Marco Oradei

Cost-effectiveness analysis of transnasal fentanyl citrate for the treatment of breakthrough cancer pain

Introduction: Pain is a symptom of cancer and is categorized in two forms: background pain to be treated with analgesics, and breakthrough cancer pain (BTcP), which needs drug treatment on demand. We present a cost-effectiveness analysis of transnasal fentanyl citrate as an alternative to morphine. Methods: A Markov model considers a cohort of 100 patients on a daily basis. Effectiveness was included by selecting three clinical studies. Side effects, hospitalizations and visits were valued by referring to national formularies. Utility data were used to differentiate the health status inherent to BTcP. Results: The incremental cost-effectiveness ratio of transnasal fentanyl citrate is 10,140 euros/QALY. Sensitivity analysis shows that with a threshold of 30,000 euros/QALY, the treatment of BTcP with transnasal fentanyl citrate would have an 86% probability of being cost-effective. Conclusion: Transnasal Fentanyl citrate is cost-effective, therefore represents a good investment in health.

Use of robot-specific resources and operating room times: the case of Telelap Alf-X robotic hysterectomy

The aim of this study was to identify, quantify and evaluate the use of robotic materials and operating theatre times in Telelap ALF‐X robotic hysterectomy.

Economic evaluation of nuclear medicine procedures

Healthcare regulators anxious to contain spiralling healthcare costs have started to look hard at the area of medical imaging, alarmed by its rapid expansion. However, although it may be tempting to spend less on medical imaging in an attempt to cut costs, in many settings increasing medical imaging would actually reduce healthcare costs, and also improve patient outcomes [1]. So-called health economic evaluations are studies that consider the costs and outcomes of given diagnostic procedures and interventions, aiming to optimise the allocation of health service resources and thereby maximise the level of health in the population of interest. There are three main types of evaluation: cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA) [2]. The CEA takes a common effectiveness measure (e.g. cost per accurately diagnosed patient or per life year gained) and uses it to compare alternative interventions, also taking into account their relative costs. The incremental cost-effectiveness ratio (ICER) is a parameter calculated in order to effect these comparisons, whose results may, for example, be stated in terms of costs per life year gained. The ICER highlights the additional costs generated by the implementation of a new diagnostic test or intervention and relates them to the health outcome: ICER=(costsnew test— costsstandard test)/( life years gainednew test—life years gainedstandard test). Acceptable ICER thresholds (maximum ICERs)—i.e., the levels at which the funding of health interventions is deemed justified on the basis of the benefit to the population—differ between countries according to wealth and societal preferences. For instance, the UK National Institute for Health and Clinical Excellence (NICE) defines a threshold of £30,000 per additional life year gained as acceptable. The advantages of the CEA are its simplicity and its costs, which are usually lower than those incurred by the CUA and the CBA. In fact, whereas CEAs usually measure effectiveness in daily, routine care or in clinical trials, in CUAs and CBAs patients have to be specially interviewed [2]. Cost-effectiveness analyses usually measure health outcome in terms of life years gained, but in some cases it is necessary to consider not only the “quantity” of life gained but also the “quality” of life (as in the case of palliative care, for example). In such cases, the unit of measure normally used is defined “quality-adjusted life year” (QALY) and the CUA “Focus on...” abridgements aim to highlight papers published within the past year and draw extensively on the texts and summaries of the articles referenced. Less recent citations are also included when deemed useful to provide background information on the topic reviewed.

Impact of technology overlapping: A case study on colorectal cancer screening

OBJECTIVES Technology overlapping is a phenomenon based on the availability of different technologies to treat the same morbidity in the same patient group. The aim of this study was to explore the cost-effectiveness of technology overlapping in a case study on colorectal cancer (CRC), and describe an approach to investigate the phenomena and to propose adequate interventions. METHODS A Semi-Markov model, based on a cohort of 10,000 people undergoing a CRC diagnostic test, was developed to simulate the overlapping phenomena and compare it with hypothetical scenarios where only one diagnostic tool is available. Deterministic sensitivity analyses were conducted on parameters with the greatest uncertainty. RESULTS The results of the Semi-Markov model indicated that technology overlapping is not cost-effective. CONCLUSIONS This study is a first attempt to address the significance of technology overlapping. The Semi-Markov model demonstrated that technology overlapping is the least cost-effective arm, so alternate health care policies must be investigated.

