Costs of intensive treatment and follow-up of patients with multiple myeloma

In a retrospective study, we calculated the treatment and follow-up costs of patients with newly diagnosed multiple myeloma. The total treatment programme consisted of eight phases: VAD or VAMP chemotherapy, follow-up I, high-dose melphalan followed by transplantation of whole blood, follow-up II, collection of peripheral blood progenitor cells by leukapheresis, follow-up III, high-dose chemotherapy (busulfan/cyclophosphamide) followed by reinfusion of peripheral stem cells and follow-up IV (until 3 months from hospital discharge after peripheral stem cell transplantation). For each phase the average costs were calculated for all patients who were on treatment/follow-up in each particular phase. The total average cumulative costs of treatment and follow-up of all patients amounted to US$49850. Considering only the patients who completed the total treatment programme as it was scheduled, the average total treatment and follow-up costs were US$44800. The average costs of treatment and follow-up of patients who did not complete the programme as it was scheduled (patients who died, patients who were withdrawn from treatment and patients who received additional treatment) were US$57025.     

Improving the prediction of visual field progression in glaucoma using spatial processing

AIMS: To estimate the cost of population screening for haemochromatosis in Australia and to compare the cost of alternative screening strategies. METHODS: The costs of screening for haemochromatosis were analysed in a hypothetical study using transferrin saturation as the primary screening test, with confirmation of the diagnosis by either liver biopsy or DNA testing for the recently-described haemochromatosis gene. RESULTS: Screening, with confirmation of the diagnosis by liver biopsy, would cost between US$5079 and US$8813 per case detected (excluding administrative costs), depending on the screening strategy (Aust$ = US$0.80). If a DNA test were used instead of liver biopsy, the cost would be reduced to an estimated US$3954-US$4410 per case. This would be further reduced to US$2457 by detection of additional cases by screening family members. The least costly strategy utilised a transferrin saturation threshold of 55% and DNA testing for confirmation of the diagnosis; however, a transferrin saturation threshold of 45% increased the cost only marginally. The initial screening step (transferrin saturation) accounted for 74%-94% of the estimated cost of the screening programme. CONCLUSIONS: Screening for haemochromatosis using transferrin saturation involves relatively modest costs which may be recovered if complications of haemochromatosis can be prevented by early detection and treatment. The most cost-effective strategies utilised transferrin saturation for initial screening, followed by DNA testing. Reduction in the cost of transferrin saturation would lead to a significant reduction in total screening costs. Additional benefits of a screening programme include detection of other iron overload disorders and iron deficiency.     

Antiretroviral drugs as a public health intervention for pregnant HIV-infected women in rural South Africa: an issue of cost-effectiveness and capacity

OBJECTIVE: To estimate cost-effectiveness and capacity requirements for providing antiretroviral drugs to pregnant HIV-infected women in rural South Africa. SETTING: Hlabisa health district, where HIV prevalence among pregnant women was 26.0% in 1997. METHODS: Calculation of the number of paediatric HIV infections averted under three scenarios, and their cost. No intervention was compared with scenario A (zidovudine delivered within current infrastructure), scenario B (zidovudine delivered through enhanced infrastructure), and scenario C (short-course zidovudine plus lamivudine delivered through enhanced infrastructure). Cost-effectiveness was defined as cost per infection averted and cost per potential life-year gained. Capacity was determined in terms of staff and infrastructure required to effectively implement the scenarios. RESULTS: With no intervention, 657 paediatric HIV infections were projected for 1997. In scenario A this could be reduced by 15% at a cost of US$ 574 825, in scenario B by 42% at US$ 1520770, and in scenario C by 47% at US$ 764901. In scenario C, drugs accounted for 76% of costs, whereas additional staff accounted for 18%. Cost per infection averted was US$ 2492 and cost per potential life-year gained (discounted at 3%) was US$ 88. Cost of scenario C was equivalent to 14% of the 1997 district health budget. At least 12 extra counsellors and nurses and one laboratory technician, together with substantial logistical and managerial support, would be needed to deliver an effective intervention. CONCLUSION: Although antiretrovirals may be relatively cost-effective in this setting, the budget required is currently unaffordable. Developing the capacity required to deliver the intervention would pose both a major challenge, and an opportunity, to improve health services.     

