Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective.

Objectives: Atrial fibrillation (AF) is the most common arrhythmia and a major marker of ischemic stroke risk. Early detection is crucial and, once diagnosed, anticoagulation therapy can be initiated to reduce stroke risk. The aim of this study was to assess the cost-effectiveness of employing an insertable cardiac monitor (ICM), BIOMONITOR, for the detection of AF compared to standard of care (SoC) ECG and Holter monitoring in patients with cryptogenic stroke, that is, stroke of unknown origin and where paroxysmal, silent AF is suspected. Materials and methods: A Markov model was developed which consisted of five main health states reflecting the potential lifetime evolution of the AF disease: post cryptogenic stroke (index event), subsequent mild, moderate and severe stroke, and death. Sub-states were included to track a patient's AF diagnostic status and the use of antiplatelet or anticoagulant therapy. AF detection was assumed to result in a treatment switch from aspirin to anticoagulants, except among those with a history of major bleeding. Detection yield and accuracy, clinical actions and treatment effects were derived from the literature and validated by an expert clinician. All relevant costs from a US Medicare perspective were included. Results and conclusions: An ICM-based strategy was associated with a reduction of 37 secondary ischemic strokes per 1000 patients monitored compared with SoC. Total per-patient costs with an ICM were higher (US$90,052 vs. US$85,157) although stroke-related costs were reduced. The use of an ICM was associated with a base-case incremental cost-effectiveness ratio of US$18,487 per life year gained compared with SoC and US$25,098 per quality-adjusted life year gained, below established willingness-to-pay thresholds. The conclusions were found to be robust over a range of input values. From a US Medicare perspective the use of a BIOMONITOR ICM represents a cost-effective diagnostic strategy for patients with cryptogenic stroke and suspected AF.

Clopidogrel versus aspirin in patients with atherothrombosis: CAPRIE-based calculation of cost-effectiveness for Germany.

OBJECTIVES: To model the 2-year cost-effectiveness of secondary prevention with clopidogrel versus aspirin (acetylsalicylic acid) (ASS) in German patients with myocardial infarction (MI), ischaemic stroke (IS) or diagnosed with peripheral arterial disease (PAD), based on CAPRIE trial data and from the perspective of German third party payers (TPP). METHODS: An existing Markov model was adapted to Germany by using German cost data. The model was extended by using different datasets for cardiovascular event survival times (Framingham vs. Saskatchewan health databases) and in two separate scenarios. RESULTS: The treatment with clopidogrel leads to a reduction of 13.19 vascular events per 1000 patients, of which 2.21 are vascular deaths. The overall incremental costs for the 2-year management of atherothrombotic patients with clopidogrel instead of ASS are calculated to be about euro1 241 440 per 1000 patients. The number of life-years saved (LYS) has been calculated as the difference in the number of life-years lost due to vascular death or events with ASS versus clopidogrel: it is 86.35 LYS when analysis is based on Framingham data and 66.07 LYS with Saskatchewan-based survival data. The incremental costs per LYS are euro14 380 and euro18 790, respectively. Cost-effectiveness is sensitive to changes in survival data, discounting and daily costs of clopidogrel, but stable against substantial (+/- 25%) changes in all other cost data. CONCLUSION: The findings for Germany are in line with published results for Belgium (euro13 390 per LYS) and also with results for Italy (euro17 500 per LYS), both based on Saskatchewan data, and with a French analysis based on Framingham data (euro15 907 per LYS). Even if no officially accepted cost-effectiveness threshold exists for Germany at present, incremental cost-effectiveness results of less than euro20 000 per LYS for the treatment with clopidogrel can be assumed to be acceptable for German third party payers.

Cost of illness of atopic asthma and seasonal allergic rhinitis in Germany: 1-yr retrospective study.

The purpose of this study was to evaluate the cost of illness of moderate-to-severe atopic asthma and/or seasonal allergic rhinitis (SAR) in Germany from the perspective of third-party payers (TPP) and patients. Five-hundred patients (276 children/adolescents) with moderate-to-severe asthma and/or SAR were included in this cross-sectional study. Information was collected using a specific patient questionnaire and the abstraction of patient records. Overall, annual costs per patient increased with the severity of atopic asthma and if it was associated with SAR. The average annual cost of SAR was Euro1,089 per child/adolescent and Euro1,543 per adult. Annual costs of severe asthma plus SAR increased to Euro7,928 per child/adolescent and to Euro9,287 per adult. For TPPs, the main cost drivers were medication, hospitalisation, and rehabilitation. The most significant costs for patients were household modifications. For children/adolescents, 60-78% of the expenditures were direct costs, while in adults, 58% of expenditures were indirect costs. It was also observed that patients with moderate and severe asthma used inhaled corticosteroids less frequently than recommended by treatment guidelines. In summary, the total cost for patients increases with the severity of atopic asthma and/or seasonal allergic rhinitis and indirect costs represent a large proportion of the total cost.

Evaluation of healthcare utilization and health status of patients with Parkinson's disease treated with deep brain stimulation of the subthalamic nucleus.

