Imaging versus Intervention in Managing Small Unruptured Intracranial Aneurysms: A Cost-Effectiveness Analysis

2021 ◽  
pp. 1-11
Author(s):  
Clark A. Veet ◽  
Stephen Capone ◽  
David Panczykowski ◽  
Natasha Parekh ◽  
Kenneth J. Smith ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Surgical Treatment ◽  
Active Surveillance ◽  
Intracranial Aneurysms ◽  
Surgical Complication ◽  
Cost Effective ◽  
Anterior Circulation ◽  
Complication Risk ◽  
Immediate Surgery ◽  
The Cost

<b><i>Objective:</i></b> Current guidelines recommend active surveillance with serial magnetic resonance angiography (MRA) for management of small, asymptomatic unruptured anterior circulation aneurysms (UIAs). We sought to determine the cost-effectiveness of active surveillance compared to immediate surgery. <b><i>Methods:</i></b> We developed a Markov cost-effectiveness model simulating patients with small (&#x3c;7 mm) UIAs managed by active surveillance via MRA, immediate surgery, or watchful waiting. Inputs for the model were abstracted from the literature and used to construct a comprehensive model following persons from diagnosis to death. Outcomes were quality-adjusted life-years (QALYs), lifetime medical costs (2015 USD), and incremental cost-effectiveness ratios (ICERs). Cost-effectiveness, deterministic, and probabilistic sensitivity analyses were performed. <b><i>Results:</i></b> Immediate surgical treatment was the most cost-effective management strategy for small UIAs with ICER of USD 45,772 relative to active surveillance. Sensitivity analysis demonstrated immediate surgery was the preferred strategy, if rupture rate was &#x3e;0.1%/year and if the diagnosis age was &#x3c;70 years, while active surveillance was preferred if surgical complication risk was &#x3e;11%. Probabilistic sensitivity analysis demonstrated that at a willingness-to-pay of USD 100,000/QALY, immediate surgical treatment was the most cost-effective strategy in 64% of iterations. <b><i>Conclusion:</i></b> Immediate surgical treatment is a cost-effective strategy for initial management of small UIAs in patients &#x3c;70 years of age. While more costly than MRA, surgical treatment increased QALY. The cost-effectiveness of immediate surgery is highly sensitive to diagnosis age, rupture rate, and surgical complication risk. Though there are a wide range of rupture rates and complications associated with treatment, this analysis supports the treatment of small, unruptured anterior circulation intracranial aneurysms in patients &#x3c;70 years of age.

scholarly journals Cost-Effectiveness Analysis of Active Surveillance for Small Asymptomatic Intracranial Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
David M Panczykowski ◽  
Clark Veet ◽  
Natasha Parekh ◽  
Spiros L Blackburn
Keyword(s):  
Cost Effectiveness ◽  
Active Surveillance ◽  
Watchful Waiting ◽  
Surgical Complication ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Rupture Rate ◽  
Effectiveness Analysis ◽  
Immediate Surgery ◽  
The Cost

Abstract INTRODUCTION The current recommended management strategy for small, asymptomatic unruptured anterior circulation aneurysms (UIAs) is active surveillance utilizing serial magnetic resonance angiography (MRA). Our objective was to determine the cost-effectiveness of active surveillance via MRA, immediate surgery, and watchful waiting for small UIAs. METHODS We developed a Markov cost-effectiveness model simulating a cohort of patients with small (<7 mm) UIAs diagnosed at age 50-yr who were treated with active surveillance via MRA, immediate surgery, or watchful waiting. Model inputs (eg risk of aneurysm growth, rupture rate, treatment complications, etc) were abstracted from peer-reviewed literature. Outcomes were quality-adjusted life-years (QALY), lifetime medical costs (2015 US$), and incremental cost-effectiveness ratios (ICER). Cost-effectiveness analysis as well as deterministic and probabilistic sensitivity analyses were performed. Willingness to pay (WTP) threshold was $100,000/QALY. RESULTS At a WTP of $100,000/QALY, immediate surgical treatment was the most cost-effective management strategy for small UIAs; ICER of $43,880 relative to active surveillance. Sensitivity analyses demonstrated immediate surgery was the preferred strategy if rupture rate was >0.1%/yr and if diagnosis age was <70 yr. Active surveillance became the preferred strategy if surgical complication risk was >11% and if diagnosis age was >70-yr. MRA surveillance interval did not significantly impact cost-effectiveness (surveillance frequency range 6 mo-10 yr). Probabilistic sensitivity analysis demonstrated that at a WTP of $100,000/QALY immediate surgery was the most cost-effective strategy in 64% of iterations (compared to active surveillance in 34%, and watchful waiting in 1.4%). CONCLUSION Immediate surgical treatment is a reasonable and cost-effective strategy for initial management of small UIAs. The cost-effectiveness of immediate surgery is highly sensitive to age at diagnosis, rupture rate, and probability of surgical complication. As there are wide published ranges for rates of rupture and surgical complications, individual lesion characteristics and surgeon-specific complication metrics should be considered in counseling patients.

