Cost-Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation

ObjectivesWe sought to compare the cost-effectiveness of left atrial catheter ablation (LACA), amiodarone, and rate control therapy in the management of atrial fibrillation (AF).BackgroundLeft atrial catheter ablation has been performed to eliminate AF, but its cost-effectiveness is unknown.MethodsWe developed a decision-analytic model to evaluate the cost-effectiveness of LACA in 55- and 65-year-old cohorts with AF at moderate and low stroke risk. Costs, health utilities, and transition probabilities were derived from published literature and Medicare data. We performed primary threshold analyses to determine the minimum level of LACA efficacy and stroke risk reduction needed to make LACA cost-effective at $50,000 and$100,000 per quality-adjusted life-year (QALY) thresholds.ResultsIn 65-year-old subjects with AF at moderate stroke risk, relative reduction in stroke risk with an 80% LACA efficacy rate for sinus rhythm restoration would need to be ≥42% and ≥11% to yield incremental cost-effectiveness ratios (ICERs) <$50,000 and$100,000 per QALY, respectively. Higher and lower LACA efficacy rates would require correspondingly lower and higher stroke risk reduction for equivalent ICER thresholds. In the 55-year-old moderate stroke risk cohort, lower LACA efficacy rates or stroke risk reduction would be needed for the same ICER thresholds. In patients at low stroke risk, LACA was unlikely to be cost-effective.ConclusionsThe use of LACA may be cost-effective in patients with AF at moderate risk for stroke, but it is not cost-effective in low-risk patients. Our threshold analyses may provide a framework for the design of future clinical trials by providing effect size estimates for LACA efficacy needed

Informal Caregiving for Diabetes and Diabetic Complications Among Elderly Americans

Objectives: Little is known regarding the amount of time spent by unpaid caregivers providing help to elderly individuals for disabilities associated with diabetes mellitus (DM). We sought to obtain nationally representative estimates of the time, and associated cost, of informal caregiving provided to the elderly with diabetes, and to determine the complications of DM that contribute most significantly to the subsequent need for informal care. Methods: We estimated multivariable regression models using data from the 1993 Asset and Health Dynamics (AHEAD) Study, a nationally representative survey of people aged 70 or older (N=7,443), to determine the weekly hours of informal caregiving and imputed cost of caregiver time for community-dwelling elderly with and without a diagnosis of DM. Results: Those without DM received an average of 6.1 hours per week of informal care, those with DM taking no medications received 10.5 hours, those with DM taking oral medications received 10.1 hours, and those with DM taking insulin received 14.4 hours of care (P

Investigation Of Foam Stability On Injection Rate

The project is basically about simulation study to identify the effect of injection rate on the foam stability based on a foam model. Gas has properties of higher mobility ratio and very low density. Due to this properties, the gas tends moves upwards and override the oil zones causing less oil production. Foam flooding was introduced to avoid this gas overriding problem. The foam model was built based on reservoir rock properties and foam half-life parameter. The analysis were done focusing on injection rate, bottom-hole pressure and decaying rate of the foam over injection time. The model was run for 19 years with injector and producer wel

Systematic review with network meta‐analysis: the efficacy of anti‐ TNF agents for the treatment of Crohn's disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107372/1/apt12749.pd

Letter: biological drugs for inducing remission in ulcerative colitis – authors' reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106897/1/apt12724.pd

Letter: comparative efficacy of biological therapy in patients with ulcerative colitis – authors’ reply

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107370/1/apt12773.pd

Comparison of iron-sucrose with ferric carboxymaltose for treatment of postpartum iron deficiency anaemia

Background: Anaemia is a major public health problem worldwide. Haemoglobin (Hb) cut-off in anaemia should be taken as 11 gm/dl in the first and third trimester and 10.5 gm/dl in the second trimester, and a post-partum Hb of 10.0 gm/dl. The aim of the study is to compare the efficacy of iron-sucrose versus ferric carboxymaltose (FCM) in the treatment of postpartum anaemia.Methods: A prospective randomized interventional study of 132 post-partum females was conducted at a tertiary care hospital, over a 6-month period. Post-partum females delivered via normal vaginal delivery or caesarean section with Hb levels of above 7 gm/dl and below 9.9 gm/dl were randomized into 2 groups. Iron deficit calculated, in mg, according to Ganzoni’s formula. One group received intravenous FCM – 500 mg in 250 ml normal saline (NS) over 30 minutes and the other received intravenous iron sucrose - each ampoule containing 200 mg in 100 ml NS over 30 minutes up to a maximum dose of 1000 mg. Follow up done after 15 days, 4 weeks and 6 weeks. The data was tabulated and compared using statistical analysis.Results: At a 4 and 6 weeks follow up, the mean rise in hemoglobin (Hb) of group A (1.4 g/dl) was significantly greater than that of group B (0.89 g/dl).Conclusions: The study concludes that thought efficacy of drugs is similar, injection FCM shows a prompt rise in Hb, allows a higher dose to be dispensed in a single seating and is more significant in improving quality of life over a period of time even though it has a marginally higher cost

Cost-effectiveness analysis of 3-D computerized tomography colonography versus optical colonoscopy for imaging symptomatic gastroenterology patients.

