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Biomedical subjects

Bernie J O'Brien

Publications and source records attributed to Bernie J O'Brien.

At least 37 records · Page 2Linked to original sources
PubMed2003

Cost-effectiveness analysis of predischarge monitoring for apnea of prematurity.

OBJECTIVE: It is standard practice to defer discharge of premature infants until they have achieved a set number of days without experiencing apnea. The duration of this period, however, is highly variable across institutions, and there is scant literature on its effectiveness or value-for-money. Our objective was to establish the economic impact of varying durations of predischarge observation for apnea of prematurity. METHODS: Using computer simulation, we compared the alternatives of hospital monitoring for 1 to 10 days, after apparent cessation of apnea, with no monitoring and with the next longest period of monitoring. The daily probability of apnea requiring stimulation after a given number of apnea-free days was obtained from chart review of 216 infants, beginning on the day they attained both full feeds and temperature stability in an open crib. Baseline rates of survival or impairment, utilities for calculation of quality-adjusted life years (QALYs), outcomes for respiratory arrest at home, and long-run costs for neurodevelopmental impairment were derived from the literature. Hospital expenditures were obtained from itemized billing records for infants on each of the final 10 days of hospitalization and converted to costs using Medicare cost-to-charge ratios. Costs are reported in 2000 US dollars. RESULTS: For infants born at 24 to 26 weeks' gestation, each additional day of monitoring cost from $41000 per QALY saved for the first day to >$130000 per additional QALY gained for the tenth day. Cost-effectiveness was poorer for infants who were born at gestational ages >30 weeks. Results were sensitive to the proportion of charted apneas requiring stimulation that would actually progress, without intervention, to respiratory arrest. CONCLUSIONS: In this model, the cost-effectiveness of predischarge monitoring for apnea of prematurity declined significantly as the duration of monitoring was increased. Consideration should be given to alternative uses for resources in formulating neonatal discharge guidelines.

Apnea↗
PubMed2003

Cost-effectiveness of a transplantation strategy compared to melphalan and prednisone in younger patients with multiple myeloma.

High dose chemotherapy with autologous stem cell transplantation (ASCT) improves outcomes in patients 65 years of age or less with multiple myeloma. Survival and costs in a cohort of 16 patients who received melphalan and prednisone as part of a clinical trial were compared with those of 36 patients referred to our centre for consideration of ASCT. In the transplant group, survival and costs were extrapolated to match the period of observation in the melphalan and prednisone group. Patient-specific and average costs were calculated from the perspective of the Ontario Ministry of Health. Costs and survival were varied by 50% in the sensitivity analysis. Transplantation improved life expectancy by 19.3 months with a cost difference of 30,517 Canadian dollars. The incremental cost-effectiveness of transplantation compared with melphalan and prednisone was 25,710 Canadian dollars per life-year gained when additional pamidronate and follow-up costs were considered. Discounting costs and survival at 3 and 5% did not result in important differences. The sensitivity analysis resulted in best and worse case scenarios for transplantation compared with melphalan and prednisone of 13,049 dollars and 63,954 dollars per life-year gained respectively. In comparison with melphalan and prednisone, ASCT appears to be cost-effective in patients 65 years old or younger with myeloma.

Adult↗
PubMed2003

Rapid increase in statins newly dispensed to Ontario seniors between 1994 and 2000.

BACKGROUND: The Ontario government spent approximately 10% (CDN $148 million) of the provincial medication budget on statins in 1998. This number can be expected to grow in light of new guidelines from the United States recommending that three times as many patients should be receiving antihyperlipidemic therapy. There is scant population-based information on the age and sex distributions of patients receiving these medications. OBJECTIVES: To estimate the rates of new use of statin medications among community-dwelling elderly adults in Ontario between 1994 and 2000. METHODS: Data from the Ontario Drug Benefit program were used on all medications dispensed to noninstitutionalized Ontarians over 65 years of age to estimate age- and sex-specific annual rates of patients newly dispensed a statin. Changes in rates were estimated using Poisson regression. RESULTS: The number of elderly Ontarians newly dispensed a statin increased rapidly between 1994 and 2000, with age-standardized rates rising from approximately 840 to 2600/100,000 women and from 810 to about 3100/100,000 men. The highest rates of new use were observed among patients of both sexes aged 65 to 74 years. However, the rate of change increased with advancing age so that the biggest increase was observed among those aged 85 years and above, among whom there was an 8.5-fold increase among women and a 12-fold increase among men. CONCLUSIONS: Statins have been shown to be safe, efficacious and cost effective in reducing the risk of sudden cardiac death and other acute coronary events among middle-aged patients with pre-existing cardiovascular disease. The present study showed that there was a rapid increase in the rate of statins newly dispensed to elderly patients in Ontario, among whom estimates of safety, efficacy and cost effectiveness are not well quantified. Better estimates of these parameters in the elderly are required because of the high costs and benefits and potential unintended beneficial and harmful effects of statins.

