This is a prospective, non-randomized pilot study comparing the cost-utility of hepatic resection, radiofrequency ablation (RFA), systemic chemotherapy, and symptom control only for the treatment of colorectal liver metastases. Seven patients underwent hepatic resection, 7 underwent RFA, 20 received chemotherapy, and 6 received symptom control alone. Liver resection provided an average of 2.51 QALY’s compared to 1.99 QALY’s for RFA, and 1.18 QALY’s for chemotherapy, and 0.82 QALY’s for symptom control alone. The costs were $20,122, $ 15,845, $15,069, and $3,899, respectively. The cost-utilities of liver resection and RFA were similar at $8,027 and $7,965 per QALY, respectively, although patients receiving RFA generally had more advanced disease. The cost-utility of chemotherapy was $12,751/QALY and the cost-utility of symptom control alone was $4,788/QALY. RFA is still a relatively new. However, if long-term survival proves promising, it may prove to be a viable alternative to liver resection.

Submitted by Dayane Cristina Queiroz (dayanecristina_45@yahoo.com.br) on 2018-04-26T13:57:31Z No. of bitstreams: 1 Dissertação Final - Dayane Cristina Queiroz.pdf: 1409189 bytes, checksum: 3169693862475b542779a92e70841858 (MD5) / Approved for entry into archive by Claudia Adriana Spindola null (claudia@fct.unesp.br) on 2018-04-26T14:09:43Z (GMT) No. of bitstreams: 1 queiroz_dc_me_prud.pdf: 1409189 bytes, checksum: 3169693862475b542779a92e70841858 (MD5) / Made available in DSpace on 2018-04-26T14:09:43Z (GMT). No. of bitstreams: 1 queiroz_dc_me_prud.pdf: 1409189 bytes, checksum: 3169693862475b542779a92e70841858 (MD5) Previous issue date: 2018-03-23 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O alto índice de doenças crônicas têm se associado diretamente com elevados custos relacionados à saúde, influenciando diretamente na diminuição da qualidade de vida. Entretanto, estudos brasileiros que avaliam custo-utilidade através de medidas de qualidade de vida e recursos gastos com saúde, ainda são escassos na literatura. Dessa forma, o objetivo do estudo foi avaliar a razão custo-utilidade do tratamento de pacientes da rede primária de saúde de Presidente Prudente/SP. A amostra foi composta por 292 pacientes, de ambos os sexos, com idade igual ou superior a 50 anos. Os pacientes foram avaliados quanto: i) qualidade de vida; ii) QALY; iii) custos com saúde; iv) nível de atividade física; e v) uso de medicamentos. Para análise estatística, foram usados valores de média, desvio padrão, mediana, diferença entre quartil e valores percentuais para estatística descritiva, teste t para amostras independentes, correlação de Pearson para variáveis numéricas e o teste de qui-quadrado para variáveis categóricas. Para o custo-utilidade dos tratamentos, foram utilizados valores de QALY e o custo médio/ano para cada tratamento. A significância estatística (p-valor) foi pré-fixada em valores inferiores a 5%. O software utilizado foi o BioEstat (versão 5.0). Houve correlação negativa entre o domínio atividade física no lazer e locomoção com consultas e custos adicionais (pvalor<0,05), medicamentos e custos totais (p-valor<0,01), e atividade física habitual com consultas, custos adicionais e custos totais (p-valor<0,01). Consultas, custos adicionais, medicamentos e custo total foram maiores em pacientes que reportaram maior número de doenças (p-valor=0,001). O custo-utilidade do tratamento dos pacientes da atenção primária foi maior no grupo tratamento medicamentoso, seguida do grupo medicamentoso atrelada ao exercício físico que se apresentou custo-efetivo com média de QALY alto. Maiores escores de QV foi observado em homens quando comparados mulheres. Entretanto, variáveis como peso, IMC e presença de hipertensão arterial se associaram com menores escores para QV. Além disso, dados quanto internações e cirurgias foram analisados impactando a QV dos avaliados e por fim custos