scholarly journals Cost-Effectiveness of Percutaneous Automated Lumbar Nucleotomy

1999 ◽  
Vol 5 (1) ◽  
pp. 35-42 ◽  
Author(s):  
R. Dullerud ◽  
H. Lie ◽  
B. Magnæs
Keyword(s):  
Cost Effectiveness ◽  
Surgical Treatment ◽  
Lumbar Disc ◽  
Invasive Procedure ◽  
Cost Effective ◽  
Clinical Results ◽  
Complication Rates ◽  
Success Rates ◽  
One Year ◽  
The Cost

This study was conducted in order to evaluate the cost-effectiveness of percutaneous automated lumbar nucleotomy in comparison with traditional macro-procedure discectomy in the treatment of herniated discs. Sixty-eight patients undergoing surgical procedures and 90 treated with nucleotomy were consecutively included. Both cohorts were assessed pre-operatively and at regular intervals for one year or more after treatment by independent observers, using a clinical overall scoring system (COS) with 0 being the best attainable result and 1000 the poorest conceivable status of the patients. There were better clinical results after surgery with 78% successes after one year compared to 62% after nucleotomy. By including subsequent operations and re-operations after failure to respond to the primary treatment, the success rates rose to 79% and 77%, respectively. The cost of surgical treatment was calculated to USD 6.119 per patient and the cost of a nucleotomy procedure was USD 1.252. Owing to an almost five times higher price of surgery than nucleotomy, the latter turned out to be 2.7 to 3.9 times more cost-effective, depending on whether secondary treatment was included or not. Due to the minimal difference in final outcome between the groups, however, the marginal cost per extra success in patients primarily treated with surgery was as high as USD 205.850. The study concludes that nucleotomy, as a mini-invasive procedure with low complication rates and the potential of a quick recovery, is more cost-effective than traditional surgical treatment for lumbar disc herniation.

scholarly journals Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China

BMJ Open ◽  
2018 ◽  
Vol 8 (2) ◽  
pp. e018951 ◽  
Author(s):  
Yuesong Pan ◽  
Xueli Cai ◽  
Xiaochuan Huo ◽  
Xingquan Zhao ◽  
Liping Liu ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Ischaemic Stroke ◽  
Low Income ◽  
Acute Ischaemic Stroke ◽  
Mechanical Thrombectomy ◽  
Cost Effective ◽  
Sensitivity Analyses ◽  
Anterior Circulation ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Cost

ObjectivesEndovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country.DesignA combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results.SettingHospitals in China.ParticipantsThe patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours.InterventionsMechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone.Outcome measuresThe benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years).ResultsThe addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY.ConclusionsMechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.

scholarly journals Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis

2017 ◽  
Vol 42 (6) ◽  
pp. E6 ◽  
Author(s):  
Arvin R. Wali ◽  
Charlie C. Park ◽  
David R. Santiago-Dieppa ◽  
Florin Vaida ◽  
James D. Murphy ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Intracranial Aneurysms ◽  
Cost Effective ◽  
Endovascular Coiling ◽  
Effective Strategy ◽  
Pipeline Embolization Device ◽  
Cost Effective Strategy ◽  
Effectiveness Analysis ◽  
Giant Intracranial Aneurysms ◽  
The Cost

OBJECTIVERupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms.METHODSA Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed.RESULTSThe base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations.CONCLUSIONSThe authors’ cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.

scholarly journals Cost-Effectiveness Analysis of BCG Vaccination against Tuberculosis in Indonesia: A Model-Based Study