Aged↗
PubMed2003

Coding accuracy of administrative drug claims in the Ontario Drug Benefit database.

BACKGROUND: Every year in Ontario, the records of over 42 million prescriptions dispensed to persons eligible for Ontario Drug Benefit (ODB) benefits are transmitted to a central database. The ODB database is the second largest database of medications in Canada, containing records on almost half of all medications dispensed in Ontario. There is no information about the reliability of the coding on the ODB drug claims database and, therefore, the objective of this study was to estimate the reliability of coding of the Drug Identification Number, and the date, quantity and duration of the dispensation on claims sent to the ODB. METHODS: To meet this objective, approximately 100 randomly selected prescriptions dispensed from each of 50 pharmacies in southern Ontario between July 1, 1998 and December 31, 1999 were audited. For each claim, the written information on the prescription was compared with the electronic information submitted to the ODB database. Logistic regression was used to test the association between coding errors and the location, owner affiliation, and productivity of each pharmacy (defined as the annual volume of dispensations divided by the annual number of hours worked by all pharmacists and pharmacy assistants). RESULTS: Of the 183 pharmacies owners invited to participate, consent to abstract information was obtained in 50, yielding a participation rate of 27%. Of the 5155 dispensed prescriptions, 37 errors were found, yielding an overall error rate of 0.7% (95% CI 0.5% to 0.9%). None of the characteristics of pharmacies that were examined (location, owner affiliation, productivity) was associated with coding errors. CONCLUSIONS: Pharmacists almost always dispense the medication that is prescribed and this information is reliably transmitted to the ODB drug claims database. This means that any conclusions drawn by researchers using these data are not likely to be compromised by low coding reliability.

Clinical Pharmacy Information Systems↗
PubMed2003

Review of economic evaluations of radiofrequency catheter ablation for cardiac arrhythmias.

A systematic review of current studies on the cost effectiveness of catheter ablation for treatment of tachycardia in adults was undertaken. The results are summarized based on a predefined framework of principles for economic evaluation. Of 192 abstracts identified, only three cost effectiveness studies were identified. Each focused on a different and specific patient group with selected target disorders, and used decision analysis modelling to estimate cost effectiveness. Radiofrequency catheter ablation is likely to be economically attractive compared with drug therapy in adult patients with frequently symptomatic paroxysmal supraventricular tachycardia (radiofrequency catheter ablation dominates drug therapy options) or in ventricular tachycardia patients with pre-existing ischemic coronary disease (cost effectiveness ratio of about US $21,000 per quality adjusted life year), but not in the treatment of asymptomatic Wolff-Parkinson-White syndrome patients. However, these studies evaluated different types of tachycardias in differing patient populations and all are based on United States data, so decision-makers must be cautious when applying these results to a general population with tachycardia in the Canadian context.

Adult↗
PubMed2002

Impact of reference-based pricing for histamine-2 receptor antagonists and restricted access for proton pump inhibitors in British Columbia.