associados aos serviços de saúde também apresentaram relação com a QV. / The high index of chronic diseases has been directly associated with high costs related to health, directly influencing the reduction of quality of life. However, Brazilian studies that evaluate cost-utility through measures of quality of life and resources spent on health are still scarce in the literature. Thus, the objective of the study was to evaluate the cost-utility ratio of the treatment of patients in the primary health network of Presidente Prudente/SP. The sample consisted of 292 patients, of both sexes, aged 50 years or more. Patients were assessed for: i) quality of life; ii) QALY; iii) health costs; iv) level of physical activity; and v) use of medications. For statistical analysis, mean values, standard deviation, median, difference between quartile and percentage values were used for descriptive statistics, t-test for independent samples, Pearson's correlation for numerical variables and the chisquare test for categorical variables. For the cost-utility of the treatments, values of QALY and the mean cost / year for each treatment were used. Statistical significance (p-value) was set at values below 5%. The software used was BioEstat (version 5.0). There was a negative correlation between the physical activity domain in leisure and locomotion with additional consultations and costs (p-value <0.05), medication and total costs (p-value <0.01), and habitual physical activity with consultations, additional costs and total costs (p-value <0.01). Consultations, additional costs, medications and total cost were higher in patients who reported higher number of diseases (pvalue = 0.001). The cost-utility of the treatment of primary care patients was higher in the drug treatment group, followed by the drug group linked to physical exercise that was cost-effective with a high QALY mean. Higher QOL scores were observed in males when compared to females. However, variables such as weight, BMI and presence of arterial hypertension were associated with lower QOL scores. In addition, data regarding hospitalizations and surgeries were analyzed impacting the QoL of the evaluated patients and, finally, costs associated with health services were also related to QoL. / FAPESP: 2016/12071-8

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-12T10:02:58Z No. of bitstreams: 1 marciofernandesdosreis.pdf: 2095493 bytes, checksum: 8a2b414902083a840d9170782a7c84d2 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T17:11:59Z (GMT) No. of bitstreams: 1 marciofernandesdosreis.pdf: 2095493 bytes, checksum: 8a2b414902083a840d9170782a7c84d2 (MD5) / Made available in DSpace on 2016-01-25T17:11:59Z (GMT). No. of bitstreams: 1 marciofernandesdosreis.pdf: 2095493 bytes, checksum: 8a2b414902083a840d9170782a7c84d2 (MD5) Previous issue date: 2015-04-10 / Introdução: as doenças crônico-degenerativas, entre elas as cerebrovasculares ocupam posição de destaque em relação às suas comordidades e taxas de mortalidades mundiais. O acidente vascular cerebral (AVC) se enquadra no rol dessas doenças e é caracterizada pela obstrução ou ruptura de um vaso sanguíneo no cérebro, ocasionando comprometimentos psicomotores ou até mesmo a morte. Fatores relacionados à idade avançada, hipertensão arterial, presença de diabetes e hipercolesterolemia estão entre os principais fatores de risco para a doença. A economia da saúde estuda novas perspectivas para compreender a área, integrando elementos da economia como os custos, gastos e resultados nos processos de avaliação da saúde. O principal objetivo foi identificar o custo total do tratamento ambulatorial desses pacientes pela perspectiva do Sistema Único de Saúde. Material e Métodos: a pesquisa foi transversal, com avaliação dos pacientes hemiplégicos agendados para tratamento fisioterapêutico na Subsecretaria da Cidade de Juiz de Fora. Compuseram a pesquisa, além da