Jeffrey S. Hoch

Cost implications of testing strategy in patients with syncope: Randomized assessment of syncope trial

OBJECTIVES We sought to assess the cost implications of two investigation strategies in patients with unexplained syncope. BACKGROUND Establishing a diagnosis in patients with unexplained syncope is complicated by infrequent and unpredictable events. The cost-effectiveness of immediate, prolonged monitoring as an alternative to conventional diagnostic strategies has not been studied. METHODS Sixty patients (age 66 +/- 14 years; 33 males) with unexplained syncope and LV ejection fraction >35% were randomized to conventional testing with an external loop recorder, tilt and electrophysiologic (EP) testing, or prolonged monitoring with an implantable loop recorder with one-year monitoring. If patients remained undiagnosed after their assigned strategy, they were offered a crossover to the alternate strategy. Cost analysis of the two testing strategies was performed. RESULTS Fourteen of 30 patients who were being monitored were diagnosed at a cost of 2,731 Canadian dollars +/- 285 Canadian dollars per patient and 5,852 Canadian dollars +/- 610 Canadian dollars per diagnosis. In contrast, only six of 30 conventional patients were diagnosed (20% vs. 47%, p = 0.029), at a cost of 1,683 Canadian dollars +/- 505 Canadian dollars per patient (p < 0.0001) and 8,414 Canadian dollars +/- 2,527 Canadian dollars per diagnosis (p < 0.0001). After crossover, a diagnosis was obtained in 1 of 5 patients undergoing conventional testing, compared with 8 of 21 patients who completed monitoring (20% vs. 38%, p = 0.44). Overall, a strategy of monitoring followed by tilt and EP testing was associated with a diagnostic yield of 50%, at a cost of 2,937 Canadian dollars +/- 579 Canadian dollars per patient and 5,875 Canadian dollars +/- 1,159 Canadian dollars per diagnosis. Conventional testing followed by monitoring was associated with a diagnostic yield of 47%, at a greater cost of 3,683 Canadian dollars +/- 1,490 Canadian dollars per patient (p = 0.013) and a greater cost per diagnosis (7,891 Canadian dollars +/- 3,193 Canadian dollars, p = 0.002). CONCLUSIONS A strategy of primary monitoring is more cost-effective than conventional testing in establishing a diagnosis in recurrent unexplained syncope.

Pathogen inactivation: making decisions about new technologies Report of a consensus conference

Methods to remove and inactivate pathogens, used extensively in the manufacture of plasma protein fractions, have all but eliminated transmission of infectious agents by these products. 1 Technologies for reducing the risk of infection from single donor blood components have not been embraced as enthusiastically. Several methods have been introduced in Europe. Treatment with solvent/detergent (S/D) or methylene blue have both been applied to plasma components, and psoralen treatment of platelets (PLTs) has begun in several countries. 2-4 Although S/D-treated pooled plasma has been approved for use in the United States and Canada, none of these methods has been adopted for single-donor products in North America. Reasons for slow acceptance include 1) the current safety of the volunteer blood supply; 2) the success of surveillance and development of screening tests to deal with emerging pathogens; 3) the inability of current technologies to inactivate some agents such as spores, prions, and certain small nonencapsulated viruses; 4) concerns regarding remote risks from the residual chemical agents used during the pathogen inactivation (PI) process; 5) absence of any single method to treat whole blood or all components; and 6) the costeffectiveness of these technologies especially compared to strategies to reduce noninfectious risks of transfusion. 5

Using the Net Benefit Regression Framework to Construct Cost-effectiveness Acceptability Curves: An Example Using Data from a Trial of External Loop Recorders versus Holter Monitoring for Ambulatory Monitoring of "Community Acquired" Syncope

BackgroundCost-effectiveness acceptability curves (CEACs) describe the probability that a new treatment or intervention is cost-effective. The net benefit regression framework (NBRF) allows cost-effectiveness analysis to be done in a simple regression framework. The objective of the paper is to illustrate how net benefit regression can be used to construct a CEAC.MethodsOne hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a one-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). The primary endpoint was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan (OHIP) fee schedule combined with hospital case costing of labour, materials, service and overhead costs for diagnostic testing and related equipment.ResultsIn the loop recorder group, 63.27% of patients (31/49) had symptom recurrence and successful activation, compared to 23.53% in the Holter group (12/51). The cost in US dollars for loop recording was

Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services.

648.50 and

Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis.

212.92 for Holter monitoring. The incremental cost-effectiveness ratio (ICER) of the loop recorder was

Comparison of five measures of motivation to quit smoking among a sample of hospitalized smokers

1,096 per extra successful diagnosis. The probability that the loop recorder was cost-effective compared to the Holter monitor was estimated using net benefit regression and plotted on a CEAC. In a sensitivity analysis, bootstrapping was used to examine the effect of distributional assumptions.ConclusionThe NBRF is straightforward to use and interpret. The resulting uncertainty surrounding the regression coefficient relates to the CEAC. When the link from the regressions p-value to the probability of cost-effectiveness is tentative, bootstrapping may be used.

Cost Effectiveness of EML4-ALK Fusion Testing and First-Line Crizotinib Treatment for Patients With Advanced ALK-Positive Non–Small-Cell Lung Cancer

BackgroundHomeless individuals often suffer from serious health conditions and are frequently hospitalized. This study compares hospitalization costs for homeless and housed patients, with and without adjustment for patient and service characteristics. MethodsAdministrative data on 93,426 admissions at an academic teaching hospital in Toronto, Canada, were collected over a 5-year period. These data included an identifier for patients who were homeless. Each admission was allocated a cost in Canadian dollars based on Ontario Case Costing methodology. Associations between homeless status and cost were examined for the entire sample and stratified by medical, surgical, and psychiatric services. ResultsData were analyzed for 90,345 housed patient admissions (mean cost,

End-of-Life Care for Lung Cancer Patients in the United States and Ontario

12,555) and 3081 homeless patient admissions (mean cost,

Cost-effectiveness of screening for anal precancers in HIV-positive men.

13,516). After adjustment for age, gender, and resource intensity weight, homeless patient admissions cost

Impact of a specialized early intervention service for psychotic disorders on patient characteristics, service use, and hospital costs in a defined catchment area.

2559 more than housed patient admissions (95% CI,