Health economic analysis of laparoscopic lavage versus Hartmann's procedure for diverticulitis in the randomized DILALA trial.

BACKGROUND: Open surgery with resection and colostomy (Hartmann's procedure) has been the standard treatment for perforated diverticulitis with purulent peritonitis. In recent years laparoscopic lavage has emerged as an alternative, with potential benefits for patients with purulent peritonitis, Hinchey grade III. The aim of this study was to compare laparoscopic lavage and Hartmann's procedure with health economic evaluation within the framework of the DILALA (DIverticulitis - LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) trial. METHODS: Clinical effectiveness and resource use were derived from the DILALA trial and unit costs from Swedish sources. Costs were analysed from the perspective of the healthcare sector. The study period was divided into short-term analysis (base-case A), within 12 months, and long-term analysis (base-case B), from inclusion in the trial throughout the patient's expected life. RESULTS: The study included 43 patients who underwent laparoscopic lavage and 40 who had Hartmann's procedure in Denmark and Sweden during 2010-2014. In base-case A, the difference in mean cost per patient between laparoscopic lavage and Hartmann's procedure was €-8983 (95 per cent c.i. -16 232 to -1735). The mean(s.d.) costs per patient in base-case B were €25 703(27 544) and €45 498(38 928) for laparoscopic lavage and Hartmann's procedure respectively, resulting in a difference of €-19 794 (95 per cent c.i. -34 657 to -4931). The results were robust as demonstrated in sensitivity analyses. CONCLUSION: The significant cost reduction in this study, together with results of safety and efficacy from RCTs, support the routine use of laparoscopic lavage as treatment for complicated diverticulitis with purulent peritonitis.

Cost-savings achieved by eradication of epidemic methicillin-resistant Staphylococcus aureus (EMRSA)-16 from a large teaching hospital.

Methicillin-resistant Staphylococcus aureus continues to be an increasing problem worldwide, although its prevalence in the Nordic countries still is low. In 1997 an unusually readily transmissible strain of epidemic methicillin-resistant S. aureus, EMRSA-16, was introduced by a single patient into a 2,600 bed teaching hospital in Sweden. Despite the standard "search and destroy" policy (Standard MRSA Control Programme), the outbreak took on epidemic proportions. Therefore, the hospital management chose to implement vigorous and costly actions (Intensive MRSA Control Programme). These measures were successful, and the strain was completely eradicated. Whether the actions taken were cost-effective was analysed using an analytical framework in which different scenarios were simulated (decision analytic modelling). Thus, the relative costs and consequences of the Standard MRSA Control Programme and the Intensive MRSA Control Programme could be compared in a simple manner. Coefficients were developed from the observations of the transmission of the bacteria during the period preceding the study period. These were then used to simulate the outcome of the alternative programmes. The uncertainty of the results was explored in sensitivity analyses. The Intensive MRSA Control Programme was shown to be cost saving after slightly more than 24 months of implementation. In conclusion, due to vigorous control efforts, a large EMRSA-16 outbreak in a university hospital was stopped. The initial costs of the control programme were high, but future healthcare resources were saved.

Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer.

BACKGROUND: There has been no randomized clinical trial of the costs of laparoscopic colonic resection (LCR) compared with those of open colonic resection (OCR) in the treatment of colonic cancer. METHODS: A subset of Swedish patients included in the Colon Cancer Open Or Laparoscopic Resection (COLOR) trial was included in a prospective cost analysis; costs were calculated up to 12 weeks after surgery. All relevant costs to society were included. No effects of the procedures, such as quality of life or survival, were taken into account. RESULTS: Two hundred and ten patients were included in the primary analysis, 98 of whom had LCR and 112 OCR. Total costs to society did not differ significantly between groups (difference in means for LCR versus OCR euro1846; P = 0.104). The cost of operation was significantly higher for LCR than for OCR (difference in means euro1171; P < 0.001), as was the cost of the first admission (difference in means euro1556; P = 0.015) and the total cost to the healthcare system (difference in means euro2244; P = 0.018). CONCLUSION: Within 12 weeks of surgery for colonic cancer, there was no difference in total costs to society incurred by LCR and OCR. The LCR procedure, however, was more costly to the healthcare system.

The cost-effectiveness of ramipril in the treatment of patients at high risk of cardiovascular events: a Swedish sub-study to the HOPE study.

OBJECTIVE: To evaluate if long-term treatment with ramipril is cost-effective in patients at high risk of cardiovascular events. DESIGN: Randomized double-blind and placebo controlled. Information was gathered prospectively for a number of direct medical, direct nonmedical and indirect costs. SETTING AND SUBJECT: This is a sub-study to the Heart Outcomes Prevention Evaluation (HOPE) study performed in Swedish patients. All Swedish centres (19; n= 554) were invited to take part and 18 centres agreed to do so (n=537). The patients were managed in a specialist setting with a mean follow-up period of 4.5 years. Main outcome measures. The number of life-years saved was derived from the global HOPE study (n=9297) and subsequently the estimated life expectancy of those who completed the clinical study alive was added to the calculation. Direct medical costs related to cardiovascular disease only were considered in the primary analysis, whilst all kinds of costs and costs for all kinds of diseases were included in subsequent analyses. The cost of added years of life, according to the future cost method, was included in sensitivity analyses. RESULTS: The cost per life-year gained was SEK 16 600 (Euro 1940) when direct medical costs for cardiovascular reasons only were considered and SEK 45 400 (Euro 5300) when direct medical costs for all diseases were considered. The corresponding costs when direct nonmedical and indirect cost were added to the estimate were SEK 16 100 (Euro 1880) and SEK 54 600 (Euro 6380), respectively. When the future cost method was applied, the cost per life-year gained was SEK 208 300 (Euro 24 300). CONCLUSION: Ramipril is highly cost-effective in the treatment of patients at high risk of cardiovascular events.

Pharmacoeconomic impact of HOPE.

The HOPE (Heart Outcomes and Prevention Evaluation) study has demonstrated a clear and beneficial effect of ramipril on cardiovascular events and disease progression. The cost-effectiveness of treatment with ramipril remains an important question that is being addressed by analysis of data from the main HOPE study and from a Swedish substudy. Data from the main HOPE study indicate that hospital costs per patient were reduced in the ramipril group compared with the placebo group. The net effect indicates that ramipril is cost neutral or could even be cost saving in US non-Medicare patients. In the Swedish health economic substudy, a separate protocol and separate case record forms were utilised to generate more specific data from the 537 Swedish patients taking part in HOPE. In this analysis, costs and effects associated with each treatment group were assessed and incremental cost-effectiveness ratios were calculated. The primary analysis was cost per life year gained which amounted to 29,000 Swedish Kroner. In a world with a growing prevalence of cardiovascular disease and with additional constraints on healthcare expenditure, analysis of the cost-effectiveness of preventive and curative medications is increasingly important. In this context, the early observations on the cost-effectiveness of ramipril appear very hopeful.