descrição do perfil clínico-epidemiológico do usuário, o custo total (custos indiretos e diretos) e o custo-utilidade do tratamento. Assim, um questionário elaborado pelo autor foi aplicado nesses pacientes, propiciando obter dados para as avaliações econômicas e clínico-epidemiológicas. Resultados: O custo total do tratamento dos pacientes sequelados de AVC no ano de 2014 foi de R$ 656.025,00, com média de R$ 6.904,00 por paciente, sendo composto pelos custos diretos (11%) e pelos custos indiretos (89%). Metade dos custos diretos foi relacionado ao tratamento fisioterapêutico, seguido dos gastos com medicamentos (26%), uso de órteses (8%), recebimento de vale-transporte para o tratamento (7%), exames complementares (5%) e consultas médicas (4%). Os custos indiretos foram divididos pela aposentadoria por invalidez (53%) e os benefícios concedidos pelo INSS (47%). A relação custo-utilidade encontrada para esses pacientes foi de R$ 13.052,93 ao ano. Na avaliação dos custos por categorias foram encontradas diferenças estatísticas entre os custos totais quando comparadas pela idade atual do paciente e idade no momento do AVC, cronicidade da doença, existência de trabalho próprio no momento do trauma e valor da renda (p<0,05). Conclusão: os custos totais do tratamento ambulatorial de pacientes de AVC na cidade de Juiz de Fora variaram principalmente em função dos custos indiretos, com maiores cifras para os pacientes mais jovens, inseridos há mais tempo no serviço de reabilitação, economicamente ativos no momento do AVC e maior valor da renda. / Introduction: chronic degenerative diseases like cerebrovascular entity occupy a prominent position in relation to their morbidity and global mortality rates. The stroke falls within the list of such diseases and is characterized by blockage or rupture of a blood vessel in the brain, causing psychomotor impairment or even death. Advanced age, hypertension, diabetes and hypercholesterolemia are among the main factors of risk for the disease. Health economics provide new perspectives to understanding health, integrating elements of the economy as costs and the search for results in the health assessment processes. The main objective was to identify the total cost of treating these patients by the National Health System perspective. Material and methods: a cross-sectional survey, with evaluation of patients scheduled for physical therapy in Juiz de Fora City Secretariat. Components of the research, besides the clinical and epidemiological user profile description, were the total cost (direct and indirect costs) and the cost-utility of treatment. A questionnaire prepared by the author was applied to these patients, providing patient information, which was followed by a statistical analysis. Results: the total cost of treatment spent in the year 2014 was R$ 656,025.00, with an average of R$ 6,904.00 per patient, being composed of direct costs (11%) and indirect costs (89%). Integrating the direct costs, physical therapy accounted for half of the expenses (50%), followed by spending on medicines (26%), use of orthoses (8%), use of transporting support for treatment (7%), additional tests (5%) and medical consultation (4%). Indirect costs were composed of the disability retirement (53%) and benefits granted by INSS (47%). The cost-utility found for these patients was R$ R$ 13,052.93 per year. When assessing costs among categories statistical differences were found between the total costs when compared to the actual patient age and age at stroke, chronic disease, existence of own work at the time of the accident and the amount of money received (p <0.05). Conclusion: the total costs in the stroke patients treatment in Juiz de Fora city varied mainly due to indirect costs, with higher rates for younger patients, inserted for a longer time the rehabilitation service, economically active at the time of the stroke and greater income.