BACKGROUND: Two programs to reduce expenditures for common gastrointestinal drugs were introduced simultaneously by British Columbia (BC) Pharmacare in 1995. Reference-based pricing restricted reimbursement for all histamine-2 receptor antagonists (H2RAs) to the cost of the least expensive H2RA available, generic cimetidine. Special authority restricted reimbursement for proton pump inhibitors (PPIs) to patients who met certain eligibility criteria. We evaluated the effect of reference-based pricing for H2RAs and special authority for PPIs on dispensing and reimbursement for senior citizen beneficiaries of BC Pharmacare. METHODS: Itemized monthly claims data for upper gastrointestinal drugs were obtained from BC Pharmacare for all beneficiaries 65 years of age or older. Periods before and after implementation of reference-based pricing and special authority were compared with respect to defined daily doses dispensed per 100,000 beneficiaries, BC Pharmacare reimbursement per 100,000 beneficiaries, BC Pharmacare reimbursement per defined daily dose and beneficiary contributions per defined daily dose. We used regression models to project forward trends in expenditures observed before implementation of the new policies and hence to estimate accrued cost savings. RESULTS: Before reference-based pricing and special authority, the numbers of defined daily doses that were dispensed and total BC Pharmacare reimbursements for H2RAs appeared to be declining gradually, whereas those for PPIs were rising. With reference-based pricing, the monthly defined daily dose of cimetidine dispensed increased more than 4-fold, to 116,257 per 100,000 beneficiaries, while those of other restricted H2RAs decreased by more than half, to 50,927 per 100,000 beneficiaries. Special authority immediately reduced the dispensed volumes of PPIs by one-fourth, but growth in volume then appeared to resume at its previous rate. The estimated annualized cost savings achieved by reference-based pricing and special authority were $1.8 million to $3.2 million for H2RAs (depending on the estimation method used) and $5.5 million for PPIs. However, beneficiary contributions for H2RAs increased from negligible amounts to approximately 16% of total drug expenditures. INTERPRETATION: Reference-based pricing and special authority appear to have been successful in altering prescribing habits and reducing provincial expenditures for upper gastrointestinal drugs, but they have increased the financial burden on senior citizen beneficiaries.

Aged↗
PubMed2002

Is there a kink in consumers' threshold value for cost-effectiveness in health care?

BACKGROUND: A reproducible observation is that consumers' willingness-to-accept (WTA) monetary compensation to forgo a program is greater than their stated willingness-to-pay (WTP) for the same benefit. Several explanations exist, including the psychological principle that the utility of losses weighs heavier than gains. We sought to quantify the WTP-WTA disparity from published literature and explore implications for cost-effectiveness analysis accept-reject thresholds in the south-west quadrant of the cost-effectiveness plane (less effect, less cost). METHODS: We reviewed published studies (health and non-health) to estimate the ratio of WTA to WTP for the same program benefit for each study and to determine if WTA is consistently greater than WTP in the literature. RESULTS: WTA/WTP ratios were greater than unity for every study we reviewed. The ratios ranged from 3.2 to 89.4 for environmental studies (n=7), 1.9 to 6.4 for health care studies (n=2), 1.1 to 3.6 for safety studies (n=4) and 1.3 to 2.6 for experimental studies (n=7). CONCLUSIONS: Given that WTA is greater than WTP based on individual preferences, should not societal preferences used to determine cost-effectiveness thresholds reflect this disparity? Current convention in cost-effectiveness analysis is that any given accept-rejection criterion (e.g. $50 k/QALY gained) is symmetric - a straight line through the origin of the cost-effectiveness plane. The WTA-WTP evidence suggests a downward 'kink' through the origin for the south-west quadrant, such that the 'selling price' of a QALY is greater than the 'buying price'. The possibility of 'kinky cost-effectiveness' decision rules and the size of the kink merits further exploration.

Attitude to Health↗
PubMed2002

Quality of life in the Canadian Implantable Defibrillator Study (CIDS).

