New Perspectives on the Cost-Effectiveness of Palmaz-Schatzª Coronary Stenting, Balloon Angioplasty, and Coronary Artery Bypass Surgery Ñ A Decision Model Analysis.

We developed an outcomes model to compare both the clinical effects and cost-effectiveness of the following strategies for treating patients with single (SVD) and multi-vessel (MVD) coronary artery disease: coronary stent implantation (CSI), balloon angioplasty (PTCA), and coronary artery bypass surgery (CABG). These analyses have been carried out in five European countries: France, Germany, Italy, The Netherlands, and Spain, accounting for approximately 75% of revascularization procedures performed in Europe. This paper describes the methodology, details the model, discusses input data, and reports on clinical outcomes. Country-specific data and findings are reported in five ÒsatelliteÓ papers to this communication. The clinical outcomes predicted in our model are different from those of earlier studies in that we have found stenting to be clinically more superior to PTCA in terms of improving event-free survival than previously reported in SVD (89% vs. 75% at 1 year; 82% vs. 68% at 3 years). This is due to the clinical input data and expert estimates used, which consider the most recent advances in stent technology: heparin-coated stents, high-pressure post-stent dilatation, the replacement of anticoagulation with antiplatelet therapy, and a shortened length of hospital stay due to reduced complications. In MVD, CABG is the superior treatment strategy, with a predicted event-free survival of 90% at 3-years. MVD stenting is predicted to markedly improve patient outcomes as compared to PTCA, and is not far behind CABG (76% at 3 years).

Cost-Effectiveness of Palmaz-Schatzª Stenting for Patients with Coronary Artery Disease in France.

The increasing use of stent implantation in coronary artery disease raises economic concerns for health care decision-makers. This model analysis, which applies to the French health care system and uses the latest clinical and economic data, demonstrates coronary stent implantation (CSI) in single-vessel disease (SVD) to be clinically and economically superior to conventional balloon angioplasty (PTCA). Although the procedural cost for CSI remains higher than for PTCA (FF 19,500 vs. FF 12,400), this cost difference in the cath lab is decreased to approximately FF 4,800 during the in-hospital period due to avoided procedural complications and associated bail-out treatments. By the end of year one, the incremental cost of CSI is virtually recouped through savings in revascularization procedures (cost difference FF 150), and the result is maintained over subsequent years. this favorable cost outcome, combined with a higher rate of event-free patients, also improves the cost-effectiveness of CSI which has a 29.4%, 30.5% and 32.2% lower cost per event-free survivor than PTCA at the 1Ð, 2Ð and 3Ðyear follow-ups, respectively. In multi-vessel disease, CSI also appears to be a cost-effective alternative to CABG.

Cost-Effectiveness of Palmaz-Schatzª Stenting in Patients with Coronary Artery Disease in Germany.

The increasing use of stent implantation in coronary artery disease raises economic concerns for health care decision-makers. This model analysis, applying to the German health care system and using the latest clinical and economic data, demonstrates coronary stent implantation (CSI) in single-vessel disease (SVD) to be superior to conventional balloon angioplasty (PTCA). Although the procedural cost for CSI remains higher than for PTCA (DM 6,776 vs. DM 5,117), this cost difference in the cath lab is decreased to approximately DM 800 during the in-hospital period due to avoided procedural complications and associated bail-out treatments. By the end of year one, the incremental cost of CSI is more than recouped through savings in revascularization procedures, and the result is maintained over subsequent years. This favorable cost outcome, combined with a higher rate of event-free patients, also improves the cost-effectiveness of CSI, which has a 34.6%, 35.4%, and 36.8% lower cost per event-free survivor than PTCA at the 1-, 2-, and 3-year follow-ups, respectively. In multi-vessel disease, CSI also appears to be a cost-effective alternative to CABG.

Cost-Effectiveness of Palmaz-Schatzª Stenting for Patients with Coronary Artery Disease in Italy.

