Exposure to Tuberculosis among Newborns in a Nursery: Decision Analysis for Initiation of Prophylaxis

Objective.Newborns in a hospital nursery were exposed to a mother whose sputum was direct-smear negative for acid-fast bacilli but culture positive for Mycobacterium tuberculosis. Given the low risk for exposure, the high susceptibility of infants to M. tuberculosis infection, and the possibility of hepatotoxicity due to isoniazid therapy, a decision analysis model was used to determine whether administration of isoniazid prophylaxis against tuberculosis is preferable to no administration of prophylaxis.Design.A decision analysis tree was constructed with software, using probabilities from the literature and costs from local health facilities. The expected values for each strategy were obtained, and sensitivity analyses were performed.Results.For the strategy in which prophylaxis was administered under direct observation (DO), the probability for survival was 0.999980. For the strategy in which no prophylaxis was administered, the probability of survival was 0.999950, which corresponds to 3 more deaths per 100,000 patients than with the DO prophylaxis strategy. The incremental cost-effectiveness of the DO prophylaxis strategy was $21,710,000 per death prevented. Sensitivity analysis for survival showed that the DO prophylaxis strategy was preferable to the strategy in which no prophylaxis is given if the probability of infection was >0.0002, the probability of tuberculous disease in an infected infant who did not receive prophylaxis was greater than 0.12, the probability of dying from tuberculosis was greater than 0.025, the probability of hepatotoxicity was less than 0.004, and the probability of dying from hepatotoxicity was less than 0.04. For the strategy in which prophylaxis was administered under non-DO conditions (ie, by parents), the incremental cost-effectiveness was $929,500 per death prevented, which is approximately 5% of the incremental cost-effectiveness of the DO prophylaxis strategy.Conclusion.This model provides a structure for determining the preferable prophylaxis strategies for different risks of exposure to tuberculosis in a nursery. Administration of prophylaxis is preferable to no administration of prophylaxis, unless the probability of infection is extremely low.

Download Full-text

Percutaneous Stenting of Incidental Unilateral Renal Artery Stenosis: Decision Analysis of Costs and Benefits

Journal of Endovascular Therapy ◽

10.1177/152660280301000321 ◽

2003 ◽

Vol 10 (3) ◽

pp. 546-556 ◽

Cited By ~ 7

Author(s):

David A. Axelrod ◽

A. Mark Fendrick ◽

Ruth C. Carlos ◽

Robert J. Lederman ◽

James B. Froehlich ◽

...

Keyword(s):

Cost Effectiveness ◽

Decision Analysis ◽

Renal Artery ◽

Incremental Cost ◽

Renal Artery Stenosis ◽

Cost Effective ◽

Artery Stenosis ◽

Decision Analysis Model ◽

Analysis Model ◽

Refractory Hypertension

Purpose: To determine the incremental cost-effectiveness of prophylactic percutaneous transluminal angioplasty with stent placement (PTA-S) in patients with incidentally discovered, asymptomatic renal artery stenosis (RAS) compared to delaying PTA-S until patients develop refractory hypertension or renal insufficiency (therapeutic PTA-S). Methods: The Markov decision analysis model was used to determine the incremental cost per quality adjusted life year (QALY) saved for prophylactic PTA-S as compared to therapeutic PTA-S in a hypothetical cohort of patients with 50% unilateral atherosclerotic RAS followed from age 61 to death. Results: Prophylactic PTA-S compared to therapeutic PTA-S results in more QALYs/patient (10.9 versus 10.3) at higher lifetime costs ($23,664 versus $16,558). The incremental cost effectiveness of prophylactic PTA-S was estimated to be $12,466/QALY. Prophylactic stenting was not cost effective (>$50,000/QALY) if the modeled incidence of stent restenosis exceeded 15%/year and the incidence of progression in the contralateral renal artery was <2% of arteries/year. Conclusions: PTA-S of incidental, asymptomatic unilateral RAS may improve patients' quality of life at an acceptable incremental cost. However, this technology should be used hesitantly until a randomized comparison confirms its effectiveness.