Change of refraction in premature infants after cryotherapy for retinopathy of prematurity between the age of six months and three years

A community volunteer programme was initiated in rural Jamaica in May 1990. The main aim of the programme was to monitor the growth of children less than 36 months of age through community health volunteers (CHVs) and improve their nutritional status. At the end of the second year the programme was evaluated to determine its effectiveness. The results of the evaluation indicated that almost all (95.6%) of the children were covered by the CHVs. In addition the participation rate was high (78.5%). However, only 50% of the children were adequately covered. Nonetheless, 81% of them gained adequate weight. Indeed, malnutrition levels declined by 34.5%. The annual cost per child per year for the total programme was fairly moderate (US$14.5) with growth monitoring accounting for nearly half (42.7). The results suggest that CHVs can play an important role in primary health care programmes in developing countries.     

One world, one hope: the cost of providing antiretroviral therapy to all nations

OBJECTIVE: To estimate the potential direct cost of making triple combination antiretroviral therapy widely available to HIV-positive adults and children living in countries throughout the world. METHODS: For each country, antiretroviral costs were obtained by multiplying the annual cost of triple antiretroviral therapy by the estimated number of HIV-positive persons accessing therapy. Per capita antiretroviral costs were computed by dividing the antiretroviral costs by the country's total population. The potential economic burden was calculated by dividing per capita antiretroviral costs by the gross national product (GNP) per capita. All values are expressed in 1997 US dollars. RESULTS: The potential cost of making triple combination antiretroviral therapy available to HIV-positive individuals throughout the world was estimated to be over US$ 65.8 billion. By far the greatest financial burden was on sub-Saharan Africa. The highest per capita drug cost in this region would be incurred in the subregions of Southern Africa (US$ 149) followed by East Africa (US$ 116), Middle Africa (US$ 44), and West Africa (US$ 42). In the Americas, subregional data indicated the highest per capita drug cost would be in the Latin Caribbean (US$ 22), followed by the Caribbean (US$ 17), Andean Area (US$ 7), the Southern Cone (US$ 6), North America (US$ 6), and Central American Isthmus (US$ 5). In Asia and Europe the percentage of the GNP necessary to finance drug therapy was less than 1% in most countries examined. CONCLUSION: Our results demonstrate that the cost of making combination antiretroviral therapy available worldwide would be exceedingly high, especially in countries with limited financial resources.     

Outpatient haemorrhoidectomy under local anaesthesia

OBJECTIVE: To compare early and late results and costs of outpatient haemorrhoidectomy under local anaesthesia with those of inpatient haemorrhoidectomy. DESIGN: Prospective study with historical controls. SETTING: University hospital, Brazil. SUBJECTS: 51 patients who required haemorrhoidectomy. INTERVENTIONS: Outpatient haemorrhoidectomy under local anaesthesia. MAIN OUTCOME MEASURES: Early and late results and comparative costs. RESULTS: One patient was withdrawn from the study because of hypertension and subsequently lost to follow-up. The remaining 50 patients were discharged a mean of 68 (23) minutes after operation. Twelve patients complained of severe pain, one had faecal impaction and 2 developed bleeding. One patient developed urinary retention, compared with 18 in the historical group (p < 0.001). Forty-two patients (84%) were thoroughly satisfied with their treatment. Late complications did not differ significantly from those observed in the historical group. The estimated hospital costs were US$ 313.6 for outpatient, and US$ 716 for inpatient treatment. CONCLUSION: Outpatient haemorrhoidectomy under local anaesthesia was safe and comfortable for most patients, with complication rates comparable to or better than those observed after inpatient treatment and at less than half the cost.     