BACKGROUND: The primary aim of this study was to compare quality-of-life outcome between patients randomized to implantable cardioverter defibrillator (ICD) therapy and patients randomized to amiodarone treatment in the Canadian Implantable Defibrillator Study (CIDS). A secondary aim was to evaluate the effects on quality-of-life outcomes of receiving shocks from the device. METHODS: Quality of life was assessed in 317 English-speaking participants by use of the Rand Corporation's 38-item Mental Health Inventory (MHI) and the Nottingham Health Profile (NHP). Assessments were done in the hospital at baseline and with mailed questionnaires after 2, 6, and 12 months of follow-up. Sixty-two percent of patients completed the follow-up assessments at 6 and 12 months. RESULTS: Repeated measures analysis of variance revealed significant time by treatment group interaction effect on total MHI and the psychological distress and psychological well-being sub-scales, and on 5 of the 7 NHP scales (energy, physical mobility, emotional reactions, sleep disturbance, and lifestyle impairment) (P <.05). Emotional and physical health scores were shown to improve significantly in the ICD group and were either unchanged (emotional health) or deteriorated (energy and physical mobility) in the amiodarone-treated group by means of post-hoc comparisons. Quality of life did not improve in the subgroup of patients in the ICD-treated group who received > or =5 shocks from their device. CONCLUSION: Quality of life is better with ICD therapy than with amiodarone therapy. The beneficial quality-of-life effects from an ICD are not evident in patients who receive numerous shocks from their device.

Aged↗
PubMed2002

Use and misuse of cost-effectiveness terminology in the gastroenterology literature: a systematic review.

OBJECTIVES: The increased popularity of economic analyses for evaluating medical interventions has given rise to concern about the rigor with which economic constructs and terminology are used. True cost-effectiveness analysis considers both the costs and outcomes of alternative interventions. A systematic review of the gastroenterology literature was undertaken to evaluate how appropriately cost-effectiveness is assessed. METHODS: A structured MEDLINE search identified all studies published in major gastroenterology journals between 1980 and 1998 that claimed in their abstracts to have assessed the cost-effectiveness of an intervention. Blinded copies of eligible studies were assessed by two independent reviewers who used standard criteria to evaluate the use of economic terminology and key economic constructs. Discrepancies were resolved by consensus. Studies met a "broad criterion" for appropriateness by evaluating both costs and effects and a "strict criterion" by demonstrating dominance of one strategy or considering both incremental costs and incremental effects. RESULTS: Of 110 eligible studies, 77 (70.0%) met the broad criterion and 62 (56.4%) met the strict criterion for appropriateness. This did not seem to vary with either journal impact factor or publication year. Only eight of 18 studies reporting an incremental cost-effectiveness ratio compared its value to an external standard. Few studies explicitly stated their analytic perspective, and a minority of those with time horizons longer than 1 yr had discounted future costs or effects. CONCLUSIONS: Although most studies seem to use cost-effectiveness terminology well, there remains room to improve the rigor with which economic terminology and constructs are applied.

Canada↗
PubMed2002

The role of models within economic analysis: focus on type 2 diabetes mellitus.

Economic analysis of healthcare interventions is increasingly reliant on decision models to estimate the long-term costs and benefits of new therapies. Models permit analysts to take short-term clinical data to forecast long-term costs and benefits. Models should follow certain basic principles and can be appraised in terms of three broad characteristics: clinical relevance, transparency and analytical ability. The purpose of this paper is to explore the role of modelling in the economic analysis of interventions for type 2 diabetes mellitus. A review of existing models for diabetes identified five complex disease models appropriate for economic analysis. These models were broadly similar in structure and in source of input parameters. However, models did vary according to the coverage of relevant disease complications and the complexity of analysis possible. Models could be enhanced by improving their transparency and by using data relevant to type 2 diabetes. In addition, enhancing clinical knowledge through the provision of long-term data on effectiveness may reduce concern relating to the appropriateness of the assumptions currently required within models. The value of such further information must be weighed against the costs of its acquisition.

Clinical Trials as Topic↗
PubMed2002

Cost effectiveness of implantable cardioverter defibrillator therapy versus drug therapy for patients at high risk of sudden cardiac death.