Sammanfattning Bakgrund: Ortopedtekniska hjälpmedel har som övergripande syfte att göra det möjligt för människor att i sin vardag och livsstil vara rörliga, aktiva och delaktiga trots en fysisk funktionsnedsättning. För finansiering av ortopedtekniska hjälpmedel i Sverige ansvarar uteslutande det offentliga i form av landsting och regioner, vilka har en begränsad summa pengar att hushålla med. Det ligger därför i samhällets intresse att dessa pengar satsas på insatser som är av god kvalitet och främjar medborgarnas hälsa. Hälsoekonomiska utvärderingar som jämför kostnader och effekter av olika alternativ utgör en del av beslutsunderlaget för sådana prioriteringar. Det saknas emellertid användbara utvärderingar av ortoser och proteser, både vad gäller effekt och kostnadseffektivitet. Syfte: Syftet med studien var att analysera ortoser för nedre extremiteten ur ett hälsoekonomiskt perspektiv baserat på sjukvårdens direkta kostnader och förändring i patienters självupplevda hälsa. Metod: Totalt 17 patienter, vid fyra ortopedtekniska mottagningar, som ordinerats ortoser för nedre extremiteten, genomförde EQ-5D-3L-enkäten före och sex veckor efter utprovningstillfället. Hälsoprofiler från enkäterna överfördes via nationella tariffer till hälsoindex som representerar hälsokomponenten i QALY. Nyttan bedömdes genom att jämföra hälsoindex före och sex veckor efter utprovningstillfället. Kostnadsanalysanalys utfördes sedan genom att dividera landstingets/regionens direkta kostnad för ortoserna med skillnaden i hälsoindex. Resultat: Studien visar att ortoser för nedre extremiteten inte medför någon förändring i patienters självupplevda hälsa och därför inte kan anses vara kostnadseffektivt. För att kunna utvärdera metoden och göra dra några statistiska slutsatser behöver fler enkäter samlas in. Implikation: På lång sikt kan resultat från en kostnadsnyttoanalys, genom att visa patientnyttan med ortopedtekniska hjälpmedel, bidra till en högre kvalitet på den ortopedtekniska verksamheten och även fungera som beslutsstöd vid val av lämpligt hjälpmedel.

Background and Objectives: Economic evaluation and decision analysis provide a framework to evaluate incremental costs and effects associated with alternative health interventions. These methods can also be used as a tool to evaluate alternative clinical behaviours or practice patterns. The objective of this thesis was to investigate the impact of current Canadian practices in human epidermal growth factor receptor-2 (HER2) testing to target trastuzumab in early-stage breast cancer (BC). Methods: Project 1: A systematic review of previous trastuzumab and HER2 testing economic analyses was conducted to identify methodological gaps and key lessons. Project 2: A population-level, retrospective cohort was studied to determine HER2 testing and trastuzumab treatment patterns in Ontario early-stage BC patients. Project 3: A cost-utility analysis of alternative test-treat strategies was conducted using a Markov model of BC calibrated to the Canadian setting, and incorporating Project 2 findings. Results: Project 1: Previous economic evaluations demonstrated that HER2 test accuracy and sequencing were key considerations when modelling the cost-effectiveness of trastuzumab treatment. Consideration of local testing and treatment practices was lacking. Project 2: HER2 testing and treatment practice differed from guidelines, where documentation was available. Only 88% of equivocal results were confirmed, while 57% of HER2 positive patients received trastuzumab. Project 3: Calibration of the BC model minimised gaps between trial-based survival and expected Canadian survival patterns. Deviations from guidelines in practice suggest that primary testing with fluorescence in situ hybridization (FISH) would produce greater health gains at a reduced cost vs. primary immunohistochemistry with FISH confirmation. This finding was more apparent as the prevalence of HER2 positive disease increased. Introduction of newer in situ hybridisation tests may be cost-effective as well. Conclusions: Practice deviations from guidelines are an important consideration when modelling the cost-effectiveness of trastuzumab therapy. Underlying local disease progression and prevalence can also significantly impact outcomes. / Dissertation / Doctor of Philosophy (PhD)

No description available.

No description available.

