Análisis coste-efectividad de distintos métodos de dagnóstico por imagen del tromboembolismo pulmonar agudo / Cost-Effectiveness Analysis of Different Imaging for the Diagnosis of Acute Pulmonary Embolism

Fundamento. La técnica diagnóstica óptima para detectar tromboembolismo pulmonar agudo (TEP) continúa en discusión. La gammagrafía pulmonar de ventilación/perfusión ha sido el examen preferido durante décadas, pero con el advenimiento de nuevas pruebas de imágenes las posibilidades diagnósticas se ampliaron, siendo necesario evaluarlas desde la perspectiva del coste y de la efectividad. El objetivo de este trabajo fue evaluar distintos métodos de diagnóstico por imagen para detectar TEP agudo para determinar el más coste-efectivo.Métodos. Análisis de coste-efectividad (CE) empleando un árbol de decisiones para modelar distintas pruebas (centellograma V/Q, TC helicoidal, angiografía por tomografía computada multidetector (TCMD), resonancia magnética por imágenes (RMI) y arteriografía convencional). Se obtuvieron valores de sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN) de las pruebas diagnósticas. Resultado medido: “caso detectado de TEP”. Los costes evaluados fueron los directos, expresados en euros (t), incluyendo los secundarios a las complicaciones de los métodos diagnósticos. Se realizó un análisis de sensibilidad de una vía para evaluar la robustez de las conclusiones.Resultados. No se eliminaron pruebas por dominancia extendida. La tasa cruda de CE para TCMD fue de 486 t por cada caso de TEP detectado. El coste marginal entre la TC helicoidal y el centellograma V/Q fue de 103 t para detectar 8 casos adicionales de TEP, mientras que el coste marginal entre la TCMD y la TC helicoidal fue de 229 t para detectar un caso adicional de TEP.Conclusiones. La prueba diagnóstica más coste-efectiva fue la TCMD, hallazgo que mostró robustez en el análisis de sensibilidad. Sin embargo, el análisis de C-E incremental nos mostró que la TCMD costó 229 t más respeto a la TC helicoidal para lograr una mínima mejora en la efectividad de la prueba (detección de TEP agudo) (AU)

acute pulmonary embolism (APE) is still under discussion. The ventilation /perfusion scanning has been the preferred examination for several decades, but with the development of new tests the diagnostic posibilities have increased. It is necessary to evaluate them from the cost-effectiveness perspective. The goal of this study was to evaluate several methods of imaging diagnosis so as to determine the most cost-effective for detecting APE.Methods. Cost-effectiveness (CE) analysis using a decision tree to model various diagnostic test (V/Q lung scan, spiral CT, angiography by MDCT, MRI and conventional arteriography). Sensitivity and specificity values, and positive and negative predictive values of diagnostic tests were calculated. Expected outcome: “new APE case detected.” The direct costs were evaluated in Euros (t), including the secondary complications of diagnostic methods. To assess the robustness of the findings, a one way sensitivity analysis was performed.Results. The most cost-effective diagnostic test was angiography by MDCT. No diagnostic test were eliminated by extended dominance. The crude rate of CE for MDCT was ¤ 486 t per case of APE detected. The marginal cost between spiral CT and V / Q lung scan was t 103 for 8 cases of APE detected additionally, while the marginal cost between MDCT and spiral CT was 229 t to detect an additional case of APE.Conclusions. The most cost-effective diagnostic test was the MDCT; this finding showed to be robust in relationship to sensitivity, specificity and costs changes. However, the incremental C-E analysis showed that MDCT was capable to detect only one additional case of APE than spiral CT, with an incremental cost of 229 t. When peripheral branches are affected, high negative predictive value of the MDCT justify its conduct (AU)

[Mortality rate trends for breast cancer in Rosario, Argentina. Association with socioeconomic factors]. / Evolución de las tasas de mortalidad por cáncer de mama en Rosario, Argentina. Asociación con factores socioeconómicos.

This report is based on data from death certificates of all women whose cause of death was breast cancer, residents in Rosario City, during two 5-year-periods: 1977-81 and 1988-92, in order to know these rates evolution. Deaths, which were allocated to the last residence of the decedents, were aggregated into the 22 census areas of the city. Age-standardized mortality rates (SMR) by area were correlated with socioeconomic variables. The SMR for the whole city was not different in the two studied periods: 38%000 and 36%000, respectively. However, while small changes were found in the high socioeconomic areas, important increments were found in the poorest ones, mainly in postmenopausal women. Consequently, geographic correlations also changed between the two studied periods. While in the first period negative correlations were found with variables considered as socioenvironmental pointers, such as fertility and infant mortality rates, these associations were positive in the last one.