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

2003 ◽  
Vol 10 (3) ◽  
pp. 546-556 ◽  
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.

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.

scholarly journals The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States

2004 ◽  
Vol 132 (6) ◽  
pp. 1055-1063 ◽  
Author(s):  
P. MUENNIG ◽  
D. PALLIN ◽  
C. CHALLAH ◽  
K. KHAN
Keyword(s):  
Cost Effectiveness ◽  
Incremental Cost ◽  
Treatment Strategies ◽  
Cost Effective ◽  
Strongyloides Stercoralis ◽  
The United States ◽  
Decision Analysis Model ◽  
Analysis Model ◽  
Presumptive Treatment ◽  
The Cost

The presumptive treatment of parasitosis among immigrants with albendazole has been shown to save both money and lives, primarily via a reduction in the burden of Strongyloides stercoralis. Ivermectin is more effective than albendazole, but is also more expensive. This coupled with confusion surrounding the cost-effectiveness of guiding therapy based on eosinophil counts has led to disparate practices. We used the newly arrived year 2000 immigrant population as a hypothetical cohort in a decision analysis model to examine the cost-effectiveness of various interventions to reduce parasitosis among immigrants. When the prevalence of S. stercoralis is greater than 2%, the incremental cost-effectiveness ratios of all presumptive treatment strategies were similar. Ivermectin is associated with an incremental cost-effectiveness ratio of $1700 per QALY gained for treatment with 12 mg ivermectin relative to 5 days of albendazole when the prevalence is 10%. Any presumptive treatment strategy is cost-effective when compared with most common medical interventions.

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.

Cost-Effectiveness: Cholinesterase Inhibitors and Memantine in Vascular Dementia

2009 ◽  
Vol 36 (6) ◽  
pp. 735-739 ◽  
Author(s):  
Camilla L. Wong ◽  
Nick Bansback ◽  
Philip E. Lee ◽  
Aslam H. Anis
Keyword(s):  
Cost Effectiveness ◽  
Adverse Events ◽  
Incremental Cost ◽  
Vascular Dementia ◽  
Standard Care ◽  
Cholinesterase Inhibitors ◽  
Cost Effective ◽  
Decision Analysis Model ◽  
Physician Visits ◽  
Cost Effective Treatment

Background:Several randomized controlled trials of cholinesterase inhibitors and memantine in mild to moderate vascular dementia have demonstrated the efficacy of these treatments. However, given these drugs incur considerable cost, the economic argument for their use is less clear.Objective:To determine the incremental cost-effectiveness of cholinesterase inhibitors and memantine for mild to moderate vascular dementia.Design:A decision analysis model using a 24-28 week time horizon was developed. Outcomes of cholinesterase inhibitors and memantine and probabilities of adverse events were extracted from a systematic review. Costs of adverse events, medications, and physician visits were obtained from local estimates. Robustness was tested with probabilistic sensitivity analysis using a Monte Carlo simulation.Interventions:Donepezil 5 mg daily, donepezil 10 mg daily, galantamine 16-24 mg daily, rivastigmine flexible dosing up to 6 mg twice daily, or memantine 10 mg twice daily versus standard care.Main Outcome Measures:Incremental cost-effectiveness ratio (ICER) expressed as cost per unit decrease in the Alzheimer's Disease Assessment Scale-cognitive (ADAS-cog) subscale.Results:Donepezil 10 mg daily was found to be the most cost-effective treatment with an ICER of $400.64 (95%CI, $281.10-$596.35) per unit decline in the ADAS-cog subscale. All other treatments were dominated by donepezil 10 mg, that is, more costly and less effective.Conclusion:From a societal perspective, treatment with cholinesterase inhibitors or memantine was more effective but also more costly than standard care for mild to moderate vascular dementia. The donepezil 10 mg strategy was the most cost-effective and also dominated the other alternatives.

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.

scholarly journals Refractory hypertension secondary to renal artery stenosis with a honeycomb-like structure

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Cheng Chen ◽  
Ying Zhang ◽  
Da Yin ◽  
Yan Liu ◽  
Yunpeng Cheng ◽  
...  
Keyword(s):  
Renal Artery ◽  
Renal Artery Stenosis ◽  
Fibrous Tissue ◽  
Honeycomb Structure ◽  
Artery Stenosis ◽  
Proximal Segment ◽  
Left Renal Artery ◽  
Renal Infarction ◽  
Refractory Hypertension ◽  
Spider Web

Abstract Background A honeycomb-like structure (HLS) is a rare abnormality characterized by a braid-like appearance. Angiograph and intravascular examination, including coherence tomography and intravascular ultrasound (IVUS), can further confirm the multiple intraluminal channels or honeycomb structure, which can also be described as looking like ‘swiss cheese’, a ‘spider web’ or a ‘lotus root’. Previous studies have mostly reported this abnormality in coronary arteries, with a few cases in renal arteries. More information about the characteristics and development of HLS is needed. Case presentation A 69-year-old Han man with resistant hypertension received abdominal enhanced computerised tomography and was revealed to have left renal artery stenosis with the possibility of left renal infarction. Renal artery angiography confirmed a 95% stenosis located in the proximal segment of the left renal artery, and the middle segment was blurred with multi-channel-like blood flow. Further IVUS was performed and identified multiple channels surrounded by fibrous tissue. It was a rare case of HLS in the renal artery secondary to the thrombus, with organisation and recanalisation. Balloon dilatation and stent implantation at the proximal segment of the left renal artery were performed successfully. Blood pressure was well controlled after the procedure. Conclusions The IVUS findings are helpful for forming interventional therapeutic strategies for HLS lesions in the renal artery.

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