Lumbar epidural steroids are not cost effective in sciatica

Background Lumbar Epidural Steroids Injections (ESI’s) have previously been shown to provide some degree of pain relief in sciatica. Number Needed To Treat (NNT) to achieve 50% pain relief has been estimated at 7 from the results of randomised controlled trials. Pain relief is temporary. They remain one of the most commonly provided procedures in the UK. It is unknown whether this pain relief represents good value for money. Methods 228 patients were randomised into a multi-centre Double Blind Randomised Controlled Trial. Subjects received up to 3 ESI’s or intra-spinous saline depending on response and fall off with the first injection. All other treatments were permitted. All received a review of analgesia, education and physical therapy. Quality of life was assessed using the SF36 at 6 points and compared using independent sample t-tests. Follow up was up to 1 yr. Missing data was imputed using last observation carried forward (LOCF). QALY’s (Quality of Life Years) were derived from preference based heath values (summary health utility score). SF-6D health state classification was derived from SF-36 raw score data. Standard gambles (SG) were calculated using Model 10. SG scores were calculated on trial results. LOCF was not used for this. Instead average SG were derived for a subset of patients with observations for all visits up to week 12. Incremental QALY’s were derived as the difference in the area between the SG curve for the active group and placebo group. Results SF36 domains showed a significant improvement in pain at week 3 but this was not sustained (mean 54 Active vs 61 Placebo P<0.05). Other domains did not show any significant gains compared with placebo. For derivation of SG the number in the sample in each period differed. In week 12, average SG scores for active and placebo converged. In other words, the health gain for the active group as measured by SG was achieved by the placebo group by week 12. The incremental QALY gained for a patient under the trial protocol compared with the standard care package was 0.0059350. This is equivalent to an additional 2.2 days of full health. The cost per QALY gained to the provider from a patient management strategy administering one epidural as suggested by results was £25 745.68. This result was derived assuming that the gain in QALY data calculated for patients under the trial protocol would approximate that under a patient management strategy based on the trial results (one ESI). This is above the threshold suggested by some as a cost effective treatment. Conclusions The transient benefit in pain relief afforded by ESI’s does not appear to be cost-effective. Further work is needed to develop more cost-effective conservative treatments for sciatica.

Design-led innovation : Overcoming challenges to designing competitiveness to succeed in high cost environments

This chapter focuses on demonstrating the role of Design-Led Innovation (DLI) as an enabler for the success of Small to Medium Enterprises (SMEs) within high growth environments. This chapter is targeted toward businesses that may have been exposed to the concept of design previously at a product level and now seek to better understand its value through implementation at a strategic level offering. The decision to engage in the DLI process is made by firms who want to remain competitive as they struggle to compete in high cost environments, such as the state of the Australian economy at present. The results presented in this chapter outline the challenges in the adoption of the DLI process and the implications it can have. An understanding of the value of DLI in practice—as an enabler of business transformation in Australia—is of benefit to government and the broader design community.

Creating flexible mappings between building information models and cost information

During the early design stages of construction projects, accurate and timely cost feedback is critical to design decision making. This is particularly challenging for cost estimators, as they must quickly and accurately estimate the cost of the building when the design is still incomplete and evolving. State-of-the-art software tools typically use a rule-based approach to generate detailed quantities from the design details present in a building model and relate them to the cost items in a cost estimating database. In this paper, we propose a generic approach for creating and maintaining a cost estimate using flexible mappings between a building model and a cost estimate. The approach uses queries on the building design that are used to populate views, and each view is then associated with one or more cost items. The benefit of this approach is that the flexibility of modern query languages allows the estimator to encode a broad variety of relationships between the design and estimate. It also avoids the use of a common standard to which both designers and estimators must conform, allowing the estimator added flexibility and functionality to their work.

What do most Americans think of cost-effectiveness research in health care?

My impression is that explicit data on the cost-effectiveness of different health care services are not valued highly by US policy makers. An example is a recent decision to approve ipilimumab for the treatment of metastatic melanoma. The extra health benefit over standard treatment is 2.1 months in previously untreated patients and the cost is $120,000 for 4 doses. This is poor value for money. Had $120,000 been allocated to an intensive lifestyle modification programme for diabetes risk (Diabet Med. 2004 Nov;21(11):1229-36) then 67 years of life or 800 months could have been returned. A massive increase in health benefits for the same costs.

