Instructor, Medicine - Primary Care Outcomes Research
Comparative effectiveness research suggests that conservative management (CM) strategies are no less effective than active initial treatment for many men with localized prostate cancer. We estimate longer-term costs of initial management strategies and potential US health expenditure savings by increased use of conservative management for men with localized prostate cancer. Five-year total health expenditures attributed to initial management strategies for localized prostate cancer were calculated using commercial claims data from 1998 to 2006, and savings were estimated from a US population health-care expenditure model. Our analysis finds that patients receiving combinations of active treatments have the highest additional costs over conservative management at $63 500, followed by $48 550 for intensity-modulated radiation therapy, $37 500 for primary androgen deprivation therapy, and $28 600 for brachytherapy. Radical prostatectomy ($15 200) and external beam radiation therapy ($18 900) were associated with the lowest costs. The population model estimated that US health expenditures could be lowered by 1) use of initial CM over all active treatment ($2.9-3.25 billion annual savings), 2) shifting patients receiving intensity-modulated radiation therapy to CM ($680-930 million), 3) foregoing primary androgen deprivation therapy($555 million), 4) reducing the use of adjuvant androgen deprivation in addition to local therapies ($630 million), and 5) using single treatments rather than combination local treatment ($620-655 million). In conclusion, we find that all active treatments are associated with higher longer-term costs than CM. Substantial savings, representing up to 30% of total costs, could be realized by adopting CM strategies, including active surveillance, for initial management of men with localized prostate cancer.
View details for DOI 10.1093/jncimonographs/lgs037
View details for PubMedID 23271781
The optimal community-level approach to control pandemic influenza is unknown.We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization.At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater).Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.
View details for DOI 10.1086/649867
View details for Web of Science ID 000273069100003
View details for PubMedID 20021259
Comparative effectiveness research (CER) has the potential to slow health care spending growth by focusing resources on health interventions that provide the most value. In this article, we discuss issues surrounding CER and its implementation and apply these methods to a salient clinical example: treatment of prostate cancer. Physicians have several options for treating patients recently diagnosed with localized disease, including removal of the prostate (radical prostatectomy), treatment with radioactive seeds (brachytherapy), radiation therapy (IMRT), or--if none of these are pursued--active surveillance. Using a commercial health insurance claims database and after adjustment for comorbid conditions, we estimate that the additional cost of treatment with radical prostatectomy is $7,300, while other alternatives are more expensive--$19,000 for brachytherapy and $46,900 for IMRT. However a review of the clinical literature uncovers no evidence that justifies the use of these more expensive approaches. These results imply that if patient management strategies were shifted to those supported by CER-based criteria, an estimated $1.7 to $3.0 billion (2009 present value) could be saved each year.
View details for Web of Science ID 000284671700010
View details for PubMedID 21302424
Thrombolytic therapy is controversial in patients with submassive pulmonary embolism.We performed a cost-effectiveness analysis to compare health effects and costs of treatment with alteplase plus heparin sodium vs heparin alone in hemodynamically stable patients with pulmonary embolism and right ventricular dysfunction by developing a Markov model and using data from clinical trials and administrative sources.Based on data from a recent randomized trial, we assumed that the risk of clinical deterioration requiring treatment escalation was almost 3 times higher in patients who received heparin alone (23.2% vs 7.6%) but that the risk of death was equal in the 2 cohorts (2.7%). Based on registry data, we assumed that the risk of intracranial hemorrhage was approximately 3 times higher in patients who received alteplase plus heparin (1.2% vs 0.4%). Under these and other assumptions, thrombolysis resulted in marginally higher total lifetime health care costs ($43,900 vs $43,300) and was slightly less effective (10.52 vs 10.57 quality-adjusted life-years) than treatment with heparin alone. Thrombolysis was more effective and cost less than $50,000 per quality-adjusted life-year gained when we assumed that the baseline risk of death in the heparin group was 3 times the base-case value (8.1%) and that alteplase reduced the relative risk of death by at least 10%.Available data do not support the routine use of thrombolysis to treat patients with submassive pulmonary embolism. However, thrombolysis may prove to be cost-effective in selected subgroups of hemodynamically stable patients in whom the risk of death is higher.
View details for Web of Science ID 000243336200010
View details for PubMedID 17210881