Alvin I. Mushlin

The Cost-effectiveness of Automatic Implantable Cardiac Defibrillators:: Results From MADIT

BACKGROUND The recently reported Multicenter Automatic Defibrillator Implantation Trial (MADIT) showed improved survival in selected asymptomatic patients with coronary disease and nonsustained ventricular tachycardia. The economic consequences of defibrillator management in this patient population are unknown. METHODS AND RESULTS Patients were followed up to quantify their use of healthcare services, including hospitalizations, physician visits, medications, laboratory tests, and procedures, during the trial. The costs of these services, including the costs of the defibrillator, were determined in patients randomized to defibrillator and nondefibrillator therapy. Incremental cost-effectiveness ratios were calculated by relating these costs to the increased survival associated with the use of the defibrillator. The average survival for the defibrillator group over a 4-year period was 3.66 years compared with 2.80 years for conventionally treated patients. Accumulated net costs were

Carotid Plaque MRI and Stroke Risk A Systematic Review and Meta-analysis

97,560 for the defibrillator group compared with

The cost-effectiveness of low-dose CT screening for lung cancer: preliminary results of baseline screening.

75,980 for individuals treated with medications alone. The resulting incremental cost-effectiveness ratio of

Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention

27,000 per life-year saved compares favorably with other cardiac interventions. Sensitivity analyses showed that the incremental cost-effectiveness ratio would be reduced to approximately

On the (NEAR) equivalence of cost-effectiveness and cost-benefit analyses

23,000 per life-year saved if transvenous defibrillators were used instead of the older devices, which required thoracic surgery for implantation. CONCLUSIONS An implanted cardiac defibrillator is cost-effective in selected individuals at high risk for ventricular arrhythmias.

Focusing Technology Assessment Using Medical Decision Theory

Background and Purpose— MRI characterization of carotid plaque has been studied recently as a potential tool to predict stroke caused by carotid atherosclerosis. We performed a systematic review and meta-analysis to summarize the association of MRI-determined intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap with subsequent ischemic events. Methods— We performed a comprehensive literature search evaluating the association of carotid plaque composition on MRI with ischemic outcomes. We included cohort studies examining intraplaque hemorrhage, lipid-rich necrotic core, or thinning/rupture of the fibrous cap with mean follow-up of ≥1 month and an outcome measure of ipsilateral stroke or transient ischemic attack. A meta-analysis using a random-effects model with assessment of study heterogeneity and publication bias was performed. Results— Of the 3436 articles screened, 9 studies with a total of 779 subjects met eligibility for systematic review. The hazard ratios for intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap as predictors of subsequent stroke/transient ischemic attack were 4.59 (95% confidence interval, 2.91–7.24), 3.00 (95% confidence interval, 1.51–5.95), and 5.93 (95% confidence interval, 2.65–13.20), respectively. No statistically significant heterogeneity or publication bias was present in the 3 main meta-analyses performed. Conclusions— The presence of intraplaque hemorrhage, lipid-rich necrotic core, and thinning/rupture of the fibrous cap on MRI of carotid plaque is associated with increased risk of future stroke or transient ischemic attack in patients with carotid atherosclerotic disease. Dedicated MRI of plaque composition offers stroke risk information beyond measurement of luminal stenosis in carotid atherosclerotic disease.

Clinical InvestigationsCANCERThe Cost-Effectiveness of Low-Dose CT Screening for Lung Cancer*: Preliminary Results of Baseline Screening

BACKGROUND Low-dose CT scan screening greatly improves the likelihood of detecting small nodules and, thus, of detecting lung cancer at a potentially more curable stage. METHODS To evaluate the cost-effectiveness of a single baseline low-dose CT scan for lung cancer screening in high-risk individuals, data from the Early Lung Cancer Action Project (ELCAP) was incorporated into a decision analysis model comparing low-dose CT scan screening of high-risk individuals (ie, those > or = 60 years with at least 10 pack-years of cigarette smoking and no other malignancies) to observation without screening. Cost-effectiveness was expressed as the incremental cost per year of life saved. The analysis adopted the perspectives of the health-care system. The probability of the different outcomes following the decision either to screen or not to screen an individual at risk was based on data from ELCAP and the Surveillance, Epidemiology, and End Results Registry or published data, respectively. The cost of the screening and treatment of patients with lung cancer was established based on data from the New York Presbyterian Hospitals financial system. The base-case analysis was conducted under the assumption of similar aggressiveness of screen-detected and incidentally discovered lung cancers and then was followed by multiple sensitivity analyses to relax these assumptions. RESULTS The incremental cost-effectiveness ratio of a single baseline low-dose CT scan was 2,500 US dollars per year of life saved. The base-case analysis showed that screening would be expected to increase survival by 0.1 year at an incremental cost of approximately 230 US dollars. Only when the likelihood of overdiagnosis was > 50% did the cost effectiveness ratio exceed 50,000 US dollars per year of life saved. The cost-effectiveness ratios were also relatively insensitive to estimates of the potential lead-time bias. CONCLUSIONS A baseline low-dose CT scan for lung cancer screening is potentially highly cost-effective and compares favorably to the cost-effectiveness ratios of other screening programs.

Influence of Surgical Subspecialty Training on in-Hospital Mortality for Gastrectomy and Colectomy Patients

CONTEXT The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial. OBJECTIVE To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial. DESIGN, SETTING, AND PARTICIPANTS An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin). MAIN OUTCOME MEASURES Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods. RESULTS Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001). CONCLUSION Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.

Diagnostic Decision: The Utility of Routine Chest Radiographs

Many people believe that cost-effectiveness (CE) and cost-benefit (CB) analyses require different assumptions. However, when CE analysis supports decisions to use medical resources, it makes the same assumptions that CB analysis requires. They are mathematically equivalent. Differences between CE and CB hinge more on reporting style than on fundamental assumptions.

Quality Report Cards, Selection of Cardiac Surgeons, and Racial Disparities: A Study of the Publication of the New York State Cardiac Surgery Reports

Combining medical decision theory and epidemiologic information, the authors have devel oped a strategy to assess diagnostic technologies. For any patient, patient utilities with new diagnostic information are compared with the preferred fallback action absent that diagnostic information. After determination of whether the expected value of diagnostic information (EVDI) justifies its cost, the method adds across the eligible population to determine whether the global EVDI justifies the technologys deployment, employing a screen (Hurdle 1) that assumes that the diagnostic device has perfect accuracy. This preliminary evaluation relies on published data on treatment efficacy, population probabilities of illness, etc., but not on new clinical trials. If the technology is not sufficiently cost-effective, even with this optimistic assumption, the strategy recommends against its use. Otherwise, the next step is Hurdle II, in which the critical clinical studies, identified by the decision-theory model, are undertaken. These commonly include measuring the actual diagnostic accuracy of a device, with which the cost-effectiveness is recalculated. These studies in general do not require randomized controlled trials. Key words: technology assessment; decision theory; diagnostic information. (Med Decis Making 8:279-289, 1988)