Final report of Working Group 2: Traffic psychology [A COST Action TU1101 / HOPE collaboration]

BACKGROUND The workgroup of Traffic Psychology is concerned with the social, behavioral, and perceptual aspects that are associated with use and non-use of bicycle helmets, in their various forms and under various cycling conditions. OBJECTIVES The objectives of WG2 are to (1) share current knowledge among the people already working in the field, (2) suggest new ideas for research on and evaluation of the design of bicycle helmets, and (3) discuss options for funding of such research within the individual frameworks of the participants. Areas for research include 3.1. The patterns of use of helmets among different users: children, adults, and sports enthusiasts. 3.2. The use of helmets in different environments: rural roads, urban streets, and bike trails. 3.3. Concerns bicyclists have relative to their safety and convenience and the perceived impact of using helmets on comfort and convenience. 3.4. The benefit of helmets for enhancing visibility, and how variations in helmet design and colors affect daytime, nighttime, and dusktime visibility. 3.5. The role of helmets in the acceptance of city-wide pickup-and-drop-off bicycles. 3.6. The impact of helmets on visual search behaviour of bicyclists.

Predicting risk and benefit a priori in biological control of invasive plant species: a systems modelling approach

While the method using specialist herbivores in managing invasive plants (classical biological control) is regarded as relatively safe and cost-effective in comparison to other methods of management, the rarity of strict monophagy among insect herbivores illustrates that, like any management option, biological control is not risk-free. The challenge for classical biological control is therefore to predict risks and benefits a priori. In this study we develop a simulation model that may aid in this process. We use this model to predict the risks and benefits of introducing the chrysomelid beetle Charidotis auroguttata to manage the invasive liana Macfadyena unguis-cati in Australia. Preliminary host-specificity testing of this herbivore indicated that there was limited feeding on a non-target plant, although the non-target was only able to sustain some transitions of the life cycle of the herbivore. The model includes herbivore, target and non-target life history and incorporates spillover dynamics of populations of this herbivore from the target to the non-target under a variety of scenarios. Data from studies of this herbivore in the native range and under quarantine were used to parameterize the model and predict the relative risks and benefits of this herbivore when the target and non-target plants co-occur. Key model outputs include population dynamics on target (apparent benefit) and non-target (apparent risk) and fitness consequences to the target (actual benefit) and non-target plant (actual risk) of herbivore damage. The model predicted that risk to the non-target became unacceptable (i.e. significant negative effects on fitness) when the ratio of target to non-target in a given patch ranged from 1:1 to 3:2. By comparing the current known distribution of the non-target and the predicted distribution of the target we were able to identify regions in Australia where the agent may be pose an unacceptable risk. By considering risk and benefit simultaneously, we highlight how such a simulation modelling approach can assist scientists and regulators in making more objective decisions a priori, on the value of releasing specialist herbivores as biological control agents.

Predicting the cost of eradication for 41 Class 1 declared weeds in Queensland

The feasibility of state-wide eradication of 41 invasive plant taxa currently listed as ‘Class 1 declared pests’ under the Queensland Land Protection (Pest and Stock Route Management) Act 2002 was assessed using the predictive model ‘WeedSearch’. Results indicated that all but one species (Alternanthera philoxeroides) could be eradicated, provided sufficient funding and labour were available. Slightly less than one quarter (24.4%) (n = 10) of Class 1 weed taxa could be eradicated for less than $100 000 per taxon. An additional 43.9% (n = 18) could be eradicated for between $100 000 and $1M per taxon. Hence, 68.3% of Class 1 weed taxa (n = 28) could be eradicated for less than $1M per taxon. Eradication of 29.3% (n = 12) is predicted to cost more than $1M per taxon. Comparison of these WeedSearch outputs with either empirical analysis or results from a previous application of the model suggests that these costs may, in fact, be underestimates. Considering the likelihood that each weed will cost the state many millions of dollars in long-term losses (e.g. losses to primary production, environmental impacts and control costs), eradication seems a wise investment. Even where predicted costs are over $1M, eradication can still offer highly favourable benefit:cost ratios. The total (cumulative) cost of eradication of all 41 weed taxa is substantial; for all taxa, the estimated cost of eradication in the first year alone is $8 618 000. This study provides important information for policy makers, who must decide where to invest public funding.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Improving cost-effectiveness of supplementation systems for breeder herds in northern Australia

Low level strategic supplements constitute one of the few options for northern beef producers to increase breeder productivity and profitability. Objectives of the project were to improve the cost-effectiveness of using such supplements and to improve supplement delivery systems. Urea-based supplements fed during the dry season can substantially reduce breeder liveweight loss and increase fertility during severe dry seasons. Also when fed during the late wet season these supplements increased breeder body liveweight and increased fertility of breeders in low body condition. Intake of dry lick supplements fed free choice is apparently determined primarily by the palatability of supplements relative to pasture, and training of cattle appears to be of limited importance. Siting of supplementation points has some effect on supplement intake, but little effect on grazing behaviour. Economic analysis of supplementation (urea, phosphorus or molasses) and weaning strategies was based on the relative efficacy of these strategies to maintain breeder body condition late in the dry season. Adequate body condition of breeders at this time of the year is needed to avoid mortality from under-nutrition and achieve satisfactory fertility of breeders during the following wet season. Supplements were highly cost-effective when they reduced mortality, but economic returns were generally low if the only benefit was increased fertility.

