Ingela Björholt

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

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.

LAPPRO: A prospective multicentre comparative study of robot-assisted laparoscopic and retropubic radical prostatectomy for prostate cancer

Abstract Objective. This study describes the study design and procedures for a prospective, non-randomized trial comparing open retropubic and robot-assisted laparoscopic radical prostatectomy regarding functional and oncological outcomes. Material and methods. The aim was to achieve a detailed prospective registration of symptoms experienced by patients using validated questionnaires in addition to documentation of surgical details, clinical examinations, medical facts and resource use. Four patient questionnaires and six case-report forms were especially designed to collect data before, during and after surgery with a follow-up time of 2 years. The primary endpoint is urinary leakage 1 year after surgery. Secondary endpoints include erectile dysfunction, oncological outcome, quality of life and cost-effectiveness at 3, 12 and 24 months after surgery. Results. The study started in September 2008 with accrual continuing to October 2011. Twelve urological departments in Sweden well established in performing radical prostatectomy are participating. Personal contact with the participating departments and patients was established to ascertain a high response rate. To reach 80% statistical power to detect a difference of 5 absolute per cent in incidence of urinary leakage, 700 men in the retropubic group and 1400 in the robotic group are needed. Conclusions. The Swedish healthcare context is well suited to performing multicentre long-term prospective clinical trials. The similar care protocols and congruent specialist training are particularly favourable. The LAPPRO trial aims to compare the two surgical techniques in aspects of short- and long-term functional and oncological outcome, cost effectiveness and quality of life, supplying new knowledge to support future decisions in treatment strategies for prostate cancer.

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.

A cost analysis of participation via personal attendance versus telemedicine at a head and neck oncology multidisciplinary team meeting

Multidisciplinary team (MDT) meetings are used for establishing diagnosis, for tumour, node, metastasis (TNM) classification and for treatment in head and neck tumour patients in the western region of Sweden. Because of the distances, telemedicine was introduced to link the regional hospital to two of the three district general hospitals (DGHs). We evaluated the costs of presenting patients face to face (FTF) versus via telemedicine. Cost analyses were based on questionnaires completed by patients presented at the MDT meeting. A total of 39 patients were included in the FTF group and 45 patients in the telemedicine group. The cost analysis showed that FTF presentation cost SEK 2267 versus SEK 2036 by telemedicine (difference not significant). The small difference was explained by the fact that the responsible physician accompanied only six of 39 patients when presented FTF, but when presented via telemedicine the DGH physician always participated. A sensitivity analysis revealed that if the responsible physician always accompanied his/her patient for presentation FTF, the cost would be SEK 5366 per patient. This study shows that costs may be saved by carrying out MDT meetings by means of telemedicine instead of FTF.

The cost of monitoring warfarin in patients with chronic atrial fibrillation in primary care in Sweden

BackgroundWarfarin is used for the prevention of stroke in chronic atrial fibrillation. The product has a narrow therapeutic index and to obtain treatment success, patients must be maintained within a given therapeutic range (International Normalised Ratio;INR). To ensure a wise allocation of health care resources, scrutiny of costs associated with various treatments is justified. The objective of this study was to estimate the health care cost of INR controls in patients on warfarin treatment with chronic atrial fibrillation in primary care in Sweden.MethodsData from various sources were applied in the analysis. Resource consumption was derived from two observational studies based on electronic patient records and two Delphi-panel studies performed in two and three rounds, respectively. Unit costs were taken from official databases and primary health care centres.ResultsThe mean cost of one INR control was SEK 550. The mean costs of INR controls during the first three months, the first year and during the second year of treatment were SEK 6,811, SEK 16,244 and SEK 8,904 respectively.ConclusionINR controls of patients on warfarin treatment in primary care in Sweden represent a substantial cost to the health care provider and they are particularly costly when undertaken in home care. The cost may however be off-set by the reduced incidence of stroke.

