Decision-analytic evaluation of the clinical effectiveness and cost-effectiveness of management programmes in chronic heart failure.

BACKGROUND AND AIMS: While management programmes (MPs) for chronic heart failure (CHF) are clinically effective, their cost-effectiveness remains uncertain. Thus, this study sought to determine the cost-effectiveness of MPs. METHODS AND RESULTS: We developed a Markov model to estimate life expectancy, quality-adjusted life expectancy, lifetime costs, and the incremental cost-effectiveness of MPs as compared to standard care. Standard care was defined by the EuroHeart Failure Survey for Germany, MP efficacy was derived from our recent meta-analysis and cost estimates were based on the German healthcare system. For a population with a mean age 67 years (35% female) at onset of CHF, our model predicted an average quality-adjusted life expectancy of 2.64 years for standard care and 2.83 years for MP. MP yielded additional lifetime costs of euro1700 resulting in an incremental cost-utility ratio (ICUR) of euro8900 (95% CI: dominant to 177,100) per quality-adjusted life year (QALY) gained. Sensitivity analyses demonstrated that the ICUR was sensitive to age and sex. CONCLUSION: MPs increase life expectancy in patients with CHF by an average of 84 days and increase lifetime cost of care by approximately euro1700. MPs improve outcomes in a cost-effective manner, although they are not cost-saving on a lifetime horizon.

A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure.

BACKGROUND: We sought to systematically combine the evidence on efficacy of disease management programs (DMPs) in the treatment of congestive heart failure (CHF), to identify and explain heterogeneity of results from prior studies of DMPs, and to assess potential publication bias from these studies. METHODS AND RESULTS: We conducted a systematic literature search on randomized clinical trials investigating the effect of DMPs on CHF outcomes and performed meta-analyses and meta-regressions comparing DMPs and standard care for mortality and rehospitalization. We included 36 studies from 13 different countries (with data from 8341 patients). Our meta-analysis yielded a pooled risk difference of 3% (95% confidence interval [CI] 1-6%, P < .01) for mortality and of 8% (95% CI 5-11%, P < .0001) for rehospitalization, both favoring DMP. Factors explaining heterogeneity between studies included severity of disease, proportion of beta-blocker at baseline, country, duration of follow-up, and mode of postdischarge contact. No statistically significant publication bias was detected. CONCLUSION: DMPs have the potential to reduce morbidity and mortality for patients with CHF. The benefit of the intervention depends on age, severity of disease, guideline-based treatment at baseline, and DMP modalities. Future studies should directly compare the effect of different aspects of disease management programs for different populations.

The risk of reinjury in relation to time since first injury: a retrospective population-based study.

BACKGROUND: Trauma victims have been found to be at increased risk for reinjury. Determining the risk factors for reinjury and the temporal pattern of reinjury risk can help with targeting of intervention strategies for preventing trauma recurrence. METHODS: We performed a retrospective, population-based study in Washington State from 1986 to 2001. Individuals aged 15 to 64 years who were hospitalized for injury were followed for 5 years for hospitalization or death because of reinjury. Poisson regression was used to determine the rate ratio of reinjury, compared with the baseline rate of injury, as a function of time since first injury. Among those injured, proportional hazards regression was used to determine risk factors for reinjury. RESULTS: The risk of subsequent injury hospitalization or death was elevated 2.59-fold (95% CI: 2.50, 2.68) during the period from 6 months to 5 years after the initial injury. Excluding from analysis the first 6 months after initial injury, the risk of reinjury was highest at 4.10 (95% CI: 3.83, 4.40) between 6 and 12 months after first injury, and then declined to approximately 2.0-fold increased risk above baseline by 30 months. Individuals with self-inflicted injuries were found to be at particularly high risk of reinjury [Hazard Ratio (HR) 2.60 (2.21, 3.05)]. Increasing age, male gender, and alcohol use were also associated with increased reinjury risk. Any injury to the face, spine, and extremities were associated with a decreased risk of reinjury. CONCLUSIONS: Reinjury risk is highest soon after injury, but persists for at least 5 years after initial injury. Periodic interventions through 5 years after injury, particularly in certain high-risk groups, might have lasting effects on reinjury rates.

The footprint of antibody bound to pig cells: evidence of complex surface topology.

The disaccharide Gal(alpha)1-3Gal is found on more than 45 different molecules on the endothelium of porcine cells and has recently attracted considerable interest, being the major target recognized by xenoreactive antibodies. In this study, the distribution and topology of Gal(alpha)1-3Gal on porcine endothelial cells was examined to access whether some Gal(alpha)1-3Gal-containing molecules might be preferentially recognized by antibodies binding to Gal(alpha)1-3Gal. Thirteen percent of the Gal(alpha)1-3Gal was found on glycolipid and 87% on glycoproteins. Of all the glycoproteins and glycolipids containing Gal(alpha)1-3Gal, two molecules, fibronectin and the integrin beta1 subunit, were most intensely labeled by galactose oxidase, suggesting that these molecules may be preferentially exposed on the apical surface of the endothelium. Binding of anti-Gal(alpha)1-3Gal antibodies to endothelial cell surfaces significantly diminished labeling of fibronectin and the integrin beta1 subunit by galactose oxidase, indicating that these glycoproteins are targets for the antibodies when binding to intact porcine cells.