Rapid assessment of prevalence of cataract blindness at district level

AIM: To find an optimal cluster size and number of clusters for a reasonable estimate of the prevalence of cataract blindness in people aged > or = 50 years in 19 rural districts of a state in India. MATERIALS: Cluster sampling methodology was used in 19 rural districts of Karnataka State, India. In each district, 15 clusters were randomly selected and 90 people aged > or = 50 years were examined in each cluster. As a result the visual acuity and lens status of a total of 22,218 people were assessed. METHODS: For each district, the design effect for cluster size ranging from 20 to 90 was calculated and the optimal cluster size and the required number of clusters to achieve an accuracy of 1% errors and 80% confidence was assessed. RESULTS: The age and gender adjusted prevalence of cataract blindness varied from 1.58% to 7.24%, which justifies district level surveys. The design effect is nearly 1.5 for clusters of sizes 30 and 40. With an average prevalence of 4.93% with 1% error and 80% confidence level, the optimal number of clusters is 37 and 28 for a cluster size of 30 and 40 respectively and the average sample size for a district around 1100. CONCLUSIONS: Rapid assessments for cataract blindness in those aged > or = 50 years can be conducted at district level in India with existing resources and at affordable costs. These provide reliable data, essential for effective monitoring and planning. Other parameters, for instance, surgical coverage can also be assessed. The availability of standardized software for data entry and analysis and strict adherence to survey procedures is essential.     

Control of tuberculosis by community health workers in Bangladesh

BACKGROUND: Tuberculosis remains a major public-health problem in Bangladesh, despite national efforts to improve case identification and treatment compliance. In 1984, BRAC (formerly the Bangladesh Rural Advancement Committee), a national, non-governmental organisation, began an experimental tuberculosis-control programme in one thana (subdistrict). Community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy (phase one). Positive patients received 12 months of directly observed therapy. Phase two (1992-94) included another nine thanas and, in phase three (1995), eight more thanas were included. From 1995, the treatment was an 8-month oral regimen. METHODS: In 1995-96, we analysed all programme data from 1992 to 1995. First we analysed phases two (12-month therapy) and three (8-month therapy) separately for proportion cured, died, treatment, failed, defaulted, migrated, and referred. Second, we did a cross-sectional survey of tuberculosis cases in more than 9000 randomly selected households in two phase-two thanas and one non-programme thana, and analysed the follow-up of all patients treated in the programme thanas. FINDINGS: In the phase-two analysis, 3497 (90%) of 3886 cases identified had accepted 12-month treatment. In phase three, all of 1741 identified cases accepted the 8-month regimen. 2833 (81.0%) and 1496 (85.9%) in phases two and three, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. The relapse rate 2 or more years after treatment was discontinued was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey, the prevalence of tuberculosis in the two programme thanas was half of that in the comparison thana, where only government services were available (0.07 vs 0.15 per 100 [corrected]). INTERPRETATION: The BRAC tuberculosis-control programme has successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85% and a drop-out rate of 3.1%. The prevalence survey suggested that at least half of all existing cases had been detected by the programme.     

Activation of the gene encoding decay accelerating factor following nerve growth factor treatment of sensory neurons is mediated by promoter sequences within 206 bases of the transcriptional start site

This study was designed to develop a quick methodology to assess the healthcare needs of a rural community and to determine what factors make these communities 'happy' or 'unhappy' with respect to medical service provision. Two rural shires of approximately 4000 people each were chosen from different health regions of Western Australia. The methodology consisted of interviews with healthcare providers and key community informants as well as a community questionnaire. The interviewing process showed that key community informants offered no new information in addition to that already provided by the healthcare providers. Furthermore, all key points would have been covered by interviewing approximately 60% of all healthcare providers in each community. Hand delivery of the community questionnaire yielded the highest response rate. The level of community satisfaction with general practitioner (GP) and hospital services determines whether a community is medically 'happy' or 'unhappy'.     

Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up

OBJECTIVE: To compare outcome and costs between laparoscopic and open hernia repair. DESIGN: Prospective randomised study. SETTING: One university and two district hospitals in Sweden. SUBJECTS: 200 men aged 25-75 years. MAIN OUTCOME MEASURES: Operating time, hospital stay, complications, and time to recovery. A cost-minimisation-analysis was used in which the total costs were calculated for a defined period of time for each option. RESULT: The one year follow-up rate was 98%. Mean (SD) operation times in the laparoscopic and open groups were 72 (30) and 62 (25) minutes, respectively (p = 0.009). Hospital stay and complication rates did not differ between the groups. Among employees the mean (SD) periods off work in the laparoscopic and open groups were 10 (8) and 23 (21) days, respectively (p = 0.0001). The mean direct costs of the laparoscopic operation were increased by SEK 4037 (US$ 483) but the savings in indirect costs resulting from earlier return to work were SEK 11392 (US$ 1364). CONCLUSIONS: Laparoscopic hernia repair gave the employed patients faster recovery and return to work, and was the most cost-effective strategy provided that both direct and indirect costs were included.     

Social class and coronary disease in rural population of north India. The Indian Social Class and Heart Survey

OBJECTIVE: To demonstrate the association of socio-economic status with prevalence of coronary artery disease and coronary risk factors. DESIGN AND SETTING: Cross-sectional survey in two randomly selected villages in the Moradabad district in North India. SUBJECTS AND METHODS: One thousand seven hundred and sixty-seven subjects (894 males and 875 females; 25-64 years of age) were randomly selected from two villages. They were divided into social classes 1 to 4, according to education, occupation, housing conditions, ownership of land, ownership of consumer durables and per capita income. The survey was based on questionnaires administered by dietitians and physicians, physical examination and electrocardiography. RESULTS: Social classes 1 and 2 were mainly high and middle socio-economic groups and 3 and 4 low income groups. The prevalence of coronary artery disease was significantly higher among classes 1 and 2 in both sexes, and there was a higher prevalence of hypercholesterolaemia, hypertension, and sedentary lifestyle. This population also showed a significant association with higher serum cholesterol, body mass index, triglycerides and blood pressures. Logistic regression analysis with adjustment for age showed that social class positively related to coronary disease (odds ratio: men 0.83, women 0.61), hypercholesterolaemia (men 0.85, women 0.87), hypertension (men 0.89, women 0.87), body mass index (men 0.91, women 0.93) and smoking in men (0.68). Smoking and sedentary lifestyle were not associated with social class in women. The association between coronary artery disease and social class abated after adjustment for smoking, sedentary lifestyle, body mass index and blood pressure (odds ratio: men 0.96, women 0.81). CONCLUSION: Subjects in social classes 1 and 2 in rural North India have a higher prevalence of coronary artery disease and of the coronary risk factors hypercholesterolaemia, hypertension, higher body mass index and sedentary lifestyle. The overall prevalence of coronary artery disease was 3.3%.     

Constraints faced by hospitalized maternity patients in Niamey (Niger)

A cross-sectional survey was conducted in the main maternity hospital in Niamey (Maternité Poudrière) in July 1995 to evaluate the domestic and financial pressures faced by the patients. One-hundred-and-five women were included in this exhaustive survey which analyzed the socio-demographic characteristics of the patients' households, the reasons for their hospitalization, the organization of their daily life while in hospital, and the costs involved (type of costs, the amounts, and who paid which cost). Fifty-seven women lived in Niamey, and forty-eight in a rural area. The socio-demographic characteristics of the survey population were in agreement with the characteristics of Niger's census in 1988. Analysis of the patients' incomes showed that they were highly dependent on their husbands. Fifty-eight received surgical treatment, and forty-seven received medical treatment. The costs of hospitalization included the standard fee, traveling expenses, and the costs of drugs and surgery. On average, 72% of the hospitalization costs were paid by the husbands, and 15% by close members of the family. The contribution by extended family members and friends was very small. Only 40.5% of the total amounts exceeding 25,000 FCFA were wholly paid. Niger has a policy of recovering medical costs. Our survey shows the difficulties of attempting to reconcile the operation of health centers with access to specialist care.     

