Lauren E. Cipriano

An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea.

STUDY OBJECTIVESnObstructive sleep apnea (OSA) is a common disorder associated with substantially increased cardiovascular risks, reduced quality of life, and increased risk of motor vehicle collisions due to daytime sleepiness. This study evaluates the cost-effectiveness of three commonly used diagnostic strategies (full-night polysomnography, split-night polysomnography, unattended portable home-monitoring) in conjunction with continuous positive airway pressure (CPAP) therapy in patients with moderate-to-severe OSA.nnnDESIGNnA Markov model was created to compare costs and effectiveness of different diagnostic and therapeutic strategies over a 10-year interval and the expected lifetime of the patient. The primary measure of cost-effectiveness was incremental cost per quality-adjusted life year (QALY) gained.nnnPATIENTS OR PARTICIPANTSnBaseline computations were performed for a hypothetical average cohort of 50-year-old males with a 50% pretest probability of having moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour).nnnMEASUREMENTS AND RESULTSnFor a patient with moderate-to-severe OSA, CPAP therapy has an incremental cost-effectiveness ratio (ICER) of

Cost-Effectiveness Analysis of Risk-Factor Guided and Birth-Cohort Screening for Chronic Hepatitis C Infection in the United States

15,915 per QALY gained for the lifetime horizon. Over the lifetime horizon in a population with 50% prevalence of OSA, full-night polysomnography in conjunction with CPAP therapy is the most economically efficient strategy at any willingness-to-pay greater than

Cost-Effectiveness of Using High-Sensitivity C-Reactive Protein to Identify Intermediate- and Low-Cardiovascular-Risk Individuals for Statin Therapy

17,131 per-QALY gained because it dominates all other strategies in comparative analysis.nnnCONCLUSIONSnFull-night polysomnography (PSG) is cost-effective and is the preferred diagnostic strategy for adults suspected to have moderate-to-severe OSA when all diagnostic options are available. Split-night PSG and unattended home monitoring can be considered cost-effective alternatives when full-night PSG is not available.

Cost-Effectiveness Analysis of Nephron Sparing Options for the Management of Small Renal Masses

Background No consensus exists on screening to detect the estimated 2 million Americans unaware of their chronic hepatitis C infections. Advisory groups differ, recommending birth-cohort screening for baby boomers, screening only high-risk individuals, or no screening. We assessed one-time risk assessment and screening to identify previously undiagnosed 40–74 year-olds given newly available hepatitis C treatments. Methods and Findings A Markov model evaluated alternative risk-factor guided and birth-cohort screening and treatment strategies. Risk factors included drug use history, blood transfusion before 1992, and multiple sexual partners. Analyses of the National Health and Nutrition Examination Survey provided sex-, race-, age-, and risk-factor-specific hepatitis C prevalence and mortality rates. Nine strategies combined screening (no screening, risk-factor guided screening, or birth-cohort screening) and treatment (standard therapy–peginterferon alfa and ribavirin, Interleukin-28B-guided (IL28B) triple-therapy–standard therapy plus a protease inhibitor, or universal triple therapy). Response-guided treatment depended on HCV genotype. Outcomes include discounted lifetime costs (2010 dollars) and quality adjusted life-years (QALYs). Compared to no screening, risk-factor guided and birth-cohort screening for 50 year-olds gained 0.7 to 3.5 quality adjusted life-days and cost

Cost Effectiveness of Alternative Imaging Strategies for the Diagnosis of Small-Bowel Crohn's Disease

168 to

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users.

568 per person. Birth-cohort screening provided more benefit per dollar than risk-factor guided screening and cost

Cost-effectiveness of early colectomy with ileal pouch-anal anastamosis versus standard medical therapy in severe ulcerative colitis.

65,749 per QALY if followed by universal triple therapy compared to screening followed by IL28B-guided triple therapy. If only 10% of screen-detected, eligible patients initiate treatment at each opportunity, birth-cohort screening with universal triple therapy costs

Extended Abstract: Combining Statistical Analysis and Markov Models with Public Health Data to Infer Age-Specific Background Mortality Rates for Hepatitis C Infection in the U.S.

241,100 per QALY. Assuming treatment with triple therapy, screening all individuals aged 40–64 years costs less than

1526 ECONOMIC AND CLINICAL CONSEQUENCES OF NEW ONSET POST-OPERATIVE CHRONIC KIDNEY DISEASE FOLLOWING RADICAL AND PARTIAL NEPHRECTOMY IN THE MANAGEMENT OF SMALL RENAL MASSES

100,000 per QALY. Conclusions The cost-effectiveness of one-time birth-cohort hepatitis C screening for 40–64 year olds is comparable to other screening programs, provided that the healthcare system has sufficient capacity to deliver prompt treatment and appropriate follow-on care to many newly screen-detected individuals.

Economically Efficient Hepatitis C Virus Treatment Prioritization Improves Health Outcomes: Hepatitis C Virus Treatment Prioritization

Background— Many myocardial infarctions and strokes occur in individuals with low-density lipoprotein cholesterol levels below recommended treatment thresholds. High sensitivity C-reactive protein (hs-CRP) testing has been advocated to identify low- and intermediate-risk individuals who may benefit from statin therapy. Methods and Results— A decision analytic Markov model was used to follow hypothetical cohorts of individuals with normal lipid levels but without coronary artery disease, peripheral arterial disease, or diabetes mellitus. The model compared current Adult Treatment Panel III practice guidelines, a strategy of hs-CRP screening in those without an indication for statin treatment by current practice guidelines followed by treatment only in those with elevated hs-CRP levels, and a strategy of statin therapy at specified predicted risk thresholds without hs-CRP testing. Risk-based treatment without hs-CRP testing was the most cost-effective strategy, assuming that statins were equally effective regardless of hs-CRP status. However, if normal hs-CRP levels identified a subgroup with little or no benefit from statin therapy (<20% relative risk reduction), then hs-CRP screening would be the optimal strategy. If harms from statin use were greater than generally recognized, then use of current clinical guidelines would be the optimal strategy. Conclusion— Risk-based statin treatment without hs-CRP testing is more cost-effective than hs-CRP screening, assuming that statins have good long-term safety and provide benefits among low-risk people with normal hs-CRP.