No / To estimate the clinical and cost-effectiveness of using a skin protectant (Cavilon No Sting Barrier Film [NSBF] or Cavilon Durable Barrier Cream [DBC]; 3M) compared with not using a skin protectant in the management of venous leg ulcers (VLUs), in the UK. Method: A decision model was constructed depicting the patient pathways and associated management of a cohort of patients with and without a Cavilon formulation, plus dressings and compression. The model was based on the case records of a cohort of matched patients from The Health Improvement Network (THIN) database, who were first diagnosed with a VLU between 1 Jan 2008 and 31 Dec 2009. The model estimated the costs and outcomes of patient management over 6 months and the cost-effectiveness of using a Cavilon formulation relative to not using a skin protectant. Results: Patients' mean age was 80.2 years and 61% were female. Sixty-five per cent (n=166) of Cavilon patients received NSBF, and 35% received DBC. Between 6% and 9% of VLUs were healed at 6 months and 53–66% became infected. Healing was affected by a patient's age (OR: 0.944 for each additional year), but not by gender, level of exudate or wound size. There was a significantly greater reduction in wound size among patients in the NSBF group than in the other two groups (p < 0.001). Additionally, there was no significant difference in the initial wound size of those VLUs that did and did not heal in the two Cavilon groups; however, initial size of the VLUs that healed in the control group was significantly smaller than those that did not (p<0.001). Resource use was similar between the three groups. Patients were predominantly managed by practice nurses, with a mean 37–38 nurse visits over the study period. Patients' dressings were changed, on average, every 4–5 days, with a mean of 3 dressings under a compression bandage. The total 6-monthly NHS cost of managing a VLU was ∼£2200. Practice nurse visits were the primary cost driver, accounting for up to 58% of the 6-monthly NHS cost, whereas dressings accounted for < 10% of the cost. Conclusion: Use of NSBF leads to significantly greater wound size reduction than that observed in the other two groups and may facilitate the healing of larger wounds without increasing costs. Hence, use of NSBF for peri-wound skin protection in patients with exuding VLUs is the preferred treatment strategy. / 3M Health Care, manufacturers of Cavillon NSBF and Cavillon DBC

Les gouvernements mondiaux et les organismes internationaux ont placé une haute priorité dans la prévention de la transmission mère-enfant du VIH. Cependant, bien qu'il y ait eu des progrès énormes rapportés dans des nations industrialisées, la situation dans les pays en voie de développement est encore déplorable; on y constate un grand écart entre l’engagement international pour réduire cette voie de transmission et l'accès aux interventions. Ceci peut être attribué à la situation économique déplorable dans plusieurs pays en voie de développement. Des interventions prioritaires en santé doivent donc être soigneusement sélectionnées afin de maximiser l'utilisation efficace des ressources limitées. L’évaluation économique est un outil efficace qui peut aider des décideurs à identifier quelles stratégies choisir. L'objectif de cette revue systématique est de recenser toutes les études d'évaluation économique existantes qui ont été effectuées dans les pays en voie de développement sur la prévention de la transmission mère-enfant du VIH. Notre revue a retenu 16 articles qui ont répondu aux critères d'inclusion. Nous avons conçu un formulaire pour l’extraction de données, puis nous avons soumis les articles à un contrôle rigoureux de qualité. Nos résultats ont exposé un certain nombre de défauts dans la qualité des études choisies. Nous avons également noté une forte hétérogénéité dans les estimations des paramètres de coût et d'efficacité de base, dans la méthodologie appliquée, ainsi que dans les écarts utilisés dans les analyses de sensibilité. Quelques interventions comportant la thérapie à la zidovudine ou à la nevirapine à court terme se sont avérées rentables, et ont enregistré des valeurs acceptables de coût-utilité. Les résultats des évaluations économiques analysées dans cette revue ont varié sur la base des facteurs suivants : la prévalence du VIH, la classification du pays selon le revenu, les infrastructures disponible, les coûts du personnel, et finalement les coûts des interventions, particulièrement les prix des médicaments. / Local governments worldwide and international organizations have placed a high priority in the Prevention of Mother – To – Child – Transmission (pMTCT) of HIV. However, though there have been reports of tremendous progress in achieving these goals in industrialised nations, the situation in developing countries is still deplorable. In developing countries, there is a significant gap between the global and local policy commitments to reduce Mother – To – Child – Transmission (MTCT) of HIV and the access to pMTCT interventions. This can be attributed to the dire economic situation within developing countries. Healthcare interventions therefore need to be strategically prioritized in order to make maximum efficient use of these scarce resources. An effective tool to assist decision makers in identifying which strategies represent value for money is economic evaluation of these interventions. The objective of this study is systematically pool all the existing economic evaluation studies that have been carried out in developing countries on the pMTCT of HIV/AIDS, in order to present the best fit, affordable, yet effective intervention (s). Our review retained 15 articles that met the inclusion criteria. We designed an extraction form which we used to collect relevant data, after which we subjected the articles to a rigorous quality checklist. Our results exposed a number of flaws in methodological quality of the selected studies. We also recorded widespread heterogeneity in the assumptions used to estimate base case cost and effectiveness parameters, in the methodology applied, as well as in the range of valued used in sensitivity analyses. Some interventions involving short course zidovudine or nevirapine therapy were found to be cost effective, and recorded acceptable cost-utility values. The results of economic evaluations analyzed in this review varied based on the following factors: HIV prevalence, country income classification, available infrastructure, staff costs, and ultimately costs of the interventions, especially drug prices.

