The increasing use of advanced nucleic acid sequencing technologies for clinical diagnostics and therapeutics has made vital understanding the costs of performing these procedures and their value to patients, providers, and payers. The Association for Molecular Pathology invested in a cost and value analysis of specific genomic sequencing procedures (GSPs) newly coded by the American Medical Association Current Procedural Terminology Editorial Panel. Cost data and work effort, including the development and use of data analysis pipelines, were gathered from representative laboratories currently performing these GSPs. Results were aggregated to generate representative cost ranges given the complexity and variability of performing the tests. Cost-impact models for three clinical scenarios were generated with assistance from key opinion leaders: impact of using a targeted gene panel in optimizing care for patients with advanced non-small-cell lung cancer, use of a targeted gene panel in the diagnosis and management of patients with sensorineural hearing loss, and exome sequencing in the diagnosis and management of children with neurodevelopmental disorders of unknown genetic etiology. Each model demonstrated value by either reducing health care costs or identifying appropriate care pathways. The templates generated will aid laboratories in assessing their individual costs, considering the value structure in their own patient populations, and contributing their data to the ongoing dialogue regarding the impact of GSPs on improving patient care.
Mandibular advancement devices (MADs) may enhance upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility, thereby helping to prevent obstruction of the upper airway. 1 Although MADs are commonly used for the management of obstructive sleep apnea (OSA) in adults, their use in pediatric patients is less common, with limited information available regarding their efficacy. 2 However, for pediatric patients in whom continuous positive airway pressure (CPAP) has failed, who are interested in nonsurgical interventions, or who are awaiting future surgical interventions, an MAD may be an option. This report details one such case, and the successful treatment of OSA with an MAD after failure to tolerate CPAP in a pediatric patient awaiting orthognathic surgery.
BACKGROUND:
Cardiac Resynchronization Therapy (CRT) is clinically effective and cost-effective, although some patients realize 6-Month (6M) improvements while others do not. Long-term differences in outcomes among short term “responders” and “non-responders” are not reported. We compared survival, burden of Heart Failure (HF) hospitalization, and Average Length of Stay (ALOS), by Clinical Composite Score (CCS) at 6M post-implant, which was used to assess short-term CRT response.
METHODS:
MIRACLE, MIRACLE-ICD, InSync III Marquis, PROSPECT and Adaptive CRT were pooled. Classification of responder status was made at 6M; patients who died post-implant and before CCS assessment at 6M were excluded. We adjusted for differences in baseline characteristics between CCS. HF hospitalizations before 6M were excluded from HF rate calculations. Hospitalizations resulting in death were excluded from the ALOS analysis. Mortality was assessed via Kaplan-Meier curves and Cox regression; HF hospitalization rates using Poisson regression with robust variance estimates; long-term extrapolations used Markov modelling.
RESULTS:
We identified 1,089 Improved (“I”, 67.94%), 235 Unchanged (“U”, 14.66%) and 279 Worsened (“W”, 17.4%) patients. 18M post-implant, 91.5% I patients were alive vs. 89.9% U and 69.9% W (Unadjusted HR I vs. U 0.68 (0.37-1.27), I vs. W 0.24 (0.15-0.37), and U vs. W 0.34 (0.18-0.65), Log-Rank p<0.001). I patients were projected to survive 8.007 years vs. 7.967 U and 1.815 W. Post-CCS assessment HF hospitalization rates in the first year were 0.13 for I, 0.27 for U and 0.90 for W (p<0.0001) leading to a lifetime projection of 1.04, 2.14 and 2.54 total hospitalizations per patient respectively. Adjusted ALOS was directionally favoring I (4.87, 8.06 and 8.38 respectively) but non-significant (p=0.14).
CONCLUSIONS:
Patients who improve or remain unchanged 6M after CRT implant are projected to live longer and consume fewer resources than patients who worsen.
Twelve-month time horizon was developed. Cost data specific for the Polish health care system was based on retrospective medical record review of patients with ulcerative colitis. Resource use associated with the surgery was based on clinical expert opinion. The unit costs of treatment were derived from Polish official tariff lists for health care services paid by public payer. Average body weight of the patient (60 kg) was based on data from registry of patients with Crohn's disease, assuming the similar nature of the disease. RESULTS: Infliximab was associated with a gain of 0.21 quality adjusted life years (QALYs) compared with colectomy. Additional costs associated with the biological treatment were estimated at 14,793 PLN. Incremental cost-utility ratio was estimated at 69,984 PLN/QALY for infliximab compared with colectomy. The sensitivity analysis showed a relative consistency of results. CONCLUSIONS: The estimated cost per QALY is much below official threshold (99,543 PLN/QALY) which indicates that treatment with infliximab is cost effective compared with surgical treatment in Polish conditions.
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