Vaccines ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. 707
Author(s):  
Afifah Machlaurin ◽  
Franklin Christiaan Karel Dolk ◽  
Didik Setiawan ◽  
Tjipke Sytse van der Werf ◽  
Maarten J. Postma
Keyword(s):  
Cost Effectiveness ◽  
Univariate Analysis ◽  
Cost Effective ◽  
Epidemiological Data ◽  
Control Programme ◽  
Detection Rates ◽  
Middle Income ◽  
Bcg Vaccination ◽  
Life Years ◽  
The Cost

Bacillus Calmette–Guerin (BCG), the only available vaccine for tuberculosis (TB), has been applied for decades. The Indonesian government recently introduced a national TB disease control programme that includes several action plans, notably enhanced vaccination coverage, which can be strengthened through underpinning its favourable cost-effectiveness. We designed a Markov model to assess the cost-effectiveness of Indonesia’s current BCG vaccination programme. Incremental cost-effectiveness ratios (ICERs) were evaluated from the perspectives of both society and healthcare. The robustness of the analysis was confirmed through univariate and probabilistic sensitivity analysis (PSA). Using epidemiological data compiled for Indonesia, BCG vaccination at a price US$14 was estimated to be a cost-effective strategy in controlling TB disease. From societal and healthcare perspectives, ICERs were US$104 and US$112 per quality-adjusted life years (QALYs), respectively. The results were robust for variations of most variables in the univariate analysis. Notably, the vaccine’s effectiveness regarding disease protection, vaccination costs, and case detection rates were key drivers for cost-effectiveness. The PSA results indicated that vaccination was cost-effective even at US$175 threshold in 95% of cases, approximating the monthly GDP per capita. Our findings suggest that this strategy was highly cost-effective and merits prioritization and extension within the national TB programme. Our results may be relevant for other high endemic low- and middle-income countries.

scholarly journals Cost Effectiveness of Transbronchial Needle Aspiration

1999 ◽  
Vol 6 (4) ◽  
pp. 332-335 ◽  
Author(s):  
Jennifer A Crocket ◽  
Eric YL Wong ◽  
Dale C Lien ◽  
Khanh Gia Nguyen ◽  
Michelle R Chaput ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Diagnostic Procedures ◽  
Needle Aspiration ◽  
Benign Disease ◽  
University Hospital ◽  
High Yield ◽  
Transbronchial Needle Aspiration ◽  
Computed Tomographic ◽  
The Cost

OBJECTIVE: To evaluate the yield and cost effectiveness of transbronchial needle aspiration (TBNA) in the assessment of mediastinal and/or hilar lymphadenopathy.DESIGN: Retrospective study.SETTING: A university hospital.POPULATION STUDIED: Ninety-six patients referred for bronchoscopy with computed tomographic evidence of significant mediastinal or hilar adenopathy.RESULTS: Ninety-nine patient records were reviewed. Three patients had two separate bronchoscopy procedures. TBNA was positive in 42 patients (44%) and negative in 54 patients. Of the 42 patients with a positive aspirate, 40 had malignant cytology and two had cells consistent with benign disease. The positive TBNA result altered management in 22 of 40 patients with malignant disease and one of two patients with benign disease, thereby avoiding further diagnostic procedures. The cost of these subsequent procedures was estimated at $27,335. No complications related to TBNA were documented.CONCLUSIONS: TBNA is a high-yield, safe and cost effective procedure for the diagnosis and staging of bronchogenic cancer.

The cost-effectiveness of insulin analogs and regular insulin for diabetes control: a case study in Iran

2020 ◽  
Vol 33 (4/5) ◽  
pp. 323-331
Author(s):  
Mohsen pakdaman ◽  
Raheleh akbari ◽  
Hamid reza Dehghan ◽  
Asra Asgharzadeh ◽  
Mahdieh Namayandeh
Keyword(s):  
Cost Effectiveness ◽  
Cost Effective ◽  
Regular Insulin ◽  
Diabetes Control ◽  
Diabetic Patients ◽  
Insulin Analogs ◽  
Content Type ◽  
Patients With Diabetes ◽  
The Government ◽  
The Cost