Download Full-text

Abstract 6234: Cost-Effectiveness Analysis Demonstrates Superiority of Screening Young Athletes with 12-Lead Electrocardiogram versus History and Physical in Preventing Sudden Cardiac Death

Circulation ◽

10.1161/circ.118.suppl_18.s_1163-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Matthew T Wheeler ◽

Paul A Heidenreich ◽

Victor F Froelicher ◽

Mark A Hlatky ◽

Euan A Ashley

Keyword(s):

Cost Effectiveness ◽

Sudden Cardiac Death ◽

Incremental Cost ◽

Cardiac Death ◽

Cost Effective ◽

Sensitivity Analyses ◽

Decision Analysis Model ◽

Analysis Model ◽

Young Athletes ◽

Life Years

Sudden cardiac death (SCD) is a rare but frightening event among young athletes. The Italian experience demonstrates a reduction in athlete SCD by screening with history, physical, and 12-lead electrocardiogram (ECG). American guideline statements have not recommended ECG for screening athletes due to perceptions of high cost and unclear effectiveness. We sought to model the cost-effectiveness (CE) of history and physical (H&P), ECG plus H&P, and no screening in US high school and college competitive athletes. A decision analysis model was used. Risks, prevalence, and test characteristics were derived from the medical literature. Costs were derived from publicly available datasets. Markov processes were used to simulate the natural histories of screened athletes. One-way sensitivity analyses and Monte Carlo simulation of all variables in the estimated ranges were performed. A societal perspective was used. Screening with an ECG plus H&P has lower overall costs and better outcomes than use of H&P alone. Compared with no screening, H&P saves 0.57 life years (LY) per 1000 athletes screened at an incremental cost of $111 per athlete, yielding a CE ratio of $195,600 per LY saved (simulation based 95% CI $116,000–514,000). ECG plus H&P when compared to no screening saves 2.7 LY per 1000 athletes at an incremental cost of $199 per athlete, for a CE ratio of $74,100 per LY saved (95% CI $46,000–158,000). Probabilistic sensitivity analysis shows that ECG plus H&P is the preferred strategy over H&P in terms of cost-effectiveness in 99.5% of simulations. ECG plus H&P is cost-effective below a threshold value of $100,000 per LY saved in 89% of simulations, while H&P is cost-effective in 1% of simulations. If the reduction in SCD risk per screening-identified, at-risk athlete is below 33%, or if more than 12% of screens are false positive, screening with ECG plus H&P is no longer cost effective. ECG plus H&P is superior to H&P for screening young athletes in our cost-effectiveness model. The incremental cost of adding an ECG, including screening, secondary testing, and subsequent treatment is under $100 per athlete screened. These data should inform the ongoing debate concerning pre-participation screening of US student-athletes.

Download Full-text

Meta-analysis and cost-effectiveness of second-line antiepileptic drugs for status epilepticus

Neurology ◽

10.1212/wnl.0000000000007503 ◽

2019 ◽

Vol 92 (20) ◽

pp. e2339-e2348 ◽

Cited By ~ 13

Author(s):

Iván Sánchez Fernández ◽

Marina Gaínza-Lein ◽

Nathan Lamb ◽

Tobias Loddenkemper

Keyword(s):

