Costo-efectividad de los tratamientos de consolidación para la leucemia mieloide aguda en niños en riesgo alto en el sistema de salud colombiano / Cost-effectiveness of consolidation treatments for acute myeloid leukemia in high-risk pediatric patients within the Colombian healthcare system

Introducción. La leucemia mieloide aguda representa alrededor del 20 % de las leucemias en menores de 18 años. Actualmente, solo existen dos alternativas de tratamiento de consolidación: la quimioterapia y el trasplante con progenitores hematopoyéticos. Objeti vo. Evaluar el costo-efectividad del trasplante alogénico con progenitores hematopoyéticos de donantes emparentados o no emparentados, en comparación con la quimioterapia de consolidación en niños de alto riesgo con leucemia mieloide aguda. Materiales y métodos. Se construyó un árbol de decisiones utilizando los años de vida ganados como resultado. Los costos y probabilidades se extrajeron de estudios y reportes que se encuentran en la literatura científica. El umbral de costo-efectividad fue tres veces el producto interno bruto per cápita de 2010. Se hicieron análisis de sensibilidad univariados y probabilísticos, así como una curva de aceptabilidad. Resultados. Al comparar el trasplante de donante emparentado o no emparentado con los ciclos de quimioterapia, se obtuvieron tasas de costo-efectividad incremental de COP$ 9´226.421 (USD$ 4.820) y COP$ 6´544.116 (USD$ 3.419), respectivamente, cifras estas inferiores al producto interno bruto per cápita: COP$ 12´047.418 (USD$ 6.294). El trasplante resultó ser costo-efectivo en 70 % de las simulaciones y con mayor probabilidad de serlo cuando había disposición a pagar cantidades superiores a COP$ 7´200.000 (USD$ 3.762). Conclusión. El trasplante alogénico (emparentado o no) en Colombia resultó ser costo-efectivo frente al tratamiento de consolidación en niños de alto riesgo con leucemia mieloide aguda.

Introduction: Acute myeloid leukemia represents about 20% of leukemias in minors under 18 years old. At present, there are only two consolidation treatment alternatives: Chemotherapy and stem-cell transplantation. Objective: To evaluate the cost-effectiveness of unrelated and related hematopoietic stem cell transplantations, versus chemotherapy consolidation in pediatric patients with high-risk acute myeloid leukemia. Materials and methods: A decision tree was constructed with life-years gained as the outcome. Costs and probabilities were extracted from the literature. Probabilistic sensitivity analyses and acceptability curves were computed. The cost-effectiveness threshold was three times the 2010 per capita gross domestic product. Results: When compared to consolidation chemotherapy cycles, related and unrelated hematopoietic stem-cell transplantation had incremental cost-effectiveness ratios of COP$ 9,226,421 (USD$ 4,820) and COP$ 6,544,116 (USD$ 3,419) respectively, which are lower than the per capita gross domestic product (COP$ 12,047,418, USD$ 6,294). Transplant proved to be cost-effective in 70% of the simulations and had a higher probability of the willingness to pay being over than COP$ 7,200,000 (USD$ 3,762). Conclusion: In Colombia, related and unrelated hematopoietic stem-cell transplants are cost-effective alternatives to consolidation treatment for high-risk acute myeloid leukemia in pediatric patients.

Análise de custos do transplante alogênico de células-tronco hematopoiéticas: uma revisão integrativa / Análisis de costo del trasplante alogénico de células madre hematopoyéticas: una revisión integradora / Cost of hematopoietic stem cell’s allogeneic transplantation: an integrative review

Objective: Identifying what has been produced on cost analysis of allogeneic transplantation of hematopoietic stem cell. Method: It consists of an integrative review, where was done a search of studies on cost analysis in allogeneic transplantation. Results: There were found 265 articles, which, after application of inclusion and exclusion criteria, 13 articles, with twelve in English and two in Portuguese were selected. Eleven of these articles have made partial cost analysis, a study done systematic review of cost-effectiveness; one made economic evaluation of cost-effectiveness and cost evaluation study made about coverage for curative catheter in transplantation. Conclusion: There is a gap in the area of economic evaluation studies and the nurse should occupy this space, not only as a care manager, but also of cost.

Objetivo: Identificar o que se tem sido produzido sobre análise de custos do transplante alogênico de células tronco hematopoiéticas. Método: Consta de uma revisão integrativa, em que se fez a busca de estudos sobre análise de custos em transplante alogênico. Resultados: Foram encontrados 265 artigos dos quais após aplicação dos fatores de inclusão e exclusão foram selecionados 13 artigos, sendo 12 de língua inglesa e dois de língua portuguesa. Onze desses artigos fizeram análise parcial de custos, um estudo fez revisão sistemática sobre custo-efetividade, um fez avaliação econômica de custo-efetividade e um estudo fez avaliação de custo sobre cobertura para curativo de cateter no transplante. Conclusão: Existe uma lacuna na área de estudos de avaliação econômica e o enfermeiro deveria ocupar este espaço como gerenciador não só do cuidado, mas também de custos.