Corticosteroidi per via Intravitreale per il Trattamento Dell'edema Maculare: Revisione e Valutazione Della Qualità Dell'evidenza:

Intravitreal corticosteroids for the treatment of macular edema: review and assessment of quality of the evidence Introduction Treatment options for macular edema include intravitreal corticosteroids. Traditionally, an injectable suspension of triamcinolone acetonide (TA) had been employed off-label; in recent years, authorities have approved sustained-release drug delivery systems (DDSs) for corticosteroids. This review aims to compare the quality of the evidence on efficacy and safety of three different formulations of intravitreal corticosteroids: the dexamethasone (DEX) implant, the fluocinolone acetonide (FA) implant, and the preservative-free injectable suspensions of TA, in the management of two retinal pathologies: diabetic macular edema (DME) and macular edema secondary to retinal vein occlusion (RVO). Methods A search of clinical trials on MEDLINE from 01/01/2000 to 12/16/2015 was performed. Studies were included in the analysis if they met the following criteria: i) related to at least one of the preparations of interest in patients with DME or macular edema secondary to RVO; ii) included a control group treated with placebo, observation, sham procedures or conventional treatments; and iii) included visual acuity, retinal thickness and/or safety parameters as outcomes. Results were summarized in a narrative manner. Results Twenty-five publications from 19 RCTs were included. We observed increased attention of researchers towards TA compared to DEX and FA; however, studies for TA are less robust. Scientific publications related to DEX and FA implants are of higher quality, especially in terms of randomization and masking procedures. Discussion Although trials on TA are numerous, evidence on DEX and FA implants is more robust. Since their introduction, these relatively new DDSs have been included in the main guidelines for the management of macular edema.

Cost Effectiveness Analysis of Instanyl for the Treatment of Breakthrough Cancer Pain (BtcP)

Background: Breakthrough cancer pain (BTcP) is a transitory exacerbation of the intensity of the pain in a patient with background pain that is well controlled by analgesic treatment (with morphine). The drugs most widely used to treat individual episodes of BTcP are the opioids. Better results can be obtained with Instanyl. So far, while several studies have proven the effectiveness of Istanyl, limited evidence is actually available on the economic affordability for a third party payer (i.e. National Healthcare Systems). In this paper we perform a cost effectiveness analysis, whose aim is to estimate the cost per Quality Adjusted Life Year (QALYs) of Istanyl compared to the use of morphine. Methods: The analysis was carried out by constructing a Markov model that simulates the natural history of a hypothetical cohort of 100 advanced cancer patients: the patients in the case arm of the study are treated with Instanyl, and those in the control arm with morphine. Consistently with the Instanyl treatment indications, the hypothesis was that patients would have a minimum of 1 to a maximum of 4 episodes of BTcP per day, and that administration of Instanyl might cause side effects which influence both cost and quality of life (QoL). Based on the data in the literature, we populated our model considering the probability of the daily frequency of episodes of BTcP and the associated probability of side effects reported in the literature. Quality of life weights were used to differentiate the health status associated to BTcP depending on whether Instanyl or placebo was used. Probabilistic sensitivity analysis was conducted to assess the variability of results associated to the variation of costs, side effects episodes, daily BTcP episodes and BTcP prevalence. Results: The results of our analysis show that the treatment of BTcP with Instanyl costs 8,893 euros with an outcome of 0.63 QALYs, whilst the treatment with morphine costs of 6,431 euros for a QALY of 0.29. These data generate an ICER of 10,140 euros/QALY. Overall, the Cost Effectiveness Acceptability Curve shows that the treatment of BTcP with Instanyl would have an 86% probability of having a cost lower of 30,000 euro/QALY. The results clearly show that Istanyl administration is a good and sustainable investment in health, despite the collateral effects and the short life expectancy of advanced cancer patients.