–200 cells/µL. We estimated the number of CM cases and deaths nationally and treatment costs without screening. For screening we modeled the number of CrAg tests performed, number of CrAg-positive patients identified, proportion started on pre-emptive fluconazole, CM cases and deaths. Screening and treatment costs were estimated and cost per death averted or disability-adjusted life year (DALY) saved compared with no screening. Results: Without screening, we estimated 142 CM cases and 85 deaths annually among individuals with CD4 101–200 cells/µL, with treatment costs of $368,982. With CrAg screening, an estimated 33,036 CrAg tests are performed, and 48 deaths avoided (1,017 DALYs saved).  While CrAg screening costs an additional $155,601, overall treatment costs fall by $39,600 (preemptive and hospital-based CM treatment), yielding a net increase of $116,001. Compared to no screening, high coverage of CrAg screening and pre-emptive treatment for CrAg-positive individuals in this population avoids one death for $2440 and $114 per DALY saved. In sensitivity analyses assuming a higher proportion of antiretroviral therapy (ART)-naïve patients (75% versus 15%), cost per death averted was $1472; $69 per DALY saved. Conclusions: CrAg screening for individuals with CD4 101–200 cells/µL was estimated to have a modest impact, involve additional costs, and be less cost-effective than screening populations with CD4 counts ≤100 cells/µL. Additional CrAg screening costs must be considered against other health system priorities.

A cost-effectiveness analysis of primary prophylaxis (PP) versus secondary prophylaxis (SP) with biosimilar myeloid growth factors (MGFs) for preventing chemotherapy-induced febrile neutropenia (FN) in non-Hodgkin lymphoma (NHL) patients at intermediate risk.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 107-107
Author(s):  
Gary H. Lyman ◽  
Dylan Mezzio ◽  
Edward C. Li ◽  
Kim Campbell ◽  
Sanjeev Balu
Keyword(s):  
Cost Effectiveness ◽  
Incremental Cost ◽  
Cost Effective ◽  
Primary Prophylaxis ◽  
The United States ◽  
Secondary Prophylaxis ◽  
Sensitivity Analyses ◽  
Intermediate Risk ◽  
Related Factors ◽  
Hospitalization Costs

107 Background: Historically, PP with a MGF was recommended in patients with a ≥40% risk for developing chemotherapy-induced FN, based on clinical and regimen-related factors. Previous economic studies provided evidence to lower the threshold to 20%, the current high-risk threshold listed by practice guidelines. Biosimilar MGFs, such as filgrastim-sndz or LA-EP2006 (a proposed pegfilgrastim biosimilar), offer an opportunity to evaluate whether it is cost-effective to further lower the threshold for intermediate-risk regimens (i.e., 10-20% FN risk). Methods: A Markov model was constructed to evaluate the total costs and clinical outcomes of biosimilar or reference MGFs when used as PP vs. SP in patients 55 years old with NHL receiving 6 cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with no additional FN risk factors. Model inputs, including MGF efficacy and acquisition costs, were estimated from publically available data and literature, as were FN hospitalization costs and clinical utilities. Incremental cost-effectiveness ratios (ICERs) were calculated for cost per FN event avoided, life-year saved (LYS), and quality-adjusted life-year (QALY) gained from a payer perspective within the United States. Deterministic and probabilistic sensitivity analyses were conducted. Results: Use of filgrastim-sndz as PP vs. SP provided an additional 0.130 QALYs (0.144 LYS) at an incremental cost of $5,999. The ICERs were $50,676, $41,761, and $46,207 for cost per FN event avoided, cost per LYS, and cost per QALY gained, respectively. Using LA-EP2006 as PP vs. SP provided an additional 0.166 QALYs (0.184 LYS) at an incremental cost of $17,648. The ICERs were $123,840, $95,963, and $106,265 for cost per FN event avoided, cost per LYS, and cost per QALY gained, respectively. Conclusions: Within NHL patients receiving R-CHOP at an intermediate risk for FN, PP with filgrastim-sndz and LA-EP2006 are cost-effective compared to their respective use as SP based on a cost-effectiveness threshold of $150,000/QALY.

scholarly journals The Clinical Impact and Cost-effectiveness of Measles-Mumps-Rubella Vaccination to Prevent Measles Importations Among International Travelers From the United States

2018 ◽  
Vol 69 (2) ◽  
pp. 306-315 ◽  
Author(s):  
Emily P Hyle ◽  
Naomi F Fields ◽  
Amy Parker Fiebelkorn ◽  
Allison Taylor Walker ◽  
Paul Gastañaduy ◽  
...  
Keyword(s):  
United States ◽  
Cost Effectiveness ◽  
Hot Spots ◽  
Cost Effective ◽  
The United States ◽  
Clinical Impact ◽  
Sensitivity Analyses ◽  
Best Value ◽  
Measles Outbreaks ◽  
The Impact

Abstract Background Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. Methods We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. Results The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. Conclusions PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

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