Cost-Effectiveness Analysis for Surgical, Angioplasty, or Medical Therapeutics for Coronary Artery Disease 5-Year Follow-Up of Medicine, Angioplasty, or Surgery Study (MASS) II Trial

Background-The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n = 203), percutaneous coronary intervention (PCI, n = 205), or medical treatment alone (MT, n = 203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies. Methods and Results-We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT; $19 967.00 for PCI; and $18 263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P<0.01). The event-free plus angina-free costs were $16 553.00, $25 831.00, and $24 614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P<0.001); there was no difference between CABG and PCI (P>0.05). Conclusions-In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI.

Treatment failure in pneumonia: Impact of antibiotic treatment and cost analysis

The aim of this study was to investigate treatment failure (TF) in hospitalised community-acquired pneumonia (CAP) patients with regard to initial antibiotic treatment and economic impact. CAP patients were included in two open, prospective multicentre studies assessing the direct costs for in-patient treatment. Patients received treatment either with moxifloxacin (MFX) or a nonstandardised antibiotic therapy. Any change in antibiotic therapy after >72 h of treatment to a broadened antibiotic spectrum was considered as TF. Overall, 1,236 patients (mean ± SD age 69.6 ± 16.8 yrs, 691 (55.9%) male) were included. TF occurred in 197 (15.9%) subjects and led to longer hospital stay (15.4 ± 7.3 days versus 9.8 ± 4.2 days; p < 0.001) and increased median treatment costs (€2,206 versus €1,284; p<0.001). 596 (48.2%) patients received MFX and witnessed less TF (10.9% versus 20.6%; p < 0.001). After controlling for confounders in multivariate analysis, adjusted risk of TF was clearly reduced in MFX as compared with β-lactam monotherapy (adjusted OR for MFX 0.43, 95% CI 0.27-0.68) and was more comparable with a β-lactam plus macrolide combination (BLM) (OR 0.68, 95% CI 0.38-1.21). In hospitalised CAP, TF is frequent and leads to prolonged hospital stay and increased treatment costs. Initial treatment with MFX or BLM is a possible strategy to prevent TF, and may thus reduce treatment costs.

The Value of Negotiating Cost-Based Transfer Prices

This paper analyzes the potential of one-step transfer prices based on either variable or full costs for coordinating decentralized production and quality-improving investment decisions. Transfer prices based on variable costs fail to induce investments on the upstream stage. In contrast, transfer prices based on full costs provide strong investment incentives for the upstream divisions. However, they fail to coordinate the investment decisions. We show that negotiations prevent such coordination failure. In particular, we find that the firm benefits from a higher degree of decentralization so that total profit increases in the number of parameters being subject to negotiations.

Digital vs. conventional implant prosthetic workflows: a cost/time analysis.

OBJECTIVES The aim of this prospective cohort trial was to perform a cost/time analysis for implant-supported single-unit reconstructions in the digital workflow compared to the conventional pathway. MATERIALS AND METHODS A total of 20 patients were included for rehabilitation with 2 × 20 implant crowns in a crossover study design and treated consecutively each with customized titanium abutments plus CAD/CAM-zirconia-suprastructures (test: digital) and with standardized titanium abutments plus PFM-crowns (control conventional). Starting with prosthetic treatment, analysis was estimated for clinical and laboratory work steps including measure of costs in Swiss Francs (CHF), productivity rates and cost minimization for first-line therapy. Statistical calculations were performed with Wilcoxon signed-rank test. RESULTS Both protocols worked successfully for all test and control reconstructions. Direct treatment costs were significantly lower for the digital workflow 1815.35 CHF compared to the conventional pathway 2119.65 CHF [P = 0.0004]. For subprocess evaluation, total laboratory costs were calculated as 941.95 CHF for the test group and 1245.65 CHF for the control group, respectively [P = 0.003]. The clinical dental productivity rate amounted to 29.64 CHF/min (digital) and 24.37 CHF/min (conventional) [P = 0.002]. Overall, cost minimization analysis exhibited an 18% cost reduction within the digital process. CONCLUSION The digital workflow was more efficient than the established conventional pathway for implant-supported crowns in this investigation.