OBJECTIVE: To assess the effects on motor functioning, health status and direct medical costs of high-frequency stimulation of the subthalamic nucleus (DBS-STN) in patients with idiopathic Parkinson's disease (PD). In addition, the cost-effectiveness of DBS-STN vs. drug treatment was investigated. METHODS: 16 consecutive patients with PD from two centers (Düsseldorf/Cologne; Kiel) treated by DBS-STN were prospectively evaluated. Clinical evaluations were done at baseline and 1, 3, 6, 12 months following surgery by means of the Unified Parkinson's disease Rating Scale (UPDRS). Health status of PD patients was assessed using the Sickness Impact Profile (SIP) at baseline and 6 months following surgery. Relevant economic data were taken from the medical records and costs (1999) were derived from different German medical economic resources. Costs were determined from the perspective of the health care provider. RESULTS: Following DBS-STN UPDRS scores (subscores and sum score) as well as health status improved considerably in PD patients. The overall SIP score and the physical dimension score (p < 0.009) were significantly different (p < 0.01) six month after surgery compared with baseline values. Mean costs of DM 40,020 (US dollars 20,810, EURO 20,410, GB pounds 12,810) per patient were spent during the 12 month observation period for in-patient and out-patient care. These expenses included already the costs for the electronic device for bilateral stimulation. Following DBS-STN medication was considerably reduced. Mean daily drug costs at baseline were DM 46.7+/-21.8 (US dollars 24, EURO 24, GB pounds 15) and DM 18.3+/-17.7 (US dollars 10, EURO 9, GB pounds 6) at 12 months following DBS-STN. Accounting for the decreased drug consumption, total annual costs amounted to DM 31,400 (US dollars 16,330, EURO 16,010, GB pounds 10,050). Further, we estimated the incremental cost effectiveness as DBS-STN had higher costs but was more effective than baseline treatment. The incremental total cost-effectiveness ratio for DBS-STN was DM 1.800 (US dollars 940, EURO 920, GB pounds 580) for one point decrease of the UPDRS. CONCLUSION: DBS-STN is an effective treatment that considerably alleviates the severity of signs and symptoms and improves the health status of patients with PD. Compared with drug treatment, however, the expenditures associated with DBS-STN are increased when only direct medical costs are considered in a one year horizon. However, on a long-term basis costs will decrease considerably because of the reduction of the drug expenditure and improved functioning in all activities of daily living. To adequately evaluate the cost-effectiveness of DBS-STN compared with standard drug regimen for PD it is necessary to include direct, indirect and intangible costs on a long-term basis and under standardized circumstances.

[Costs of intensive insulin therapy in type 1 diabetes mellitus. Experiences from the DCCT study]. / Kosten der intensivierten Insulintherapie bei Diabetes mellitus Typ 1. Erfahrungen aus der DCCT-Studie.

Diabetes mellitus is one of the most common metabolic diseases in many countries of the world. Its prevalence in Germany has increased 7- to 8-fold over the past 30 years. The clinical and economical importance of diabetes is determined by the frequent occurrences of such serious complications as neuropathy, retinopathy and nephropathy. Intensive insulin therapy with regular monitoring of blood glucose (up to 4 measurements daily) and adjustment of the insulin dose accordingly may achieve virtually normal levels of blood glucose and thus decrease the risk of these complications. The present cost-effectiveness-study shows that the higher costs of invasive insulin therapy are offset by savings of 8.114 German marks per patient resulting from the reduction in morbidity and mortality. On the basis of an estimated 5% to 10% type 1 diabetes among the total diabetic population (prevalence 4.9%), potential saving of 1.62 to 3.24 billion marks are calculated for Germany.

[Economic evaluation of various hepatitis B vaccination strategies in children and adolescents]. / Okonomische Evaluation verschiedener Hepatitis-B-Impfstrategien bei Kindern und Jugendlichen.

AIM: In this cost-effectiveness study 4 different vaccination strategies against hepatitis B in children and adolescents are evaluated and compared with the situation without immunization. EXAMINATION: Projections are made for the population of the today's adolescents underage 15 and the newborns of the next 30 years. The number of avoided hepatitis B virus (HBV) infections and the cases of disease as well as the costs associated with treatment and vaccination are determined. The course of incidence of the hepatitis B virus is observed for different age groups. RESULTS: Compared to the situation without any vaccination against hepatitis B, a decrease of the remaining infections of at least 18,900 up to 46,600 could be expected during the next 30 years. The treatment costs for the remaining cases of disease could be reduced by 0.4 up to 1.6 billions DM. The remaining expenditures for treatment and vaccination would be limited to 2.3 up to 3.4 billions DM. The net costs of a vaccination are determined as about 14,200 up to 63,000 DM per avoided case of infection. Considering the commonly accepted number of unreported cases of hepatitis B as to be the 5- to 10 fold of the known incidence, all of the 4 compared vaccination strategies will be cost-effective and associated with net savings of about 5,900 up to 36,400 DM per avoided case of hepatitis B virus infection during 30 years. The epidemiological situation will be positive influenced by such a mass vaccination. The minimization of incidence is shown for the different age groups. CONCLUSION: Considering these economical arguments, first the vaccination of all adolescents between age 11 to 15 and second the vaccination of all children/adolescents between age 0 to 15 are the preferable strategies. The immunization of all children/adolescents between age 0 to 15 is the most effective strategy from an epidemiological point of view.