The increasing use of stent implantation in coronary artery disease raises economic concerns for health care decision-makers. This model analysis, which applies to the Italian health care system and uses the latest clinical and economic data, demonstrates coronary stent implantation (CSI) in single-vessel disease (SVD) to be clinically and economically superior to conventional balloon angioplasty (PTCA). Although the procedural cost for CSI remains higher than for PTCA (Lit. 7.5 million vs. Lit. 4.9 million), this cost difference in the cath lab is decreased to approximately Lit. 1.7 million during the in-hospital period due to avoided procedural complications and associated bail-out treatments. By the end of year one, the incremental cost of CSI is totally recouped through savings in revascularization procedures, and the result is maintained over subsequent years. This favorable cost outcome, combined with a higher rate of event-free patients, also improves the cost-effectiveness of CSI, which has a 30.2%, 31.2%, and 32.9% lower cost per event-free survivor than PTCA at the 1-, 2-, and 3-year follow-ups, respectively. In multi-vessel disease, CSI also appears to be a cost-effective alternative to CABG.

Cost-Effectiveness of Palmaz-Schatzª Stenting in Patients with Coronary Artery Disease in The Netherlands.

The increasing use of stent implantation in coronary artery disease raises economic concerns for health care decision-makers. This model analysis, applying to the Dutch health care system and using the latest clinical and economic data, demonstrates coronary stent implantation (CSI) in single-vessel disease (SVD) to be clinically and economically superior to conventional balloon angioplasty (PTCA). Although the procedural cost for CSI remains over NLG 3,300 higher than for PTCA (NLG 8,871 vs. NLG 5,510), this cost difference in the cath lab is decreased to approximately NLG 2,200 during the in-hospital period due to avoided procedural complications and associated bail-out treatments. By the end of year one, the incremental cost of CSI is virtually recouped (by over 90%) through savings in revascularization procedures, and this result is maintained over subsequent years. Combined with a higher rate of event-free patients, this virtual cost-equality improves the cost-effectiveness of CSI, which has a 27.8%, 29.4%, and 31.5% lower cost per event-free survivor than PTCA at the 1-, 2-, and 3-year follow-ups, respectively. In multi-vessel disease, CSI also appears to be a cost-effective alternative to CABG.

Cost-Effectiveness of Palmaz-Schatzª Stenting for Patients with Coronary Artery Disease in Spain.

The increasing use of stent implantation in coronary artery disease raises economic concerns for health care decision-makers. This model analysis, applying to the Spanish health care system and using the latest clinical and economic data, demonstrates coronary stent implantation (CSI) in single-vessel disease (SVD) to be clinically and economically superior to conventional balloon angioplasty (PTCA). Although the procedural cost for CSI remains higher than for PTCA (Ptas. 677,000 vs. Ptas. 436,000), this cost difference in the cath lab is decreased to approximately Ptas. 150,000 during the in-hospital period due to avoided procedural complications and associated bail-out treatments. By the end of year one, the incremental cost of CSI is more than recouped through savings in revascularization procedures, and this result is maintained over subsequent years. Combined with a higher rate of event-free patients, this cost-savings clearly improves the cost-effectiveness of CSI, which has a 31.1%, 32.0%, and 33.6% lower cost per event-free survivor than PTCA at the one-, two-, and three-year follow-ups, respectively. In multi-vessel disease, CSI also appears to be a cost-effective alternative to PTCA and perhaps CABG.

Results of a Meta-Analysis of Trapidil, a PDGF Inhibitor Ñ A Sufficient Reason for a Second Look to the Pharmacological Approach to Restenosis.

Restenosis in 30%Ð40% of patients remains the major limitation to the long-term success of balloon angioplasty (PTCA) in patients with coronary artery disease. So far, only coronary stent implantation has established its role as an effective strategy to prevent restenosis after PTCA. In contrast to numerous pharmacological strategies that all have failed to demonstrate a convincing reduction in the rate of restenosis, trapidil, a PDGF inhibitor, has shown promising and conclusive results in animal models as well as in three human trials published between 1992 and 1994. Although the results of the human trials showed trapidil to be capable of reducing restenosis after PTCA by 40%Ð53% compared to control patients, the compound is not well known and little used in interventional cardiology. Possible explanations for this situation may include trapidilÕs non-availability in the United States and most European countries, the small number of trapidil trials and treated patients, as well as a probable perception of the medical community that a pharmacological approach to restenosis prevention is unlikely to work. Additionally, clinical expert behavior has often shown not to be synchronized with accumulating evidence of efficacy. The results of this meta-analysis, however, demonstrate trapidilÕs efficacy. The rate of per-patient restenosis in the trapidil group was more than halved as compared to controls (odds ratio 0.44, 95% confidence interval 0.29Ð0.66). Tolerability with trapidil was good, and the rare adverse events observed included gastric intolerance, thrombocytopenia, headache, and increased serum AST and ALT levels which were transient or subsided with cessation of treatment.