PurposeFor years, traditional techniques have been used for diabetes treatment. There are two major types of insulin: insulin analogs and regular insulin. Insulin analogs are similar to regular insulin and lead to changes in pharmacokinetic and pharmacodynamic properties. The purpose of the present research was to determine the cost-effectiveness of insulin analogs versus regular insulin for diabetes control in Yazd Diabetes Center in 2017.Design/methodology/approachIn this descriptive–analytical research, the cost-effectiveness index was used to compare insulin analogs and regular insulin (pen/vial) for treatment of diabetes. Data were analyzed in the TreeAge Software and a decision tree was constructed. A 10% discount rate was used for ICER sensitivity analysis. Cost-effectiveness was examined from a provider's perspective.FindingsQALY was calculated to be 0.2 for diabetic patients using insulin analogs and 0.05 for those using regular insulin. The average cost was $3.228 for analog users and $1.826 for regular insulin users. An ICER of $0.093506/QALY was obtained. The present findings suggest that insulin analogs are more cost-effective than regular insulin.Originality/valueThis study was conducted using a cost-effectiveness analysis to evaluate insulin analogs versus regular insulin in controlling diabetes. The results of study are helpful to the government to allocate more resources to apply the cost-effective method of the treatment and to protect patients with diabetes from the high cost of treatment.

scholarly journals Screening for Melanoma by Primary Health Care Physicians: A Cost—Effectiveness Analysis

1996 ◽  
Vol 3 (1) ◽  
pp. 47-53 ◽  
Author(s):  
Afaf Girgis ◽  
Philip Clarke ◽  
Robert C Burton ◽  
Rob W Sanson—Fisher
Keyword(s):  
Cost Effectiveness ◽  
Screening Programme ◽  
Cost Effective ◽  
Economic Assessment ◽  
Screening Tests ◽  
Family Practitioners ◽  
Effectiveness Analysis ◽  
The Cost ◽  
Primary Health Care Physicians ◽  
Melanoma Screening

Background and design— Australia has the highest rates of skin cancer in the world, and the incidence is estimated to be doubling every 10 years. Despite advances in the early detection and treatment of melanoma about 800 people still die nationally of the disease each year. A possible strategy for further reducing the mortality from melanoma is an organised programme of population screening for unsuspected lesions in asymptomatic people. Arguments against introducing melanoma screening have been based on cost and the lack of reliable data on the efficacy of any screening tests. To date, however, there has been no systematic economic assessment of the cost effectiveness of melanoma screening. The purpose of this research was to determine whether screening may be potentially cost effective and, therefore, warrants further investigation. A computer was used to simulate the effects of a hypothetical melanoma screening programme that was in operation for 20 years, using cohorts of Australians aged 50 at the start of the programme. Based on this simulation, cost—effectiveness estimates of melanoma screening were calculated. Results— Under the standard assumptions used in the model, and setting the sensitivity of the screening test (visual inspection of the skin) at 60%, cost effectiveness ranged from Aust$6853 per life year saved for men if screening was undertaken five yearly to $12137 if screening was two yearly. For women, it ranged from $11 102 for five yearly screening to $20 877 for two yearly screening. Conclusion— The analysis suggests that a melanoma screening programme could be cost effective, particularly if five yearly screening is implemented by family practitioners for men over the age of 50.

Cost-effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis

2021 ◽  
pp. 019459982110268
Author(s):  
Joseph R. Acevedo ◽  
Ashley C. Hsu ◽  
Jeffrey C. Yu ◽  
Dale H. Rice ◽  
Daniel I. Kwon ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Submandibular Gland ◽  
Average Cost ◽  
Cost Effective ◽  
Cost Effectiveness Analysis ◽  
Effectiveness Analysis ◽  
Life Years ◽  
Probability Of Success ◽  
Markov Decision Model ◽  
The Cost

Objective To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. Study Design Cost-effectiveness analysis. Setting Outpatient surgery centers. Methods A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer’s perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. Results Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. Conclusion Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

scholarly journals Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Obinna Ikechukwu Ekwunife ◽  
Chinelo Janefrances Ofomata ◽  
Charles Ebuka Okafor ◽  
Maureen Ugonwa Anetoh ◽  
Stephen Okorafor Kalu ◽  
...  
Keyword(s):  
Viral Load ◽  
Cost Effectiveness ◽  
Service Delivery ◽  
Motivational Interviewing ◽  
Cost Effective ◽  
Economic Incentives ◽  
Additional Patient ◽  
Incentive Scheme ◽  
The Cost ◽  
The Impact

Abstract Background In sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria. Method A cost-effectiveness analysis from the healthcare provider’s perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria. Result The ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients’ acceptance of the intervention was very high. Conclusion The conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1–3 times per annum. Patients’ acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed. Trial registration This trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network (PACTR201806003040425).

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