StgR, a new Streptomyces alboniger member of the LysR family of transcriptional regulators

Many of the current tuberculosis control programmes in the Russian Federation are based on costly strategies which are underfunded and use long, individualized treatment regimens. This article compares, using a cost-effectiveness analysis, the new WHO strategy implemented in the Ivanovo Oblast (case-finding among symptomatic patients (SCF) and shorter regimens) and the old strategy (active screening of the asymptomatic population (ACF) and longer regimens). The cost per case cured was calculated at different levels of cure rate (45-95%) using three scenarios to describe the new WHO strategy (use of WHO-recommended regimens and three options at increasing rates of admission) and a fourth scenario to describe the old strategy (all patients admitted for the whole treatment and longer regimens). The cost per case detected was determined by calculating the following: yield of the new and old strategy (number of examinations necessary to diagnose one case); cost of the diagnostic process; multiplying yield per cost according to the three scenarios describing the new WHO strategy and a fourth scenario describing the old strategy. In the Ivanovo Oblast the cost per case cured, at 85% cure rate level, ranged from US$ 1197 (new strategy, scenario 1 without food) to US$ 6293 (old strategy, scenario 4) the cost per case detected ranged from US$ 1581 (new strategy, scenario 1) to US$ 4000 (old strategy, scenario 4). Significant savings can result from shifting towards the new WHO strategy. Decision-makers and health administrators should be responsible for re-investing the financial and human resources mobilized by the adoption of cost-effective strategies within the TB control programme.     

Screening for renovascular hypertension in a population with relatively low prevalence

OBJECTIVE: To evaluate the accuracy and cost-efficacy of the diagnostic procedure and treatment for renovascular hypertension. SETTING AND PATIENTS: A total of 519 patients referred to the university clinic for hypertension were screened for renovascular hypertension with 405 captopril challenge tests (CCT) and 450 captopril renographies (CRG). INTERVENTIONS: Abdominal angiography was performed on 84 patients for positive screening. Fifteen patients underwent angiography for a sole suspicious clinical presentation. The angiography revealed 17 renal artery stenoses and five occlusions in 20 patients. Fifteen technically successful angioplasties and three nephrectomies were performed. RESULTS: In the patients who underwent angiography, CCT had a specificity of 39% and a sensitivity of 67% for renovascular hypertension. CRG had a sensitivity of 100% and a specificity of 68%. In the whole study population, the estimated specificity of CCT was 88% and that of CRG 95%. Invasive treatment reduced systolic/diastolic blood pressure from 157/99 to 140/87 mmHg and the number of antihypertensive drugs used from 2.6 to 1.4 in 16 patients (mean age 49 years). Angiotensin converting enzyme (ACE) inhibition was effective in four elderly patients. Cost-efficacy analysis Screening with CRG and invasive treatment cost US$15400 per successful invasive treatment Equally effective pharmacological treatment would have cost US$10400. Limiting the screening with CRG to the 173 patients with no obvious renal parenchymal disease and with hypertension at a younger age (< or =30 years) or unresponsive to two antihypertensive drugs (diastolic blood pressure > 90 mmHg) would have yielded a prevalence of 12% and missed only one elderly patient who responded to ACE inhibition. The limited screening, along with invasive treatment, would have cost US$7300 per patient CONCLUSIONS: CRG is superior to CCT for screening of renovascular hypertension. Screening with CRG is cost-effective when limited to patients with no obvious renal parenchymal disease and with hypertension that does not respond to two antihypertensive drugs or is detected in patients no older than 30 years.     

Costs of asthma according to the degree of severity

An increase in asthma-related morbidity and mortality has been reported recently, resulting in a substantial increase in the economic impact of this condition. Little information is available relating to the costs of asthma depending on the degree of severity of the disease. Total, direct and indirect costs generated by asthma patients who sought medical care for asthma control over a one-year period in a northern area of Spain were determined. Data were obtained from the patients themselves and severity of illness was classified into mild, moderate and severe according to the International Consensus Report on Diagnosis and Treatment of Asthma, 1992. The average total annual asthma-derived cost was estimated at US$2,879 per patient, with averages of US$1,336 in mildly asthmatic patients, US$2,407 in moderate asthma and US$6,393 in severe asthma. At all levels of severity, indirect costs were twice as high as direct costs, and at the same degree of severity, direct costs due to medication and hospitalization were higher among females than males. A minority of severe asthmatics incurred some 41% of the total costs. The cost of asthma was surprisingly high and varied substantially depending on the degree of severity of the disease. Further knowledge of the costs of asthma across various levels of severity will contribute to a better characterization of optimal intervention strategies for asthma care.     