Objetivo: Identificar lo que se ha producido en el análisis de costos de trasplante de las células madre hematopoyéticas alogénicas. Método: Se trata de una revisión integradora, donde hizo la búsqueda de los estudios sobre el análisis de costos en el trasplante alogénico. Resultados: Se encontraron 265 artículos que después de la aplicación de criterios de inclusión y exclusión 13 artículos, con doce en Inglés y dos en Portugués fueron seleccionados. Once de estos artículos han hecho análisis parcial de los costos, un estudio realizado una revisión sistemática de la rentabilidad, una evaluación económica hecha de costo-efectividad y el estudio de evaluación de costos sobre la cobertura de catéter curativa en el trasplante. Conclusión: Existe un vacío en el área de estudios de evaluación económica y la enfermera debe ocupar este espacio, no sólo como gestora de la atención, sino también de costo.

Accesibilidad al trasplante de células progenitoras hematopoyéticas según entidades financiadoras de salud en Argentina, 2000-2010 / Accessibility to hematopoietic stem cell transplantatiion in Argentina, depending on health financing Instituion, 2000-2010

Introducción: Por su alto costo económico, la realización o no de un trasplante de células progenitoras hematopoyéticas(CPH) médicamente indicado puede depender sustancialmente del ente financiador. OBJETIVO: Determinar la accesibilidad diferencial al trasplante de CPH entre entes financiadores de salud. MÉTODOS: La muestra estuvo integrada por la Administración de Programas Especiales (APE), el Ente para el Financiamiento de Trasplante de Órganos (EFTO) y la Dirección de Asistencia Directa por Situaciones Especiales (DADSE). Se utilizó un diseño poblacional retrospectivo. El procesamiento de datos se realizó con el programa Excel, y la significación estadística se calculó con el programa Epi-Info, módulo StatCalc. RESULTADOS: Las diferencias entre DADSE, EFTO y APE no fueron relevantes estadísticamente. Sin embargo, en el desagregado de los datos internos de cada entidad, se comprobó que en la DADSE la tasa de uso provincial más alta es 24 veces superior a la menor y que en la APE la obra social con tasa más alta supera por 15 veces a la menor. Además, la población con seguro ajena a APE tiene un uso significativamente mayor. CONCLUSIONES: Existe una similitud en el uso entre poblaciones con y sin trabajo formal (APE y DADSE), lo que sugiere que el Estado compensa el déficit sociolaboral. Sin embargo, las profundas diferencias al interior de la DADSE y la APE, así como entre ésta y el resto de los seguros agrupados, evidencian una inequidad horizontal y alertan sobre la necesidad de evitar barreras de acceso vinculadas a los financiadores.

Introduction: Because of its high cost, the realization or not of a hematopoietic stem cell (HSC)transplantation could depend greatly on the financing institution. OBJECTIVE: To determine the difference in the degree of accessibility to HSC transplantation among health financing institutions. METHODS: The sample was composed by the Special Programs Administration (APE), the Organ Transplant Financing Institution (EFTO) of Buenos Aires Province and the Special Situations Direct Assistance Board (DADSE). A retrospective population based design was used. Data was processed using Excel. Statistical information was obtained through the Epi-Info software (StatCalc module). RESULTS: The differences between DADSE, EFTO and APE were statistically non-significant. However, data collected within each institution showed that in DADSE the highest usage ratefor a province is 24 times higher than the lowest one and that in APE the highest usage rate for a social health insuranceplan is 15 times higher than the lowest one. Population with health insurance other than APE shows a usage rate which issignificantly higher. CONCLUSIONS: There is no difference in theus age rate between populations with and without formal work (APE and DADSE), suggesting that the state compensates the socio-occupational deficit. How ever, the big differences within DADSE/APE, and between this one and other pooled entities, show a situation of horizontal inequity and high light the need to eliminate access difficulties due to financing institutions.