The implantable cardioverter defibrillator (ICD) is a therapy for patients at risk of sudden cardiac death due to ventricular tachycardia (VT) or ventricular fibrillation (VF). But the apparent high cost of ICD therapy relative to antiarrhythmic drugs such as amiodarone has raised questions about the cost effectiveness of ICD therapy versus drug therapy. To inform this debate we reviewed the literature on ICD cost effectiveness. An electronic and manual search was conducted for articles published since 1980 reporting original data on the cost effectiveness of ICD versus drug therapy for patients at risk of VT/VF. Data on costs and life-years gained were abstracted and studies were grouped into those that used decision-analysis models and those that were trial-based analyses. Cost-effectiveness ratios were inflated to 2001 US dollars. Nine studies were included in the review; five studies were modelling studies and four were part of randomised trials of ICD therapy. Studies varied in time horizon, but all except one indicated that ICD therapy was more costly than drug therapy. Early decision models assumed larger survival benefits than those observed in subsequent trials and therefore had attractive incremental cost-effectiveness ratios in the range of dollars US 27000 to dollars US 60000 per life-year gained. Trial-based studies, with the exception of one small trial, indicated cost per life-year gained in the range dollars US 44000 to dollars US 144000. Stratified analysis shows clearly that patients with a greater risk of mortality due to structural heart disease (e.g. left ventricular ejection fraction < or =35%) benefit more from ICD therapy and therefore have a more attractive cost effectiveness ratio than patients at lower risk. ICD therapy is still evolving over time with implant costs declining and device technology improving. Current evidence is that, in selected patients who are at high risk of VT/VF, ICD therapy can be a cost-effective option. Future research should focus on (i) patient selection to optimise benefits for available resources; and (ii) more comprehensive outcome measures to include health-related quality of life.

Anti-Arrhythmia Agents↗
PubMed2001

Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies.

As many more clinical trials collect economic information within their study design, so health economics analysts are increasingly working with patient-level data on both costs and effects. In this paper, we review recent advances in the use of statistical methods for economic analysis of information collected alongside clinical trials. In particular, we focus on the handling and presentation of uncertainty, including the importance of estimation rather than hypothesis testing, the use of the net-benefit statistic, and the presentation of cost-effectiveness acceptability curves. We also discuss the appropriate sample size calculations for cost-effectiveness analysis at the design stage of a study. Finally, we outline some of the challenges for future research in this area-particularly in relation to the appropriate use of Bayesian methods and methods for analyzing costs that are typically skewed and often incomplete.

Bayes Theorem↗
PubMedDate not supplied

Cost-effectiveness and cost-utility of long-term management strategies for heartburn.

OBJECTIVES: To compare the expected costs and outcomes of seven alternative long-term primary care strategies for the management of patients with moderate-to-severe heartburn over a 1-year period. METHODS: A decision-analytic model was developed to estimate costs and effects (weeks with heartburn symptoms and quality adjusted life years [QALYs]) for each strategy. Meta-analyses were used to synthesize acute treatment and maintenance studies and physician surveys to collect information on patient management. The impact of uncertainty on the base case results was assessed using probabilistic sensitivity analysis. Probability distributions were defined for key model parameters and techniques of Monte Carlo simulation were used to draw values from these distributions. Cost-effectiveness acceptability curves (CEACs) conditional on the monetary value decision makers are willing to pay for a symptom-free day or QALY were created for each strategy. RESULTS: In the base case, no strategy was strictly dominated by any other strategy. However, two strategies (maintenance H2-receptor antagonists H2RA] and step-down proton pump inhibitor PPI]) were dominated through principles of extended dominance. The least costly and least effective strategy was intermittent H2RA, while maintenance PPI was the most costly and most effective. CONCLUSIONS: This analysis showed that the best way of managing patients with heartburn depends on how much society is willing to pay to achieve health improvements. Based on the commonly quoted threshold of US 50,000 dollars per QALY, the optimal primary care strategy for managing patients with moderate-to-severe heartburn symptoms is to treat the symptoms with a PPI followed by maintenance therapy with an H2RA to prevent symptomatic recurrence.

Canada↗
PubMedDate not supplied

Oseltamivir for treatment of influenza in healthy adults: pooled trial evidence and cost-effectiveness model for Canada.