The high cost of inappropriate empiric treatment of presumed Clostridium difficile-associated diarrhea

The Center for Disease Control and Prevention (CDC) estimates that more than 2 million patients annually acquire an infection while hospitalized in U.S. hospitals for other health problems, and that 88,000 die as a direct or indirect result of these infections. Infection with Clostridium difficile is the most important common cause of health care associated infectious diarrhea in industrialized countries. The purpose of this study was to explore the cost of current treatment practice of beginning empiric metronidazole treatment for hospitalized patients with diarrhea prior to identification of an infectious agent. The records of 70 hospitalized patients were retrospectively analyzed to determine the pharmacologic treatment, laboratory testing, and radiographic studies ordered and the median cost for each of these was determined. All patients in the study were tested for C. difficile and concurrently started on empiric metronidazole. The median direct cost for metronidazole was $7.25 per patient (95% CI 5.00, 12.721). The median direct cost for laboratory charges was $468.00 (95% CI 339.26, 552.58) and for radiology the median direct cost was $970.00 (95% CI 738.00, 3406.91). Indirect costs, which are far greater than direct costs, were not studied. At St. Luke's, if every hospitalized patient with diarrhea was empirically treated with metronidazole at a median cost of $7.25, the annual direct cost is estimated to be over $9,000.00 plus uncalculated indirect costs. In the U.S., the estimated annual direct cost may be as much as $21,750,000.00, plus indirect costs. ^ An unexpected and significant finding of this study was the inconsistency in testing and treatment of patients with health care associated diarrhea. A best-practice model for C. difficile testing and treatment was not found in the literature review. In addition to the cost savings gained by not routinely beginning empiric treatment with metronidazole, significant savings and improvement in patient care may result from a more consistent approach to the diagnosis and treatment of all patients with health care associated diarrhea. A decision tree model for C. difficile testing and treatment is proposed, but further research is needed to evaluate the decision arms before a validated best practice model can be proposed. ^

Cost Reduction Effects of "pseudo FTAs" in Asia -Application of a price model based on a multilateral I/O table-

This paper examines the repercussion effects on the production cost of industries in Asian countries when some countries eliminate tariffs and import commodity taxes on all imports. This kind of analysis is related in some sense to that measuring the effects of FTAs on economies, and thus may be considered as an analysis of “pseudo FTAs.” Examining a number of combinations of “pseudo FTAs” between China, Japan, and ASEAN, it is found that the case of China plus Japan plus ASEAN is the most effective “pseudo FTA” of the combinations in terms of production cost reduction. The method is a form of price model based on the Asian International Input-Output Table. Almost no studies on price models related to multilateral I/O tables have been implemented thus far.

Optimal and Long-Term Dynamic Transport Policy Design: Seeking Maximum Social Welfare through a Pricing Scheme.

This article presents an alternative approach to the decision-making process in transport strategy design. The study explores the possibility of integrating forecasting, assessment and optimization procedures in support of a decision-making process designed to reach the best achievable scenario through mobility policies. Long-term evaluation, as required by a dynamic system such as a city, is provided by a strategic Land-Use and Transport Interaction (LUTI) model. The social welfare achieved by implementing mobility LUTI model policies is measured through a cost-benefit analysis and maximized through an optimization process throughout the evaluation period. The method is tested by optimizing a pricing policy scheme in Madrid on a cordon toll in a context requiring system efficiency, social equity and environmental quality. The optimized scheme yields an appreciable increase in social surplus through a relatively low rate compared to other similar pricing toll schemes. The results highlight the different considerations regarding mobility impacts on the case study area, as well as the major contributors to social welfare surplus. This leads the authors to reconsider the cost-analysis approach, as defined in the study, as the best option for formulating sustainability measures.

