scholarly journals Impact of Methicillin-ResistantStaphylococcus aureusPrevalence among S.aureusIsolates on Surgical Site Infection Risk after Coronary Artery Bypass Surgery

2011 ◽  
Vol 32 (4) ◽  
pp. 342-350 ◽  
Author(s):  
Loren G. Miller ◽  
James A. McKinnell ◽  
Michael E. Vollmer ◽  
Brad Spellberg
Keyword(s):  
Antibiotic Prophylaxis ◽  
Cost Minimization ◽  
Artery Bypass ◽  
Surgical Site Infections ◽  
Cardiothoracic Surgery ◽  
Policy Implications ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Healthcare Settings

Objective.Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients withβ-lactam allergy or in settings with a “high” prevalence of methicillin-resistantStaphylococcus aureus(MRSA) among S.aureusisolates (hereafter, “MRSA prevalence”); however, “high” remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative toβ-lactam prophylaxis.Methods.We developed a decision analysis model to estimate SSI likelihood when either glycopeptides orβ-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed.Results.At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% withβ-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% withβ-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold.Conclusion.Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.

Impact of Methicillin-Resistant Staphylococcus aureus Prevalence among S. aureus Isolates on Surgical Site Infection Risk after Coronary Artery Bypass Surgery

2011 ◽  
Vol 32 (04) ◽  
pp. 342-350 ◽  
Author(s):  
Loren G. Miller ◽  
James A. McKinnell ◽  
Michael E. Vollmer ◽  
Brad Spellberg
Keyword(s):  
Staphylococcus Aureus ◽  
Antibiotic Prophylaxis ◽  
Artery Bypass ◽  
Surgical Site Infections ◽  
Cardiothoracic Surgery ◽  
Policy Implications ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Methicillin Resistant

Objective.Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients withβ-lactam allergy or in settings with a “high” prevalence of methicillin-resistantStaphylococcus aureus(MRSA) among S.aureusisolates (hereafter, “MRSA prevalence”); however, “high” remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative toβ-lactam prophylaxis.Methods.We developed a decision analysis model to estimate SSI likelihood when either glycopeptides orβ-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed.Results.At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% withβ-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% withβ-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold.Conclusion.Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.

PROBABILISTIC SENSITIVITY ANALYSIS IN COST-EFFECTIVENESS

1999 ◽  
Vol 15 (3) ◽  
pp. 563-572 ◽  
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.

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

Neurology ◽  
2019 ◽  
Vol 92 (20) ◽  
pp. e2339-e2348 ◽  
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.

Using decision analysis to explore cable television delivery

2017 ◽  
Vol 12 (2) ◽  
pp. 291-302
Author(s):  
Keith Willoughby ◽  
Christopher Zappe
Keyword(s):  
Decision Analysis ◽  
Cable Television ◽  
Quantitative Model ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Initial Attempt ◽  
Content Type ◽  
Staff Members ◽  
Trade Offs

Purpose The purpose of this paper is to demonstrate the efficacy of decision analysis in determining the most efficient strategy for installing cable television in the residence halls of Bucknell University. Design/methodology/approach The decision analysis model compared five distinct approaches for achieving and maintaining a successful delivery of cable television service to students enrolled in this private, residential institution. For each alternative, the model incorporated installation costs, likelihood of installation failure, installation failure costs, likelihood of obsolescence and obsolescence-related costs. In addition to considering the trade-offs between cost, timing and riskiness of the various alternatives, a thorough set of sensitivity analyses was performed to gain insight into the parameters that most strongly influence this decision-making process. Findings The quantitative model advocated the adoption of the university’s data network as the mode for cable delivery. Sensitivity analysis further supported this notion. Practical implications The analysis of this problem incorporated the knowledge and judgments of senior administrators and staff members, thus demonstrating the critical contributions offered by subject-matter experts in advising, informing and launching successful decision analysis projects. Incorporating stakeholder viewpoints enhances model understanding and, eventually, model implementation. Decision analysis represents a powerful approach in communicating uncertainties and advising on the benefits of particular alternatives. Originality/value To the best of the researchers’ knowledge, this paper represents an initial attempt to investigate cable delivery options within a decision analysis framework.

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 ◽  
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.