Barrett's Esophagus and Associated Adenocarcinoma : studies on pathogenesis, clinical staging and cost-utility of cancer treatment

Esophageal and gastroesophageal junction (GEJ) adenocarcinoma is rapidly increasing disease with a pathophysiology connected to oxidative stress. Exact pre-treatment clinical staging is essential for optimal care of this lethal malignancy. The cost-effectiviness of treatment is increasingly important. We measured oxidative metabolism in the distal and proximal esophagus by myeloperoxidase activity (MPA), glutathione content (GSH), and superoxide dismutase (SOD) in 20 patients operated on with Nissen fundoplication and 9 controls during a 4-year follow-up. Further, we assessed the oxidative damage of DNA by 8-hydroxydeoxyguanosine (8-OHdG) in esophageal samples of subjects (13 Barrett s metaplasia, 6 Barrett s esophagus with high-grade dysplasia, 18 adenocarcinoma of the distal esophagus/GEJ, and 14 normal controls). We estimated the accuracy (42 patients) and preoperative prognostic value (55 patients) of PET compared with computed tomography (CT) and endoscopic ultrasound (EUS) in patients with adenocarcinoma of the esophagus/GEJ. Finally, we clarified the specialty-related costs and the utility of either radical (30 patients) or palliative (23 patients) treatment of esophageal/GEJ carcinoma by the 15 D health-related quality-of-life (HRQoL) questionnaire and the survival rate. The cost-utility of radical treatment of esophageal/GEJ carcinoma was investigated using a decision tree analysis model comparing radical, palliative, and hypothetical new treatment. We found elevated oxidative stress ( measured by MPA) and decreased antioxidant defense (measured by GSH) after antireflux surgery. This indicates that antireflux surgery is not a perfect solution for oxidative stress of the esophageal mucosa. Elevated oxidative stress in turn may partly explain why adenocarcinoma of the distal esophagus is found even after successful fundoplication. In GERD patients, proximal esophageal mucosal anti-oxidative defense seems to be defective before and even years after successful antireflux surgery. In addition, antireflux surgery apparently does not change the level of oxidative stress in the proximal esophagus, suggesting that defective mucosal anti-oxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD. In the malignant transformation of Barrett s esophagus an important component appears to be oxidative stress. DNA damage may be mediated by 8-OHdG, which we found to be increased in Barrett s epithelium and in high-grade dysplasia as well as in adenocarcinoma of the esophagus/GEJ compared with controls. The entire esophagus of Barrett s patients suffers from increased oxidative stress ( measured by 8-OhdG). PET is a useful tool in the staging and prognostication of adenocarcinoma of the esophagus/GEJ detecting organ metastases better than CT, although its accuracy in staging of paratumoral and distant lymph nodes is limited. Radical surgery for esophageal/GEJ carcinoma provides the greatest benefit in terms of survival, and its cost-utility appears to be the best of currently available treatments.

Cost Sharing Mechanisms for Business Clusters with Strategic Firms

A business cluster is a co-located group of micro, small, medium scale enterprises. Such firms can benefit significantly from their co-location through shared infrastructure and shared services. Cost sharing becomes an important issue in such sharing arrangements especially when the firms exhibit strategic behavior. There are many cost sharing methods and mechanisms proposed in the literature based on game theoretic foundations. These mechanisms satisfy a variety of efficiency and fairness properties such as allocative efficiency, budget balance, individual rationality, consumer sovereignty, strategyproofness, and group strategyproofness. In this paper, we motivate the problem of cost sharing in a business cluster with strategic firms and illustrate different cost sharing mechanisms through the example of a cluster of firms sharing a logistics service. Next we look into the problem of a business cluster sharing ICT (information and communication technologies) infrastructure and explore the use of cost sharing mechanisms.