Optimal and Long-Term Dynamic Transport Policy Design: Seeking Maximum Social Welfare through a Pricing Scheme

This article presents an alternative approach to the decision-making process in transport strategy design. The study explores the possibility of integrating forecasting, assessment and optimization procedures in support of a decision-making process designed to reach the best achievable scenario through mobility policies. Long-term evaluation, as required by a dynamic system such as a city, is provided by a strategic Land-Use and Transport Interaction (LUTI) model. The social welfare achieved by implementing mobility LUTI model policies is measured through a cost-benefit analysis and maximized through an optimization process throughout the evaluation period. The method is tested by optimizing a pricing policy scheme in Madrid on a cordon toll in a context requiring system efficiency, social equity and environmental quality. The optimized scheme yields an appreciable increase in social surplus through a relatively low rate compared to other similar pricing toll schemes. The results highlight the different considerations regarding mobility impacts on the case study area, as well as the major contributors to social welfare surplus. This leads the authors to reconsider the cost-analysis approach, as defined in the study, as the best option for formulating sustainability measures.

Evaluating the equity effects of road-pricing in the European urban context - The Madrid Metropolitan Area

The paper identifies the potential spatial and social impacts of a proposed road-pricing scheme for different social groups in the Madrid Metropolitan Area (MMA). We appraise the accessibility of different districts within the MMA in terms of the actual and perceived cost of using the road infrastructure ‘before’ and ‘after’ implementation of the scheme. The appraisal framework was developed using quantitative survey data and qualitative focus group discussions with residents. We then simulated user behaviours (mode and route choice) based on the empirical evidence from a travel demand model for the MMA. The results from our simulation model demonstrated that implementation of the toll on the orbital metropolitan motorways (M40, M30, for example) decreases accessibility mostly in the districts where there are no viable public transport alternatives. Our specific study finding is that the economic burden of the road-pricing scheme particularly affects unskilled and lower income individuals living in the south of the MMA. The focus groups confirmed that low income drivers in the south part of the MMA would reduce their use of tolled roads and have to find new arrangements for these trips: i.e. switch to public transport, spend double the time travelling or stay at home. More generally, our research finds that European transport planners are still a long way from recognising the social equity implications of their policy decisions and that more thorough social appraisals are needed to avoid the social exclusion of low income populations when road tolling is proposed.

Evaluating the spatial and social equity effects of road pricing in the European urban context: the Madrid Metropolitan Area.

The paper explores the spatial and social impacts arising from implementation of a road-pricing scheme in the Madrid Metropolitan Area (MMA). Our analytical focus is on understanding the effects of the scheme on the transport accessibility of different social groups within the MMA. We define an evaluation framework to appraise the accessibility of different districts within the MMA in terms of the actual and perceived cost of using the road infrastructure "before" and "after" the implementation of the scheme. The framework was developed using quantitative survey data and qualitative data from focus group discussions with residents. We then simulated user behaviors (mode and route choice) based on the empirical evidence from a travel demand model for the MMA. The results from our simulation model demonstrated that implementation of the toll on the orbital metropolitan motorways (M40, M30, for example) decreases accessibility, mostly in the districts where there are no viable public transport alternatives. Our key finding is that the economic burden of the road-pricing scheme particularly affects unskilled and lower income individuals living in the south of the MMA. Consequently lower income people reduce their use of tolled roads and have to find new arrangements for these trips: i.e. switch to the public transport, spend double the time for their commuter trips or stay at home. The results of our research could be applicable more widely for anyone wishing to better understand the important relationship between increased transport cost and social equity, especially where there is an intention to introduce similar road-pricing schemes within the urban context.

Cost-effectiveness of Transcatheter Mitral Valve Leaflet Repair for the Treatment of Mitral Regurgitation in Heart Failure