BACKGROUND: Influenza is a common viral respiratory infection that is associated with significant morbidity. Oseltamivir (Tamiflu) is a neuraminidase inhibitor-a new class of antiviral treatment for influenza where efficacy and safety has been established but cost-effectiveness is unknown. METHODS: A decision analytic model was used to estimate the costs and effectiveness of two treatment scenarios for empiric management of otherwise healthy nonelderly patients, presenting with influenza-like illness (ILI) to primary care physicians in Canada: 1) where oseltamivir is reimbursed and on formulary for prescription; and 2) where oseltamivir is not on formulary. Outcomes are influenza-days averted and quality-adjusted life-years (QALYs) gained. Effectiveness, utility, and pneumonia complication risk estimates are by pooled analysis of patient-level data from four clinical trials. Unit cost information (Canadian dollars) was obtained from published sources in Ontario. Probabilistic sensitivity analysis was conducted using Monte Carlo simulation. RESULTS: Of 2288 patients randomized, influenza was confirmed in 1575 (69%) and oseltamivir treatment reduced the mean time to symptom alleviation by 1.08 days (95% confidence interval CI] 0.58-1.59). Infected patients treated with oseltamivir had higher utility scores (quality of life) than placebo patients over the 7 days of follow-up (P <.05). Cost per influenza-day averted with oseltamivir on formulary is 49 US dollars (95% CI 31-107) and the cost per QALY is 57,863 US dollars (95% CI 48,919- 70,149 US dollars). Results are sensitive to the percentage of patients presenting to their physician beyond 48 hours from symptom onset who get oseltamivir and the prevalence of influenza among patients presenting with ILI. CONCLUSIONS: Oseltamivir for treatment of patients with ILI is potentially cost-effective if clinical diagnostic specificity for influenza observed in clinical trials is applicable to routine practice. More population-based information on the prevalence of influenza among early (<48 hours) presenters with ILI would be valuable.

Acetamides↗
PubMedDate not supplied

A note on the estimation of confidence intervals for cost-effectiveness when costs and effects are censored.

BACKGROUND: The relation between methodological advances in estimation of confidence intervals (CIs) for incremental cost-effectiveness ratios (ICER) and estimation of cost effectiveness in the presence of censoring has not been explored. The authors address the joint problem of estimating ICER precision in the presence of censoring. METHODS: Using patient-level data (n = 168) on cost and survival from a published placebo-controlled trial, the authors compared 2 methods of measuring uncertainty with censored data: 1) Bootstrap with censor adjustment (BCA); 2) Fieller's method with censor adjustment (FCA). The authors estimate the FCA over all possible values for the correlation (rho) between costs and effects (range = -1 to + 1) and also examine the use of the correlation between cases without censoring adjustment (i.e., simple time-on-study) for costs and effects as an approximation for rho. RESULTS: Using time-on-study, which considers all censored observations as responders (deaths), yields 0.64 life-years gained at an additional cost of 87.9 for a cost per life-year of 137 (95% CI by bootstrap -5.9 to 392). Censoring adjustment corrects for the bias in the time-on-study approach and reduces the cost per life-year estimate to 132 (=72/0.54). Confidence intervals with censor adjustment were approximately 40% wider than the base-case without adjustment. Using the Fieller method with an approximation of rho based on the uncensored cost and effect correlation provides a 95% CI of (-48 to 529), which is very close to the BCA interval of (-52 to 504). CONCLUSIONS: Adjustment for censoring is necessary in cost-effectiveness studies to obtain unbiased estimates of ICER with appropriate uncertainty limits. In this study, BCA and FCA methods, the latter with approximated covariance, are simple to compute and give similar confidence intervals.

Confidence Intervals↗
PubMedDate not supplied

Probabilistic analysis of cost-effectiveness models: choosing between treatment strategies for gastroesophageal reflux disease.

When choosing between mutually exclusive treatment options, it is common to construct a cost-effectiveness frontier on the cost-effectiveness plane that represents efficient points from among the treatment choices. Treatment options internal to the frontier are considered inefficient and are excluded either by strict dominance or by appealing to the principle of extended dominance. However, when uncertainty is considered, options excluded under the baseline analysis may form part of the cost-effectiveness frontier. By adopting a Bayesian approach, where distributions for model parameters are specified, uncertainty in the decision concerning which treatment option should be implemented is addressed directly. The approach is illustrated using an example from a recently published cost-effectiveness analysis of different possible treatment strategies for gastroesophageal reflux disease. It is argued that probabilistic analyses should be encouraged because they have potential to quantify the strength of evidence in favor of particular treatment choices.

Bayes Theorem↗