Dysfunctional uterine bleeding and dysmenorrhea

OBJECTIVES: To examine the socio-economic effects of team-based clinical case management of patients with chronic minor disease bound for early retirement. DESIGN: Marginal analysis of programme costs and benefits to society compared with no-programme baseline of costs occurring in society due to productivity loss. Prospective patient data collection on admission, discharge, and at one year and five years after discharge to determine programme effectiveness. SETTING: Out-patient clinic at the department of social medicine in tertiary care hospital. SUBJECTS: 239 patients with minor disease and long-term vocational absence consecutively admitted to the study. At the one-year evaluation, 17 patients had been readmitted to the team, 7 could not be found, 6 declined the interview and 2 were deceased. At the five-year evaluation of 49 patients who were active after one year, one was deceased and 10 were unable to be found. MAIN OUTCOME MEASURES: Vocational activity. Programme costs. Benefits to society measured by decrease in indirect costs. RESULTS: The one-year vocational rehabilitation rate from the program was 20.5% and the five-year rehabilitation rate was 11.3%. The total discounted cost for case management of the 239 patients was 7.3 MSEK (600,000 Pounds). The decrease in the indirect costs to society from the 28 patients found active after five years was 35.1 MSEK (2,500,000 Pounds). The net present value of the programme at the 1991 price level was 27.5 MSEK (2,365,000 Pounds). CONCLUSIONS: Tertiary care level team-based clinical case management for vocational rehabilitation of patients with chronic minor disease has a positive cost-benefit ratio. A cross-boundary awareness at a health policy level is needed of the societal costs involved for this group of patients who fall between the traditional services in health care and social work.     

Effects of voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: A randomized controlled trial.

The aims of this study were to assess whether voucher magnitude improved cocaine abstinence and retention in an outpatient treatment for cocaine dependence, and to determine the effectiveness of a contingency management intervention in a European cultural context. A randomized controlled trial was conducted in which 96 participants who were randomly assigned to 1 of 3 treatment conditions in a community setting: standard outpatient treatment, community reinforcement approach (CRA) plus low monetary value vouchers (each point earned was equivalent to 0.125? US$ 0.18), and CRA plus high monetary value vouchers (each point was worth 0.25? US$ 0.36). In the standard treatment group, mean percentage of cocaine-negative samples was 88.45%, versus 96.09% in the CRA plus low-vouchers group, and 97.07% in the CRA plus high-vouchers group. Retention rate at 6 months was 36.5% in the standard treatment group, 53.3% in the CRA plus low-vouchers group, and 69.0% in the CRA plus high-vouchers group. The CRA plus vouchers groups obtained better results than the standard program. This study showed that treating cocaine addiction by combining CRA with vouchers was more effective than standard treatment in community outpatient programs in Spain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Frequency and characteristics of silent dementia among elderly Japanese-American men. The Honolulu-Asia Aging Study