BACKGROUND: When symptomatic gastroenterology patients have an indication for colonic imaging, clinicians have a choice between optical colonoscopy (OC) and computerized tomography colonography with three-dimensional reconstruction (3-D CTC). 3-D CTC provides a minimally invasive and rapid evaluation of the entire colon, and it can be an efficient modality for diagnosing symptoms. It allows for a more targeted use of OC, which is associated with a higher risk of major adverse events and higher procedural costs. A case can be made for 3-D CTC as a primary test for colonic imaging followed if necessary by targeted therapeutic OC; however, the relative long-term costs and benefits of introducing 3-D CTC as a first-line investigation are unknown. AIM: The aim of this study was to assess the cost effectiveness of 3-D CTC versus OC for colonic imaging of symptomatic gastroenterology patients in the UK NHS. METHODS: We used a Markov model to follow a cohort of 100,000 symptomatic gastroenterology patients, aged 50 years or older, and estimate the expected lifetime outcomes, life years (LYs) and quality-adjusted life years (QALYs), and costs (£, 2010-2011) associated with 3-D CTC and OC. Sensitivity analyses were performed to assess the robustness of the base-case cost-effectiveness results to variation in input parameters and methodological assumptions. RESULTS: 3D-CTC provided a similar number of LYs (7.737 vs 7.739) and QALYs (7.013 vs 7.018) per individual compared with OC, and it was associated with substantially lower mean costs per patient (£467 vs £583), leading to a positive incremental net benefit. After accounting for the overall uncertainty, the probability of 3-D CTC being cost effective was around 60 %, at typical willingness-to-pay values of £20,000-£30,000 per QALY gained. CONCLUSION: 3-D CTC is a cost-saving and cost-effective option for colonic imaging of symptomatic gastroenterology patients compared with OC

Patient preferences and willingness-to-pay for a home or clinic based program of chronic heart failure management: findings from the which? trial

BACKGROUND Beyond examining their overall cost-effectiveness and mechanisms of effect, it is important to understand patient preferences for the delivery of different modes of chronic heart failure management programs (CHF-MPs). We elicited patient preferences around the characteristics and willingness-to-pay (WTP) for a clinic or home-based CHF-MP. METHODOLOGY/PRINCIPAL FINDINGS A Discrete Choice Experiment was completed by a sub-set of patients (n = 91) enrolled in the WHICH? trial comparing home versus clinic-based CHF-MP. Participants provided 5 choices between hypothetical clinic and home-based programs varying by frequency of nurse consultations, nurse continuity, patient costs, and availability of telephone or education support. Participants (aged 71±13 yrs, 72.5% male, 25.3% NYHA class III/IV) displayed two distinct preference classes. A latent class model of the choice data indicated 56% of participants preferred clinic delivery, access to group CHF education classes, and lower cost programs (p<0.05). The remainder preferred home-based CHF-MPs, monthly rather than weekly visits, and access to a phone advice service (p<0.05). Continuity of nurse contact was consistently important. No significant association was observed between program preference and participant allocation in the parent trial. WTP was estimated from the model and a dichotomous bidding technique. For those preferring clinic, estimated WTP was ≈AU$9-20 per visit; however for those preferring home-based programs, WTP varied widely (AU$15-105). CONCLUSIONS/SIGNIFICANCE Patient preferences for CHF-MPs were dichotomised between a home-based model which is more likely to suit older patients, those who live alone, and those with a lower household income; and a clinic-based model which is more likely to suit those who are more socially active and wealthier. To optimise the delivery of CHF-MPs, health care services should consider their patients’ preferences when designing CHF-MPs.Jennifer A. Whitty, Simon Stewart, Melinda J. Carrington, Alicia Calderone, Thomas Marwick, John D. Horowitz, Henry Krum, Patricia M. Davidson, Peter S. Macdonald, Christopher Reid, Paul A. Scuffha

Probability of Achieving Glycemic Control with Basal Insulin in Patients with Type 2 Diabetes in Real-World Practice in the USA

Introduction: Basal insulin (BI) plays an important role in treating type 2 diabetes (T2D), especially when oral antidiabetic (OAD) medications are insufficient for glycemic control. We conducted a retrospective, observational study using electronic medical records (EMR) data from the IBM ® Explorys database to evaluate the probability of achieving glycemic control over 24 months after BI initiation in patients with T2D in the USA. Methods: A cohort of 6597 patients with T2D who started BI following OAD(s) and had at least one valid glycated hemoglobin (HbA1c) result recorded both within 90 days before and 720 days after BI initiation were selected. We estimated the changes from baseline in HbA1c every 6 months, the quarterly conditional probabilities of reaching HbA1c &lt; 7% if a patient had not achieved glycemic control prior to each quarter (Q), and the cumulative probability of reaching glycemic control over 24 months. Results: Our cohort was representative of patients with T2D who initiated BI from OADs in the USA. The average HbA1c was 9.1% at BI initiation, and decreased robustly (1.5%) in the first 6 months after initiation with no further reductions thereafter. The conditional probability of reaching glycemic control decreased rapidly in the first year (26.6% in Q2; 17.6% in Q3; 8.6% in Q4), and then remained low (≤ 6.1%) for each quarter in the second year. Cumulatively, about 38% of patients reached HbA1c &lt; 7% in the first year; only approximately 8% more did so in the second year. Conclusion: Our study of real-world data from a large US EMR database suggested that among patients with T2D who initiated BI after OADs, the likelihood of reaching glycemic control diminished over time, and remained low from 12 months onwards. Additional treatment options should be considered if patients do not reach glycemic control within 12 months of BI initiation. Funding: Sanofi Corporation. </p