Anticoagulant treatment in primary health care in Sweden - prevalence, incidence and treatment diagnosis: a retrospective study on electronic patient records in a registered population

BackgroundThe indications for warfarin treatment in primary health care are increasing. An undertreatment with warfarin is reported in the prevention of embolic stroke in patients with chronic atrial fibrillation, and can be suspected for other indications. Information on the prevalence and incidence of diseases treated with warfarin would reveal useful data for audits concerning management of anticoagulant treatment. We aimed to assess warfarin treatment in primary health care with regard to prevalence, incidence, treatment diagnosis and patient characteristics.MethodsA one-year retrospective study of electronic patient records up to May 2000 in primary health care in Stockholm, Sweden. Five primary health care centres with a registered population of 75 146. Main outcome measures were prevalence, incidence and treatment diagnosis.ResultsFive hundred and seven patients, mean age 71.9 years, were on warfarin treatment. The prevalence was 0.67% (age-adjusted 0.75%), and it was significantly higher for men (0.78%) than for women (0.58%) (p = 0.01). In the age group 75–84 years the prevalence was 4.54%. The most prevalent treatment diagnosis was chronic atrial fibrillation (0.28%), which was more predominant for males (p = 0.02), followed by cerebrovascular disease (0.13%) and deep venous thrombosis (0.13%). The yearly incidence of warfarin treatment was 0.17%, with chronic atrial fibrillation as the predominant treatment diagnosis.ConclusionWarfarin treatment in primary health care is prevalent among the elderly. Chronic atrial fibrillation is the main treatment diagnosis. There is a gender difference favouring men in general and chronic atrial fibrillation as the treatment diagnosis.

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

Open surgery with resection and colostomy (Hartmanns 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 Hartmanns procedure with health economic evaluation within the framework of the DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmanns procedure) for acute diverticulitis with peritonitis) trial.

To what extent do patients in general practice reach guideline lipid-lowering treatment goals?

Background We assessed the extent to which the 1998 European guideline goals were reached among patients on statin treatment. Design A cross-sectional study. Methods A total of 683 consecutive patients on statin treatment were recruited from 48 primary healthcare centres all over Sweden. Serum lipid levels and possible goal-reaching determinants were registered. Results The treatment goal for total cholesterol was met in 55% of patients and for low-density lipoprotein cholesterol in 60% of patients. Male sex and a history of diabetes mellitus or cardiovascular disease increased the likelihood of meeting treatment goals. Conclusions More than half of statin-treated Swedish primary care patients reached the treatment goals. Eur J Cardiovasc Prev Rehabil 14: 149-151

Health Economic Analysis of Open and Robot-assisted Laparoscopic Surgery for Prostate Cancer Within the Prospective Multicentre LAPPRO Trial

BACKGROUND The rapid adoption of robot-assisted laparoscopy in radical prostatectomy has preceded data regarding associated costs. Qualitative evidence regarding cost outcomes is lacking. OBJECTIVE This study assessed how costs were affected by robot-assisted laparoscopic prostatectomy (RALP) compared with open surgery. DESIGN, SETTING, AND PARTICIPANTS Cost analysis was based on the dataset of the LAPPRO (Laparoscopic Prostatectomy Robot Open) clinical trial, which is a prospective controlled, nonrandomised trial of patients who underwent prostatectomy at 14 centres in Sweden between September 2008 and November 2011. Currently, data are available from a follow-up period of 24 mo. INTERVENTION In the LAPPRO trial, RALP was compared with radical retropubic prostatectomy (RRP). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Costs per surgical technique were assessed based on resource variable data from the LAPPRO database. The calculation of average costs was based on mean values; Swedish currency was converted to purchasing power parity US dollar (PPP

Occurrence and quality of anticoagulant treatment of chronic atrial fibrillation in primary health care in Sweden: a retrospective study on electronic patient records

). All tests were two-tailed and conducted at α=0.05 significance level. RESULTS AND LIMITATIONS The cost analysis comprised 2638 men. Based on the LAPPRO trial data, RALP was associated with an increased cost/procedure of PPP