OBJECTIVE: To determine the frequency of unrecognized dementia in a group of men found to have dementia by population survey, and to identify factors associated with the failure of a family informant to recognize significant memory impairment. DESIGN AND SETTING: The Honolulu-Asia Aging Study, a population-based study of dementia among elderly Japanese-American men living on the island of Oahu, Hawaii. Data for this study were from the dementia prevalence survey, 1991-1993. STUDY PARTICIPANTS: A total of 191 noninstitutionalized men with dementia who had a reliable family informant. MAIN OUTCOME MEASURES: Failure of family informants to recognize a problem with thinking or memory in subjects with dementia. RESULTS: A total of 21% of family informants failed to recognize a problem with memory among subjects subsequently found to have dementia. Among subjects with very mild dementia, 52% of family informants failed to recognize a significant memory problem compared with 13% among more severely demented subjects. Of the subjects with dementia whose family informants did recognize a memory problem, 53% failed to receive a medical evaluation for this problem. For all family informants, increasing age, fewer years of education, less severe dementia, fewer behavioral complications, fewer functional disabilities, and better performance on certain tests of memory and language were significantly associated with the family informant's failure to recognize a problem with memory. When the family informants were wives living with husbands, less severe dementia, fewer behavioral complications, fewer functional disabilities, and intact remote memory were associated with unrecognized dementia. CONCLUSIONS: Unrecognized dementia was common in our population, especially among mild cases. Cognitive screening programs for the elderly and public education policies designed to increase awareness of early signs of dementia are needed if interventions for individuals with potentially treatable dementias are to be implemented.     

Cost-effectiveness of new treatments for overactive bladder: the example of tolterodine, a new muscarinic agent: a Markov model

Economic analyses of interventions for chronic diseases require evaluations over a long timeframe to illustrate the benefits and costs of treatments. Clinical trials are generally short and carried out in strictly controlled conditions. They are therefore of limited value for economic evaluation aimed at facilitating decisions about resource allocation. The objective of this study was to develop a simulation model that allows integration of data from different sources to calculate the incremental cost-effectiveness and cost-utility of new treatments for overactive bladder. The model compares tolterodine, a new treatment that aims at alleviating symptoms and improving patients' quality of life, to no treatment. Simulations for Sweden are presented as an example. The Markov model combines clinical, observational, and economic data. Markov states are defined based on severity of symptoms of overactive bladder (frequency of voids and leaks). Specific costs for drug treatment and use of sanitary protections as well as utilities are assigned for each state. The effectiveness of tolterodine is based on controlled clinical trials and open long-term extensions of these trials. Outcome is measured as quality-adjusted life years (QALYs) and as the number of months spent in a state with no or very limited symptoms. During the course of 1 year, patients treated with tolterodine spend more time in states with no or limited symptoms compared to those receiving no treatment. Tolterodine-treated patients having a better quality of life during the year. The mean utility of the treated cohort is 0.70, compared to 0.67 in the no-treatment cohort, which is equivalent to the entire cohort moving by one level to a state with less severe symptoms. Mean total costs per patient in the tolterodine arm are SEK8,595 (US $1,131; 1 US$ = 7.6 SEK) compared to SEK3,286 (US$432) in the no-treatment arm. The extra cost due to tolterodine is SEK380 (US$50) per month, which falls within the range of monthly amounts that patients were willing to pay out of pocket for a 25 or 50% improvement of their symptoms in a previous study. The cost for pads is reduced by 23%. The marginal cost per QALY gained with tolterodine is estimated at SEK213,000 (US$28,000). Based on this simulation model, it appears that treatment of overactive bladder with a well-tolerated pharmacological treatment such as tolterodine is cost-effective.     

Preschoolers monitor the relative accuracy of informants.

In 2 studies, the sensitivity of 3- and 4-year-olds to the previous accuracy of informants was assessed. Children viewed films in which 2 informants labeled familiar objects with differential accuracy (across the 2 experiments, children were exposed to the following rates of accuracy by the more and less accurate informants, respectively: 100% vs. 0%, 100% vs. 25%, 75% vs. 0%, and 75% vs. 25%). Next, children watched films in which the same 2 informants provided conflicting novel labels for unfamiliar objects. Children were asked to indicate which of the 2 labels was associated with each object. Three-year-olds trusted the more accurate informant only in conditions in which 1 of the 2 informants had been 100% accurate, whereas 4-year-olds trusted the more accurate informant in all conditions tested. These results suggest that 3-year-olds mistrust informants who make a single error, whereas 4-year-olds track the relative frequency of errors when deciding whom to trust. (PsycINFO Database Record (c) 2010 APA, all rights reserved)