Les gouvernements mondiaux et les organismes internationaux ont placé une haute priorité dans la prévention de la transmission mère-enfant du VIH. Cependant, bien qu'il y ait eu des progrès énormes rapportés dans des nations industrialisées, la situation dans les pays en voie de développement est encore déplorable; on y constate un grand écart entre l’engagement international pour réduire cette voie de transmission et l'accès aux interventions. Ceci peut être attribué à la situation économique déplorable dans plusieurs pays en voie de développement. Des interventions prioritaires en santé doivent donc être soigneusement sélectionnées afin de maximiser l'utilisation efficace des ressources limitées. L’évaluation économique est un outil efficace qui peut aider des décideurs à identifier quelles stratégies choisir. L'objectif de cette revue systématique est de recenser toutes les études d'évaluation économique existantes qui ont été effectuées dans les pays en voie de développement sur la prévention de la transmission mère-enfant du VIH. Notre revue a retenu 16 articles qui ont répondu aux critères d'inclusion. Nous avons conçu un formulaire pour l’extraction de données, puis nous avons soumis les articles à un contrôle rigoureux de qualité. Nos résultats ont exposé un certain nombre de défauts dans la qualité des études choisies. Nous avons également noté une forte hétérogénéité dans les estimations des paramètres de coût et d'efficacité de base, dans la méthodologie appliquée, ainsi que dans les écarts utilisés dans les analyses de sensibilité. Quelques interventions comportant la thérapie à la zidovudine ou à la nevirapine à court terme se sont avérées rentables, et ont enregistré des valeurs acceptables de coût-utilité. Les résultats des évaluations économiques analysées dans cette revue ont varié sur la base des facteurs suivants : la prévalence du VIH, la classification du pays selon le revenu, les infrastructures disponible, les coûts du personnel, et finalement les coûts des interventions, particulièrement les prix des médicaments. / Local governments worldwide and international organizations have placed a high priority in the Prevention of Mother – To – Child – Transmission (pMTCT) of HIV. However, though there have been reports of tremendous progress in achieving these goals in industrialised nations, the situation in developing countries is still deplorable. In developing countries, there is a significant gap between the global and local policy commitments to reduce Mother – To – Child – Transmission (MTCT) of HIV and the access to pMTCT interventions. This can be attributed to the dire economic situation within developing countries. Healthcare interventions therefore need to be strategically prioritized in order to make maximum efficient use of these scarce resources. An effective tool to assist decision makers in identifying which strategies represent value for money is economic evaluation of these interventions. The objective of this study is systematically pool all the existing economic evaluation studies that have been carried out in developing countries on the pMTCT of HIV/AIDS, in order to present the best fit, affordable, yet effective intervention (s). Our review retained 15 articles that met the inclusion criteria. We designed an extraction form which we used to collect relevant data, after which we subjected the articles to a rigorous quality checklist. Our results exposed a number of flaws in methodological quality of the selected studies. We also recorded widespread heterogeneity in the assumptions used to estimate base case cost and effectiveness parameters, in the methodology applied, as well as in the range of valued used in sensitivity analyses. Some interventions involving short course zidovudine or nevirapine therapy were found to be cost effective, and recorded acceptable cost-utility values. The results of economic evaluations analyzed in this review varied based on the following factors: HIV prevalence, country income classification, available infrastructure, staff costs, and ultimately costs of the interventions, especially drug prices.