Steven M. Teutsch

Episodic versus prophylactic infusions for hemophilia A: A cost-effectiveness analysis

OBJECTIVE To assess the incremental cost-effectiveness of prophylactic compared with episodic care in boys with severe hemophilia A. SETTING Eleven U.S. hemophilia treatment centers. METHODS Charge data from a randomly selected cohort of 70 boys receiving episodic infusions for bleeding events and from all 27 boys receiving infusions prophylactically were collected from documents obtained from the hemophilia treatment centers during a period of approximately 2 years. Published and public sources were used for conversion to cost, lifetime earnings, and earnings losses from disability. A model was constructed for a hypothetical patient from ages 3 to 50 years by means of three infusion scenarios. RESULTS The cohort receiving prophylactic treatment had fewer bleeding events each year (median, 3 vs 31) but used more concentrate (3323 vs 1015 units/kg per year). Factor VIII concentrate accounted for more than 93% of the cost of both episodic and prophylactic care. Compared with episodic infusion, prophylaxis from ages 3 to 20 years costs

Gestational Diabetes: Incidence, Maternal Characteristics, and Perinatal Outcome

1100 per bleeding event prevented, in comparison with

Mortality among Diabetic Patients Using Continuous Subcutaneous Insulin-Infusion Pumps

1380 for prophylaxis from ages 3 to 50 years. The total cost of prophylactic care from ages 3 to 50 years would equal the current total cost of episodic care if the price of the concentrate were decreased by 50%. CONCLUSION Prophylactic care markedly reduces the number of bleeding events and should prevent joint function impairment, but at substantial cost.

An Approach to the Prevention of Blindness in Diabetes

Accurate estimates of the incidence of abnormal glucose tolerance during pregnancy are virtually nonexistent. Screening select populations of women with risk factors for the condition and the nonrandom, nonpopulation-based nature of most studies have given rise to wide variances in reported incidence. We analyzed data from the states of Mississippi and Washington and from the National Natality and Fetal Mortality Surveys conducted in 1980 in an attempt to provide more accurate population-based estimates of the incidence of gestational diabetes mellitus (GDM). In the national surveys GDM was noted (screening and diagnostic criteria were unavailable) as a complication in 0.38% of all sampled pregnancies; overt (type I and type II) diabetes was noted in 0.78%. Mean maternal age for the GDM group was 28.4 yr; 85% were white (81% controls) and 15% non-white (19% controls). Prepregnancy weights were higher in the GDM group by an average of 20 Ib. However, mean weight gain was less in this group than in controls (23 versus 29 Ib). Perinatal mortality was noted in approximately 2.8% (1.3% in controls) of the offspring in GDM-complicated pregnancies and congenital malformations in 6.4% (7.9% in controls). Methodologic problems were encountered and included lack of screening and diagnostic criteria, underreporting, and underrecording.

Increasing the supply of cadaveric kidneys for transplantation.

Because of concern about deaths among diabetic patients using continuous subcutaneous insulin-infusion pumps, we conducted an investigation to determine whether the number of such deaths was excessive. By October 1982 we had identified 35 deaths among the estimated 3500 diabetic patients using pumps in the United States. The observed number of deaths was not greater than the expected number calculated from age-specific death rates for conventionally treated patients with Type I diabetes. The causes of death were not unusual, with two exceptions. One death was associated with malfunction of the device, and the other was attributed to acute bacterial endocarditis that arose from an abscess at the catheter-insertion site. Patients who died had high rates of autonomic neuropathy (66 per cent) and renal disease (39 per cent with serum creatinine levels above 5 mg per deciliter). We conclude that the use of continuous subcutaneous insulin-infusion pumps is not associated with excess mortality. However, certain types of patients may be at greater risk for death, and physicians should take great care in selecting patients for pump therapy.

An Epidemiologic Model for Diabetes Mellitus: Incidence, Prevalence, and Mortality

Diabetic eye disease is the leading cause of new cases of legal blindness in American adults under the age of 65 yr. Diabetic persons are at risk for visual loss due to diabetic retinopathy, glaucoma, and cataracts. Better understanding of the natural histories of these complications and recent advances in treatment have provided a rationale for developing an approach to prevent visual loss. This approach requires that diabetic patients who are at high risk for visual loss, and not under the care of ophthalmologists, be systematically screened, referred, and treated.

A cost-effectiveness evaluation of newborn hemoglobinopathy screening from the perspective of state health care systems

The number of cadaveric kidneys currently available for transplantation is insufficient. Therefore, the Center for Disease Control (CDC) undertook a collaborative project with the two transplant programs in Georgia to increase the retrieval of cadaveric kidneys. We used retrospective analysis to select productive hospitals, hospital-specific surveillance systems to identify potential donors, and procurement and retrieval evaluation to identify preventable deficiencies. During 900 hospital months of prospective surveillance, we identified a total of 555 potential donors by death record review, giving a potential donor rate of 2.3 donors/100 deaths (110 kidneys/million population/ year). We observed an increase in the number of referrals, consent obtained from next of kin, and kidneys retrieved. This period of intensive activity demonstrated that additional kidneys can be retrieved by using systematic methods.

Diabetes and renal mortality in the United States

An epidemiologic model is developed to describe the incidence, prevalence, and mortality of diabetes. Available data are reviewed, analyzed, and applied to the model. The model provides a framework for understanding diabetes on a population basis, and is useful inidentifying needs and facilitating health care planning.

Evidence synthesis and evidence-based decision making: related but distinct processes.

OBJECTIVE To determine the most cost-effective strategy for newborn hemoglobinopathy screening from the perspective of state health care systems. STUDY DESIGN Using Alaska as an example, we used decision analysis to compare a policy of no screening to universal or targeted screening with selective follow-up only of infants who are homozygous or compound heterozygous for an abnormal hemoglobin variant and to universal or targeted screening with complete follow-up, including follow-up of infants with clinically insignificant traits. Probabilities and costs were varied over values that might be expected for other states. RESULTS Among the selective follow-up options, targeted screening would be the most cost-effective strategy for Alaska at a cost of

Sentinel health events surveillance in diabetes Deaths among persons under age 45 with diabetes

206,192 per death averted; by contrast, universal screening would prevent 50% more deaths at an incremental cost of