Analisi di costo-efficacia della terapia combinata con pioglitazone nel trattamento del diabete mellito di tipo 2 in Italia

Analyzing cost-effectiveness of neural-monitoring in recurrent laryngeal nerve recovery course in thyroid surgery

PURPOSE

The increasing use of intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery imposes an evaluation of cost-effectiveness.

METHODS

The analysis estimated the cost versus utility of different alternatives that simulate nerve injury course and the consequences for the following cohorts of patients: (1) no RLN injury, or vocal fold palsy (VCP) recovery within 1 month (2), 2 months (3), 6 months (4), and after 12 months (5). In the model applied, the average simulated cohort consisted of a young female patient, 40 years old, employed, daily voice user, who underwent elective, conventional total thyroidectomy via cervical incision using a standardized intermittent IONM technique, for an operable benign, bilateral, diffuse, multinodular, non-toxic, non-retrosternal goiter.

RESULTS

IONM was cost-ineffective when parameters such as the rates of transient vocal fold palsy (VCP) reached 38.5%. IONM was cost-effective if the rate of VCP was 33.6% at 1 month, 22.9% at 2 months, 9.8% at 6 months, and 3.8% at 12 months, independent of phono-surgery. The described scenario is cost-effective only in a high-volume setting.

CONCLUSIONS

This study used simulation economic modeling to assess clinical and cost-effectiveness utility of IONM implementation. In light of the limitations of a simulation-based study, we conclusively assumed that IONM is cost-effective for permeant RLN injuries.

Recurrent laryngeal nerve injury in thyroid surgery: Clinical pathways and resources consumption

BACKGROUND

The impact of recurrent laryngeal nerve (RLN) injury management in thyroid surgery seems to be relevant to patients, National Healthcare System (NHS), and society.

METHODS

We studied resource consumption in the management of patients with RLN injury versus noninjured patients investigating 3 perspectives (patients, NHS, and society) in 5 clinical pathways.

RESULTS

Direct medical costs supported by the NHS range from a minimum of euro (€) 79.46 to a maximum of € 3261.95. From the patient's perspective, the direct medical costs supported by the patient increased from a minimum of € 3.60 to a maximum of € 499.45. Productivity losses were accounted in € 156 per day per patient. From the NHS perspective, the percentage increase ranged from 43.25% to 98.14%. From the patient's perspective, it ranged from 51.52% to 80.60%.

CONCLUSION

The analysis shows a significant economic impact of RLN injury management, which varies depending on the damage, duration, and severity. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Incremental costs associated with myocardial infarction and stroke in patients with type 2 diabetes mellitus: an overview for economic modeling

OBJECTIVE

To identify cost estimates related to myocardial infarction (MI) or stroke in patients with type 2 diabetes mellitus (T2DM) for use in economic models.

METHODS

A systematic literature review was conducted. Electronic databases and conference abstracts were screened against inclusion criteria, which included studies performed in patients who had T2DM before experiencing an MI or stroke. Primary cost studies and economic models were included. Costs were converted to 2012 pounds sterling.

RESULTS

Fifty-four studies were identified: 13 primary cost studies and 41 economic evaluations using secondary sources for complication costs. Primary studies provided costs from 10 countries. Estimates for a fatal event ranged from £2482-£5222 for MI and from £4900-£6694 for stroke. Costs for the year a non-fatal event occurred ranged from £5071-£29,249 for MI and from £5171-£38,732 for stroke. Annual follow-up costs ranged from £945-£1616 for an MI and from £4704-£12,926 for a stroke. Economic evaluations from 12 countries were identified, and costs of complications showed similar variability to the primary studies.

DISCUSSION

The costs identified within primary studies varied between and within countries. Many studies used costs estimated in studies not specific to patients with T2DM. Data gaps included a detailed breakdown of resource use, which affected the ability to compare data across countries.

CONCLUSIONS

In the development of economic models for patients with T2DM, the use of accurate estimates of costs associated with MI and stroke is important. When country-specific costs are not available, clear justification for the choice of estimates should be provided.

An economic evaluation based on a randomized placebo-controlled trial of varenicline in smokers with cardiovascular disease: results for Belgium, Spain, Portugal, and Italy

BACKGROUND

An estimated 17.2% of patients continue to smoke following diagnosis of cardiovascular disease (CVD). To reduce the risk of further morbidity or mortality in cardiovascular patients, smoking cessation has been shown to reduce the risk of mortality by 36% and myocardial infarction by 32%. The objective of this study was to evaluate the long-term health and economic consequences of smoking cessation in patients with CVD.