Implementation of Best Practice Guidelines as an Effort in Reducing Hospital Readmission following Coronary Artery Bypass Surgery

2021 ◽  
pp. 1-9
Author(s):  
Dragana Dinic ◽  
Milan Milojevic ◽  
Natasa Paunic ◽  
Andja Cirkovic ◽  
Miodrag Peric ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Antibiotic Prophylaxis ◽  
Coronary Artery Bypass ◽  
Best Practice ◽  
Statistical Significance ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Length Of Hospital Stay ◽  
Surgical Site Infections ◽  
The Individual

<b><i>Objectives:</i></b> The present study aimed to identify significant causes of readmission within 30 days following coronary artery bypass graft (CABG) surgery and compare readmission incidence related to surgical site infections (SSIs) before and after implementing international recommendations for antibiotic prophylaxis. <b><i>Methods:</i></b> We analyzed 2,225 CABG patients who received either guideline-directed antibiotic prophylaxis (GDAP = 568) or institutional antibiotic prophylaxis (non-GDAP = 1,657) between January 2017 and December 2019. The primary outcome was a composite of sternal wound infection (SWI) or harvest SWI. Secondary outcomes consisted of the individual components of composite end point, the incidence of in-hospital SSIs, and prolonged postoperative length of hospital stay (LOS) (&#x3e;7 days). Propensity matching was used to select pairs for final comparison. <b><i>Results:</i></b> Before implementing GDAP, the most frequent reason for readmission were SSIs, causing 58.2% of all readmissions within 30 days. Of 429 matched pairs, 48 patients in the GDAP group and 67 patients in the non-GDAP group were readmitted to a hospital within 30 days for any cause (11.2 vs. 15.6%, <i>p</i> = 0.048). We found a decreased readmission incidence for reasons related to SSIs, although these differences did not reach statistical significance (7.4 vs. 10.0%, <i>p</i> = 0.069). Adherence to GDAP was associated with reduced in-hospital risks of SSIs and prolonged postoperative LOS (19.6 vs. 26.6%, <i>p</i> = 0.015). <b><i>Conclusions:</i></b> In this contemporary clinical practice study, the adherence to GDAP was an insufficient measure to decrease rehospitalization due to SSIs. The present findings warrant further investigation on factors that may contribute to SSIs development after hospital discharge.

Efficiency of telemedicine for acute stroke: a cost-effectiveness analysis from a French pilot study

2020 ◽  
Vol 36 (2) ◽  
pp. 126-132
Author(s):  
Laure Wallut ◽  
Christine Peyron ◽  
Marie Hervieu-Bègue ◽  
Guy-Victor Osseby ◽  
Maurice Giroud ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
National Health ◽  
Population Based ◽  
Extra Cost ◽  
Sensitivity Analyses ◽  
Hospital Death ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Stroke Patients ◽  
National Health Insurance System

AbstractObjectivesTelestroke is an effective way to improve care and health outcomes for stroke patients. This study evaluates the cost-effectiveness of a French telestroke network.MethodsA decision analysis model was built using population-based data. We compared short-term clinical outcomes and costs for the management of acute ischemic stroke patients before and after the implementation of a telestroke network from the point of view of the national health insurance system. Three effectiveness endpoints were used: hospital death, death at 3 months, and severe disability 3 months after stroke (assessed with the modified Rankin scale). Most clinical and economic parameters were estimated from the medical files of 742 retrospectively included patients. Sensitivity analyses were performed.ResultsThe analyses revealed that the telestroke strategy was more effective and slightly more costly than the reference strategy (25 disability cases avoided per 1,000 at 3 months, 6.7 avoided hospital deaths, and 13 avoided deaths at 3 months for an extra cost of EUR 97, EUR 138, and EUR 154, respectively). The results remained robust in the sensitivity analyses.ConclusionsIn France, telestroke is an effective strategy for improving patient outcomes and, despite the extra cost, it has a legitimate place in the national health care system.