Predicting mortality and cost of hematopoeitic stem-cell transplantation / Preditores de mortalidade e custo de transplante de célula-tronco hematopoéticas

Objective: To evaluate whether the Pretransplantion Assesment of Mortality risk score is associated to transplant costs and can be used not only to predict mortality but also as a cost management tool. Methods: We evaluated consecutively patients submitted to allogeneic (n = 27) and autologous (n = 89) hematopoietic stem cell-transplantation from 2004 to 2006 at Hospital Israelita Albert Einstein (SP), Brazil. Participants mean age at hematopoietic stem cell-transplantation was 42 (range 1 to 72) years; there were 69 males and 47 females; 30 patients had multiple myeloma; 41 had non-Hodgkin and Hodgkin?s lymphomas; 22 had acute leukemia; 6 had chronic leukemia; and 17 had non-malignant disease. The Pretransplantion Assesment of Mortality risk score was applied in all patients using the available web site (http://cdsweb.fhcrc.org/pam/). Results: Patients could be classified in three risk categories: high, intermediate and low, having significant difference in survival (p = 0.0162). The median cost in US dollars for each group was $ 281.000, $ 73.300 and $ 54.400 for high, intermediate and low risk, respectively. The cost of hematopoietic stem cell-transplantation significantly differed for each Pretransplantin Assesment of Mortality risk group (p = 0.008). Conclusion: The validation of the Pretransplantion Assesment of Mortality risk score in our patients confirmed that this system is an important tool to be used in transplantation units, being easy to apply and fully reproducible.

Objetivo: Avaliar se o escore de risco Avaliação de Mortalidade Pré-Transplante está associado aos custos de transplante e pode ser usado não apenas para predizer a mortalidade, mas também como ferramenta de gerenciamento de custos. Métodos: Foram avaliados consecutivamente 27 pacientes submetidos a transplante alogênico e 89 a transplante autólogo de células tronco hematopoéticas no período de 2004 a 2006 no Hospital Israelita Albert Einstein (SP). A média de idade dos pacientes por ocasião do transplante foi de 42 anos (variação de 1 a 72 anos); 69 eram do gênero masculino e 47 feminino; 30 pacientes tinham mieloma múltiplo, 41 linfoma não Hodgkin e linfoma de Hodgkin; 22 tinham leucemia aguda; 6 tinham leucemia crônica; e 17 doença não maligna. O escore de risco Avaliação de Mortalidade Pré-Transplante foi aplicado a todos os pacientes usando um web site fornecido pelos autores (http://cdsweb.fhcrc.org/pam/). Resultados: Classificaram-se os pacientes em três categorias de risco: alto, intermediário e baixo, apresentando diferença significativa de sobrevivência (p = 0,0162). O custo médio, em dólares, foi de U$ 281.000, U$ 73.300 e U$ 54.400 para risco alto, intermediário e baixo, respectivamente. O custo do transplante de células tronco hematopoéticas diferiu significantemente para cada grupo de risco segundo o escore Avaliação de Mortalidade Pré-Transplante (p = 0,008). Conclusão: A validação do escore de risco Avaliação de Mortalidade Pré-transplante em nossos pacientes confirmou que esse sistema é uma importante ferramenta a ser usada em unidades de transplante, sendo facilmente aplicável e inteiramente reprodutível.

Cost analysis of hematopoietic stem cell transplantation in adult patients with acute myeloid leukemia at King Chulalongkorn Memorial Hospital.

The purpose of the study was to analyze the first-year cost ofhematopoietic stem cell transplantation (HSCT) program for the treatment of adult patients with acute myeloid leukemia (AML) at King Chulalongkorn Memorial Hospital (KCMH). The present retrospective study was carried out on 67 AML patients treated with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT) at KCMH during the period of 1994 to 2005. The actual total one-year cost from the provider perspective were determined by the reviewing medical records for medical care costs (MCCs) and by adjusting data from the reports of annual cost analysis of KCMH for routine services costs (RSCs). All costs were converted to 2006 values using the Thai consumer price indices. It was found that the full cost of allogeneic HSCT (allo-HSCT) and autologous HSCT (auto-HSCT) in the first year of the program was $22,592.85 and $24,171.25 per case respectively. Cost-effective appraisal, comparing with chemotherapy, need to be studied further.

Delayed administration of G-CSF in both mobilization and post transplantation in autologous peripheral blood stem cell transplantation.

Granulocyte colony stimulating factors (G-CSFs) play a very important role in the current technique of stem cell transplantation. The conventional timing of administration of G-CSF in both mobilization and post transplantation has been right after chemotherapy or right after transplantation. We have studied the effects of timing of administration of G-CSF in 21 patients who had autologous stem cell transplantation for breast cancer, lymphoma or nasopharyngeal cancer. Their stem cells were mobilized by chemotherapy followed by G-CSF, which were given on day +1 or day +5 after chemotherapy. The median peak percentage of CD34 positive cells harvested using both technique were 1.88 and 0.48% respectively. After transplantation, G-CSF were given on day +1 or day +6 after stem cell infusion until neutrophil recovery. The time until bone marrow recovery was significantly longer in the group with delayed administration of G-CSF (10 days versus 8 days). However, there was no difference in duration of neutropenic fever or hospital stay after transplantation. The transplantation outcome was also unaffected. We therefore concluded that G-CSF can be given in the delayed fashion in both mobilizing and post transplantation settings without jeopardizing the outcome and this would result in a significant cost saving.