Urban greenways have the potential to increase physical activity levels cost-effectively

BACKGROUND: For many, physical activity has been engineered out of daily life, leading to high levels of sedentariness and obesity. Multi-faceted physical activity interventions, combining individual, community and environmental approaches, have the greatest potential to improve public health, but few have been evaluated. METHODS: Approximately 100 000 people may benefit from improved opportunities for physical activity through an urban regeneration project in Northern Ireland, the Connswater Community Greenway. Using the macro-simulation PREVENT model, we estimated its potential health impacts and cost-effectiveness. To do so, we modelled its potential impact on the burden from cardiovascular disease, namely, ischaemic heart disease, type 2 diabetes mellitus and stroke, and colon and breast cancer, by the year 2050, if feasible increases in physical activity were to be achieved. RESULTS: If 10% of those classified as 'inactive' (perform less than 150 minutes of moderate activity/week) became 'active', 886 incident cases (1.2%) and 75 deaths (0.9%) could be prevented with an incremental cost-effectiveness ratio of £4469/disability-adjusted life year. For effectiveness estimates as low as 2%, the intervention would remain cost-effective (£18 411/disability-adjusted life year). Small gains in average life expectancy and disability-adjusted life expectancy could be achieved, and the Greenway population would benefit from 46 less years lived with disability. CONCLUSION: The Greenway intervention could be cost-effective at improving physical activity levels. Although the direct health gains are predicted to be small for any individual, summed over an entire population, they are substantial. In addition, the Greenway is likely to have much wider benefits beyond health.

Would people with Parkinson's disease benefit from palliative care?

Parkinson's disease (PD) is a chronic, progressive, degenerative disorder of the nervous system, causing substantial morbidity and has the capacity to shorten life. People with PD and their families can find the disease devastating. Nevertheless, this population of patients is not usually considered a group to be supported by palliative care specialists. But the nature of the illness and the challenges of managing its many physical and psychological effects raises questions about the potential benefits of a palliative care approach. The purpose of this project was to describe the experience of PD and consider the relevance of palliative care for this population. Semi-structured interviews were conducted with eight people with PD, 21 family caregivers and six health professionals. Five themes were developed from the data analysis: (1) emotional impact of diagnosis; (2) staying connected; (3) enduring financial hardship; (4) managing physical challenges; and (5) finding help for advanced stages. These data revealed that people with PD and family caregivers are confronted with similar issues to people with typical palliative care diagnoses, such as advanced cancer, and that a palliative approach may be helpful in the care of people with PD and their families.

Cost-effectiveness of tooth replacement strategies for partially dentate elderly: a randomized controlled clinical trial

OBJECTIVE: To conduct a cost-effectiveness analysis comparing two different tooth replacement strategies for partially dentate older patients, namely partial removable dental prostheses (RDP) and functionally orientated treatment based on the shortened dental arch concept (SDA).

METHODS: Ninety-two partially dentate older patients completed a randomized controlled clinical trial. Patients were randomly allocated to two treatment groups: the RDP group and the SDA group. Treatment effect was measured using impact on oral health-related quality of life (OHrQOL), and the costs involved in providing and maintaining care were recorded for all patients. Patients were followed for 12 months after treatment intervention. All treatment was provided by a single operator.

RESULTS: The total cost of achieving the minimally important clinical difference (MID) in OHrQOL for an average patient in the RDP group was €464.64. For the SDA group, the cost of achieving the MID for an average patient was €252.00. The cost-effectiveness ratio was therefore 1:1.84 in favour of SDA treatment.

CONCLUSION: With an increasingly ageing population, many patients will continue to benefit from removable prostheses to replace their missing natural teeth. From a purely economic standpoint, the results from this analysis suggest that the treatment of partially dentate older adults should be focused on functionally orientated treatment because it is simply more cost-effective.

Tanker Mission Implication on a Civil Aerial Refuelling Transport System’s Benefit Evaluation

As the emphasis on initiatives that can improve environmental efficiency while simultaneously maintaining economic viability has escalated in recent years, attention has turned to more radical concepts of operation. In particular, the cruiser–feeder concept has shown potential for a new generation, environmentally friendly, air-transport system to alleviate the growing pressure on the passenger air-transportation network. However, a full evaluation of realizable benefits is needed to determine how the design and operation of potential feeder-aircraft configurations impact on the feasibility of the overall concept. This paper presents an analysis of a cruiser–feeder concept, in which fuel is transferred between the feeder and the cruiser in an aerial-refueling configuration to extend range while reducing cruiser weight, compared against the effects of escalating existing technology levels while retaining the existing passenger levels. Up to 14% fuel-burn and 12% operating-cost savings can be achieved when compared to a similar technology-level aircraft concept without aerial refueling, representing up to 26% in fuel burn and 25% in total operating cost over the existing operational model at today’s standard fleet technology and performance. However, these potential savings are not uniformly distributed across the network, and the system is highly sensitive to the routes serviced, with reductions in revenue-generation potential observed across the network for aerial-refueling operations due to reductions in passenger revenue.