Health care costs of peritoneal dialysis technique failure and dialysis modality switching.

BACKGROUND: Although there is a strong economic rationale in favor of peritoneal dialysis (PD) over hemodialysis (HD), the potentially costly effect of PD technique failure is an important consideration in PD program promotion that is unknown. STUDY DESIGN: Incident dialysis patients were categorized by initial and subsequent modality changes during the first year of dialysis and tracked for inpatient and outpatient costs, physician claims, and medication costs for 3 years using merged administrative data sets. We determined unadjusted and adjusted total cumulative costs for each modality group using multivariable linear regression models. SETTING & PARTICIPANTS: All incident dialysis patients from Alberta in 1999-2003. OUTCOMES: 3-year mean adjusted total cumulative costs. MEASUREMENTS: Mean direct health care costs by modality group determined using patient-level resource utilization data. RESULTS: 3-year adjusted total cumulative costs for patients in the PD-only and HD-to-PD groups were $58,724 (95% CI, $44,123-$73,325) and $114,503 (95% CI, $96,318-$132,688), respectively, compared with $175,996 (95% CI, $134,787-$217,205) for HD only. PD technique failure was associated with lower costs by $11,466 (95% CI, $248-$22,964) at 1 year compared with HD only; however, costs were similar at 3 years. Costs drivers in PD technique failure arose primarily from costs of dialysis provision, hospitalization, medications, and physician fees. LIMITATIONS: This analysis is taken from the perspective of the health payer, and costs that are outside the health care system are not measured. CONCLUSIONS: Compared with patients who receive only HD, those who received PD only and those who transitioned from HD to PD therapy had significantly lower total health care costs at 1 and 3 years. Patients experiencing PD technique failure had costs similar and not in excess of HD-only patients at 3 years, further supporting the economic rationale for a PD-first policy in all eligible patients.

Economic analysis of epoetin alfa in critically ill trauma patients.

BACKGROUND: Recent randomized control trials (RCTs) suggest that epoetin alfa reduces mortality in critically ill trauma patients; however, epoetin alfa is also costly and associated with adverse events. This study evaluates the cost-effectiveness of epoetin alfa in surgical trauma patients in an intensive care unit setting. METHODS: We constructed a decision analytic model to compare adjunctive use of epoetin alfa with standard care in trauma patients from the perspective of a Canadian payer. Baseline risks of events, relative efficacy, and resource use were obtained from RCTs and observational studies. One-way and probabilistic sensitivity analyses were conducted and longer time horizons explored through Markov models. RESULTS: Epoetin alfa was associated with a cost per quality-adjusted life year (QALY) gained of $89,958 compared with standard care at 1 year. One-way sensitivity analyses indicated that results were sensitive to plausible ranges of mortality risk, risk of thrombosis, relative risk of mortality, relative risk of thrombosis, and quality of life estimates. Cost-effectiveness acceptability curves generated from probabilistic sensitivity analysis indicated that the probability that epoetin alfa would be considered attractive ranged from 0% to 85% over a willingness-to-pay range of $25,000 to $120,000/QALY. Consideration of lifetime time horizons reduced the cost per QALY gained to $7,203, but results were sensitive to the effect of epoetin alfa on mortality. CONCLUSION: Although the cost per QALY gained with epoetin alfa use may fall into an acceptable range, there is significant uncertainty about its true cost-effectiveness. If data regarding long-term efficacy and safety are confirmed in future trials, epoetin alfa could potentially be cost-effective in this population. LEVEL OF EVIDENCE: Economic analysis, level I.

The use of complementary and alternative medicines among patients with locally advanced breast cancer--a descriptive study.

BACKGROUND: Complementary and alternative medicine (CAM) use is common among cancer patients. This paper reviews the use of CAM in a series of patients with locally advanced breast cancer (LABC). METHODS: Women with LABC attending a specialist clinic at a single Canadian cancer centre were identified and approached. Participants completed a self-administered survey regarding CAM usage, beliefs associated with CAM usage, views of their risks of developing recurrent cancer and of dying of breast cancer. Responses were scored and compared between CAM users and non-users. RESULTS: Thirty-six patients were approached, 32 completed the questionnaire (response rate 89%). Forty-seven percent of LABC patients were identified as CAM users. CAM users were more likely to be younger, married, in a higher socioeconomic class and of Asian ethnicity than non-users. CAM users were likely to use multiple modalities simultaneously (median 4) with vitamins being the most popular (60%). Motivation for CAM therapy was described as, "assisting their body to heal" (75%), to 'boost the immune system' (56%) and to "give a feeling of control with respect to their treatment" (56%). CAM therapy was used concurrently with conventional treatment in 88% of cases, however, 12% of patients felt that CAM could replace their conventional therapy. Psychological evaluation suggests CAM users perceived their risk of dying of breast cancer was similar to that of the non-Cam group (33% vs. 35%), however the CAM group had less severe anxiety and depression. CONCLUSION: The motivation, objectives and benefits of CAM therapy in a selected population of women with LABC are similar to those reported for women diagnosed with early stage breast cancer. CAM users display less anxiety and depression and are less likely to believe they will die of their breast cancer. However the actual benefit to overall and disease free survival has yet to be demonstrated, as well as the possible interactions with conventional therapy. Consequently more research is needed in this ever-growing field.