Cost effectiveness of lumbar disc surgery and of a preventive treatment for peridural fibrosis.

STUDY DESIGN: This study used a retrospective modeling approach to predict the sequelae, treatment patterns, and economic outcomes that patients treated or not treated with ADCON-L Anti-Adhesion Barrier Gel can experience over a 1-year period following first-time surgery for herniated lumbar disc. The study was designed for and carried out in the Netherlands. OBJECTIVES: The study was carried out to investigate the economic impact of ADCON-L application in lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Patients with a poor outcome following primary lumbar disc surgery represent a medical challenge to physicians and an economic concern, as they often experience long-term sequelae. Patients who have failed to benefit adequately from primary surgery tend to be very expensive patients, receiving a costly array of conservative therapies, diagnostic measures and, sometimes, repeat surgery. METHODS: A Markov model was constructed to integrate the retrospectively assessed treatment patterns, economic outcomes, and costs of Dutch lumbar disc patients with the analysis of the benefits of ADCON-L as shown in a clinical study population derived from the preliminary results of a multicenter, randomized clinical trial of ADCON-L in Europe. RESULTS: Use of ADCON-L can recoup 20% of its proposed initial cost of NLG 1000 in direct health care savings during the first year after primary surgery. When indirect/societal as well as direct costs are considered, for every Dutch guilder invested in ADCON-L treatment, savings of NLG 1.8 are achieved. CONCLUSIONS: In patients treated with ADCON-L during lumbar discectomy, the quality of surgical outcome improves while cost per successful outcome is reduced.

Economic evaluation of immunoprophylaxis in children with recurrent ear, nose and throat infections.

This study compares the costs of immunoprophylaxis versus no immunoprophylaxis in children with recurrent ear, nose and throat (ENT) infections (otitis media and rhinopharyngitis) using ribosomal immunotherapy ('Ribomunyl'). The per-patient cost of ribosomal immunotherapy (FF297) is offset by direct savings garnered through the prevention of many acute infectious episodes. The net 6-month per-patient savings associated with immunoprophylaxis range from FF272 to FF1704, depending on the indication and the type of treatment-cost estimate. Saved healthcare resources include physician consultations and visits, laboratory tests, medicotechnical services (audiometric tests) and antibiotic therapy. Sensitivity analysis of efficacy and treatment-cost estimates enabled threshold ranges of incremental efficacy to be identified. Cost-equivalence between the 2 treatment options was found to exist when the incremental efficacy of immunoprophylaxis lay between 7.4 and 17.5% (recurrent otitis media), and between 8.9 and 26.1% (recurrent rhinopharyngitis). Thus, even when clearly lower incremental efficacy rates than those reported in controlled clinical trials (approximately 40 to 60%) are assumed, ribosomal immunotherapy can still be expected to be cost effective. An analysis of the perspectives of the various payers in the French healthcare system demonstrated that net savings occurred for all payers involved. However, social security insurance would gain most from an immunoprophylaxis programme. Based on the evidence presented here for France, physicians and payers should give increased attention to this treatment option.

A cost-comparison study: Ulobetasol versus clobetasol in severe localized psoriasis.

A computerized decision-tree model was used in a cost-comparison study of two ultra-high potency topical corticosteroids (ulobetasol and clobetasol) indicated for the initial treatment of acute attacks of severe localized psoriasis. Among the variable factors involved in this study were the different non-responder rates of the two preparations and the frequencies of the alternative treatments used for non-responders (PUVA, SUP, etretinate or dithranol). National standards for therapeutic procedures of the corticosteroid and alternative treatments used were compiled and assessed from an expert survey. Direct costs (consultations, medication, diagnostics, additional treatments) and indirect health expenditures (loss of productivity) were calculated. Results showed cost-effectiveness advantages for ulobetasol in the range 12-25%. Sensitivity analyses were carried out to test the reliability of these results further. The study revealed that a simple comparison of cost per dose is inadequate to assess fully and understand the socioeconomic dimensions of choices between alternative preparations. The study also underscored the increasing importance of comprehensive socioeconomic evaluations as aids to decision makers in the health-care field.

Marketing--putting it all together in a rural practice.

Marketing medical practices, whether in a metropolitan or rural area is a reality in today's competitive environment. This paper follows the development of a successful marketing plan for a rural medical group practice.