Impact of antidepressants on the risk of suicide in patients with depression in real-life conditions: a decision analysis model

2008 ◽  
Vol 39 (8) ◽  
pp. 1307-1315 ◽  
Author(s):  
A. Cougnard ◽  
H. Verdoux ◽  
A. Grolleau ◽  
Y. Moride ◽  
B. Begaud ◽  
...  
Keyword(s):  
Decision Analysis ◽  
Antidepressant Drug ◽  
Real Life ◽  
The Elderly ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Real Life Setting ◽  
Number Of Patients ◽  
The Impact

BackgroundThe impact of antidepressant drug treatment (ADT) on the risk of suicide is uncertain. The aim of this study was to determine in a real-life setting whether ADT is associated with an increased or a reduced risk of suicide compared to absence of ADT (no-ADT) in patients with depression.MethodA decision analysis method was used to estimate the number of suicides prevented or induced by ADT in children and adolescents (10–19 years old), adults (20–64 years old) and the elderly (⩾65 years) diagnosed with major depression. The impact of gender and parasuicide history on the findings was explored within each age group. Sensitivity analyses were used to assess the robustness of the models.ResultsPrescribing ADT to all patients diagnosed with depression would prevent more than one out of three suicide deaths compared to the no-ADT strategy, irrespective of age, gender or parasuicide history. Sensitivity analyses showed that persistence in taking ADT would be the main characteristic influencing the effectiveness of ADT on suicide risk.ConclusionsPublic health decisions that contribute directly or indirectly to reducing the number of patients with depression who are effectively administered ADT may paradoxically induce a rise in the number of suicides.

Cost-effectiveness analysis of a randomized study with stereotactic radiosurgery (SRS) alone versus SRS plus whole brain radiation therapy (WBRT) for patients with brain metastasis

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 6624-6624
Author(s):  
L. S. Lal ◽  
E. L. Chang ◽  
L. Franzini ◽  
R. B. Arbuckle ◽  
L. Miller ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Brain Metastasis ◽  
Randomized Study ◽  
Subsequent Treatment ◽  
Sensitivity Analyses ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Life Years ◽  
Wide Range ◽  
Class 1

6624 Background: This paper illustrates the incremental cost-effectiveness ratio (ICER) and cost-utility comparison of SRS alone versus SRS plus WBRT for brain metastasis. Methods: A decision analysis model, including subsequent treatment for recurrences, was developed and populated with data from patients randomized to either SRS alone (SA) versus SRS plus WBRT (SW), using costs from the healthcare institution perspective and outcomes based on actual life years saved (LYS) and quality-adjusted-life-years (QALYs). Utilities were captured through a time-trade -off methodology, utilizing three time horizons: 10 years, 5 years, and 1 year. Tornado diagrams and one-way sensitivity analyses were conducted to determine robustness of the model. Results: Fifty-eight patients were included in the final analysis, with 31 patients in the SA arm and 27 patients in the SW arm. The average cost of the SA arm is $119,000 versus $74,000 for the SW arm. The average effectiveness for the SA arm was 1.64 LYS versus 0.60 LYS for the SW arm. The ICER for total costs per LYS and QALYs were: $43,986 per LYS; $42,136 per QALY (10year); $43, 719 per QALY (5year); $44,686 (1year) for the SA arm. The surgical cost per LYS was $7,131 for the SA arm, and the radiation cost per LYS analysis was dominated. Tornado diagrams revealed that the following variables had the highest impact on the ICER: probability of being alive with SA in recursive partitioning analysis (RPA) class 2 and no recurrence; probability of no recurrence in RPA class 2 with SA; probability of being alive with SA in RPA class 2 and being treated for recurrence; probability of no recurrence in RPA class 1 with SA; and probability of being alive with no recurrence in RPA class 1 with SA. One-way sensitivity analysis exhibited a wide range variation for the first three of the above mentioned probabilities, with the final two having less variation. Conclusions: Compared to other interventions in the $50,000 to $100,000 per QALY cost-effectiveness range from an economic perspective, the application of SA, with subsequent surgical management of recurrences, is shown to be a reasonable treatment modality for brain metastasis. No significant financial relationships to disclose.

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

2006 ◽  
Vol 27 (6) ◽  
pp. 604-611 ◽  
Author(s):  
Frank E. Berkowitz ◽  
Johan L. Severens ◽  
Henry M. Blumberg
Keyword(s):  
Cost Effectiveness ◽  
Decision Analysis ◽  
Incremental Cost ◽  
Sensitivity Analyses ◽  
Local Health ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Infected Infant ◽  
Probability Of Survival ◽  
Prophylaxis Strategy

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.

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