Status Epilepticus ◽

Cost Effectiveness ◽

Antiepileptic Drugs ◽

Meta Analysis ◽

Cost Effective ◽

Sensitivity Analyses ◽

Convulsive Status Epilepticus ◽

Decision Analysis Model ◽

Analysis Model ◽

The Cost

ObjectiveCompare the cost and effectiveness of nonbenzodiazepine antiepileptic drugs (non-BZD AEDs) for treatment of BZD-resistant convulsive status epilepticus (SE).MethodsDecision analysis model populated with effectiveness data from a systematic review and meta-analysis of the literature, and cost data from publicly available prices. The primary outcome was cost per seizure stopped ($/SS). Sensitivity analyses evaluated the robustness of the results across a wide variation of the input parameters.ResultsWe included 24 studies with 1,185 SE episodes. The most effective non-BZD AED was phenobarbital (PB) with a probability of SS of 0.8 (95% confidence interval [CI]: 0.69–0.88), followed by valproate (VPA) (0.71 [95% CI: 0.61–0.79]), lacosamide (0.66 [95% CI: 0.51–0.79]), levetiracetam (LEV) (0.62 [95% CI: 0.5–0.73]), and phenytoin/fosphenytoin (PHT) (0.53 [95% CI: 0.39–0.67]). In pairwise comparisons, PB was more effective than PHT (p = 0.002), VPA was more effective than PHT (p = 0.043), and PB was more effective than LEV (p = 0.018). The most cost-effective non-BZD AED was LEV (incremental cost-effectiveness ratio [ICER]: $18.55/SS), followed by VPA (ICER: $94.44/SS), and lastly PB (ICER: $847.22/SS). PHT and lacosamide were not cost-effective compared to the other options. Sensitivity analyses showed marked overlap in cost-effectiveness, but PHT was consistently less cost-effective than LEV, VPA, and PB.ConclusionVPA and PB were more effective than PHT for SE. There is substantial overlap in the cost-effectiveness of non-BZD AEDs for SE, but available evidence does not support the preeminence of PHT, neither in terms of effectiveness nor in terms of cost-effectiveness.

Download Full-text

PCN101 COST-EFFECTIVENESS OF SHORT-ACTING OPIOIDS FOR BREAKTHROUGH PAIN IN CANCER PATIENTS—A SCOTTISH-BASED DECISION-ANALYSIS MODEL

Value in Health ◽

10.1016/s1098-3015(10)74352-7 ◽

2009 ◽

Vol 12 (7) ◽

pp. A276

Author(s):

D Vissers ◽

W Stam ◽

K Tolley ◽

V Sendersky ◽

JP Jansen

Keyword(s):

Cost Effectiveness ◽

Decision Analysis ◽

Cancer Patients ◽

Breakthrough Pain ◽

Decision Analysis Model ◽

Analysis Model ◽

Short Acting

Download Full-text

PROBABILISTIC SENSITIVITY ANALYSIS IN COST-EFFECTIVENESS

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462399153108 ◽

1999 ◽

Vol 15 (3) ◽

pp. 563-572 ◽

Cited By ~ 8

Author(s):

William Whang ◽

Jane E. Sisk ◽

Daniel F. Heitjan ◽

Alan J. Moskowitz

Keyword(s):

Sensitivity Analysis ◽

Cost Effectiveness ◽

Probabilistic Sensitivity Analysis ◽

Probabilistic Methods ◽

Policy Implications ◽

Sensitivity Analyses ◽

Decision Analysis Model ◽

Analysis Model ◽

Worst Case ◽

The Cost

Objectives: We explore the policy implications of probabilistic sensitivity analysis in cost-effectiveness analysis by applying simulation methods to a decision model.Methods: We present the multiway sensitivity analysis results of a study of the cost-effectiveness of vaccination against pneumococcal bacteremia in the elderly. We then execute a probabilistic sensitivity analysis of the cost-effectiveness ratio by specifying posterior distributions for the uncertain parameters in our decision analysis model. In order to estimate probability intervals, we rank the numerical values of the simulated incremental cost-effectiveness ratios (ICERs) to take into account preferences along the cost-effectiveness plane.Results: The 95% probability intervals for the ICER were generally much narrower than the difference between the best case and worst case results from a multiway sensitivity analysis. Although the multiway sensitivity analysis had indicated that, in the worst case, vaccination in the 85 and older age group was not acceptable from a policy standpoint, probabilistic methods indicated that the cost-effectiveness of vaccination was below $50,000 per quality-adjusted life-year in greater than 92% of the simulations and below $100,000 in greater than 95% of the simulations.Conclusions: Probabilistic methods can supplement multiway sensitivity analyses to provide a more comprehensive picture of the uncertainty associated with cost-effectiveness ratios and thereby inform policy decisions.

Download Full-text