Contexte: La régurgitation mitrale (RM) est une maladie valvulaire nécessitant une intervention dans les cas les plus grave. Une réparation percutanée de la valve mitrale avec le dispositif MitraClip est un traitement sécuritaire et efficace pour les patients à haut risque chirurgical. Nous voulons évaluer les résultats cliniques et l'impact économique de cette thérapie par rapport à la gestion médicale des patients en insuffisance cardiaque avec insuffisance mitrale symptomatique. Méthodes: L'étude a été composée de deux phases; une étude d'observation de patients souffrant d'insuffisance cardiaque et de régurgitation mitrale traitée avec une thérapie médicale ou le MitraClip, et un modèle économique. Les résultats de l'étude observationnelle ont été utilisés pour estimer les paramètres du modèle de décision, qui a estimé les coûts et les avantages d'une cohorte hypothétique de patients atteints d'insuffisance cardiaque et insuffisance mitrale sévère traitée avec soit un traitement médical standard ou MitraClip. Résultats: La cohorte de patients traités avec le système MitraClip était appariée par score de propension à une population de patients atteints d'insuffisance cardiaque, et leurs résultats ont été comparés. Avec un suivi moyen de 22 mois, la mortalité était de 21% dans la cohorte MitraClip et de 42% dans la cohorte de gestion médicale (p = 0,007). Le modèle de décision a démontré que MitraClip augmente l'espérance de vie de 1,87 à 3,60 années et des années de vie pondérées par la qualité (QALY) de 1,13 à 2,76 ans. Le coût marginal était 52.500 $ dollars canadiens, correspondant à un rapport coût-efficacité différentiel (RCED) de 32,300.00 $ par QALY gagné. Les résultats étaient sensibles à l'avantage de survie. Conclusion: Dans cette cohorte de patients atteints d'insuffisance cardiaque symptomatique et d insuffisance mitrale significative, la thérapie avec le MitraClip est associée à une survie supérieure et est rentable par rapport au traitement médical.

Historic (1971-1975) cost-revenue analysis of the automotive operations of the major U.S. automotive products manufacturers. Final report.

National Highway Traffic Safety Administration, Office of Research and Development, Washington, D.C.

Pricing of commodities and services; Specifications manual.

Prepared in the Division of Prices and Cost of Living.

Pricing of commodities and services. Specifications manual, 1956.

Mode of access: Internet.

Cost-effectiveness of combination peginterferon alpha-2a and ribavirin compared with interferon alpha-2b and ribavirin in patients with chronic hepatitis C

BACKGROUND: Sustained virological response (SVR) is the primary objective in the treatment of chronic hepatitis C (CHC). Results from a recent clinical trial of patients with previously untreated CHC demonstrate that the combination of peginterferon alpha-2a and ribavirin produces a greater SVR than interferon alpha-2b and ribavirin combination therapy. However, the cost-effectiveness of peginterferon alpha-2a plus ribavirin in the U.S. setting has not been investigated. METHODS: A Markov model was developed to investigate cost-effectiveness in patients with CHC using genotype to guide treatment duration. SVR and disease progression parameters were derived from the clinical trials and epidemiologic studies. The impact of treatment on life expectancy and costs were projected for a lifetime. Patients who had an SVR were assumed to remain virus-free for the rest of their lives. In genotype 1 patients, the SVRs were 46% for peginterferon alpha-2a plus ribavirin and 36% for interferon alpha-2b plus ribavirin. In genotype 2/3 patients, the SVRs were 76% for peginterferon alpha-2a plus ribavirin and 61% for interferon alpha-2b plus ribavirin. Quality of life and costs were based on estimates from the literature. All costs were based on published U.S. medical care costs and were adjusted to 2003 U.S. dollars. Costs and benefits beyond the first year were discounted at 3%. RESULTS: In genotype 1, peginterferon alpha-2a plus ribavirin increases quality-adjusted life expectancy (QALY) by 0.70 yr compared to interferon alpha-2b plus ribavirin, producing a cost-effectiveness ratio of $2,600 per QALY gained. In genotype 2/3 patients, peginterferon alpha-2a plus ribavirin increases QALY by 1.05 yr in comparison to interferon alpha-2b plus ribavirin. Peginterferon alpha-2a combination therapy in patients with HCV genotype 2 or 3 is dominant (more effective and cost saving) compared to interferon alpha-2b plus ribavirin. Results weighted by genotype prevalence (75% genotype 1; 25% genotype 2 or 3) also show that peginterferon alpha-2a plus ribavirin is dominant. Peginterferon alpha-2a and ribavirin remained cost-effective (below $16,500 per QALY gained) under sensitivity analyses on key clinical and cost parameters. CONCLUSION: Peginterferon alpha-2a in combination with ribavirin with duration of therapy based on genotype, is cost-effective compared with conventional interferon alpha-2b in combination with ribavirin when given to treatment-naive adults with CHC.