DESIGN AND METHODS

Results of a randomized clinical trial comparing varenicline plus counselling vs. placebo plus counselling were extrapolated using a Markov model to simulate the lifetime costs and health consequences of smoking cessation in patients with stable CVD. For the base case, we considered a payer's perspective including direct costs attributed to the healthcare provider, measuring cumulative life years (LY) and quality adjusted life (QALY) years as outcome measures. Secondary analyses were conducted from a societal perspective, evaluating lost productivity due to premature mortality. Sensitivity and subgroup analyses were also undertaken. Results were analysed for Belgium, Spain, Portugal, and Italy.

RESULTS

Varenicline plus counselling was associated with a gain in LY and QALY across all countries; relative to placebo plus counselling. From a payer's perspective, incremental cost effectiveness ratios were € 6120 (Belgium), € 5151 (Spain), € 5357 (Portugal), and € 5433 (Italy) per QALY gained. From a societal perspective, varenicline in addition to counselling was less costly than placebo and counselling in all cases. Sensitivity analyses showed little sensitivity in outcomes to model assumptions or uncertainty in model parameters.

CONCLUSIONS

Varenicline in addition to counselling is cost-effective compared to placebo and counselling in smokers with CVD.

Sacral neuromodulation for the treatment of fecal incontinence: analysis of cost-effectiveness

PURPOSE

The cost-effectiveness and budget impact of introducing sacral nerve modulation (SNM) as a treatment for fecal incontinence in Italy were evaluated in a simulation model.

METHODS

A decision-analysis model with a Markov submodel was used to represent clinical pathways for treatment of patients with fecal incontinence in a scenario with SNM and a scenario without SNM. Data were obtained from published studies and from an expert panel. Evaluation of resource consumption was conducted from the perspective of the Italian National Health Service, and costs were retrieved from the Italian NHS procedures reimbursement list. The time horizon was 5 years, and a 3% discount rate was applied to costs and outcomes. Effectiveness was measured in symptom-free years and in quality-adjusted life-years (QALYs). Fecal incontinence prevalence data and SNM usage forecasts were used to estimate budget impact over the next 5 years.

RESULTS

The incremental cost-effectiveness ratio for introducing SNM was €28,285 per QALY gained for patients with a structurally deficient anal sphincter and €38,662 per QALY gained for patients with intact anal sphincters. If a threshold of €40,000 per QALY gained is set as the level that a decision-maker would regard as cost-effective, the probability that the introduction of SNM will be cost-effective would be 99% for patients with a structurally deficient sphincter and 53% for patients with an intact sphincter. Budget impact analysis showed that introducing SNM would have an estimated budget impact of 0.56% over 5 years on the budget allocated for fecal incontinence treatment.

CONCLUSION

Our data show SNM to be an efficient investment with an acceptable incremental cost-effectiveness ratio and a limited impact on the total allocated budget for fecal incontinence.

Health-economic evaluation of three imaging strategies in patients with suspected colorectal liver metastases: Gd-EOB-DTPA-enhanced MRI vs. extracellular contrast media-enhanced MRI and 3-phase MDCT in Germany, Italy and Sweden

The purpose of this study was to perform an economic evaluation of hepatocyte-specific Gd-EOB-DTPA enhanced MRI (PV-MRI) compared to extracellular contrast-media-enhanced MRI (ECCM-MRI) and three-phase-MDCT as initial modalities in the work-up of patients with metachronous colorectal liver metastases. The economic evaluation was performed with a decision-tree model designed to estimate all aggregated costs depending on the initial investigation. Probabilities on the need for further imaging to come to a treatment decision were collected through interviews with 13 pairs of each a radiologist and a liver surgeon in Germany, Italy and Sweden. The rate of further imaging needed was 8.6% after initial PV-MRI, 18.5% after ECCM-MRI and 23.5% after MDCT. Considering the cost of all diagnostic work-up, intra-operative treatment changes and unnecessary surgery, a strategy starting with PV-MRI with 959 Euro was cost-saving compared to ECCM-MRI (1,123 Euro) and MDCT (1,044 Euro) in Sweden. In Italy and Germany, PV-MRI was cost-saving compared to ECCM-MRI and had total costs similar to MDCT. In conclusion, our results indicate that PV-MRI can lead to cost savings by improving pre-operative planning and decreasing intra-operative changes. The higher cost of imaging with PV-MRI is offset in such a scenario by lower costs for additional imaging and less intra-operative changes.