Search

To evaluate the cost-effectiveness of tympanostomy tube placement vs. nonsurgical medical management, with the option of tympanostomy tube placement in the event of treatment failure, in children with recurrent acute otitis media (AOM).A Markov decision model compared management strategies in children ages 6 to 35 months, using patient-level data from a recently completed, multicenter, randomized clinical trial of tympanostomy tube placement vs. medical management. The model ran over a two-year time horizon using a societal perspective. Probabilities, including risk of AOM symptoms, were derived from prospectively collected patient diaries. Costs and quality-of-life measures were derived from the literature. We performed one-way and probabilistic sensitivity analyses, and secondary analyses in predetermined low- and high-risk subgroups. The primary outcome was incremental cost per quality-adjusted life-year gained.Tympanostomy tubes cost $989 more per child than medical management. Children managed with tympanostomy tubes gained 0.69 more quality-adjusted life-days than children managed medically, corresponding to $520,855 per quality-adjusted life-year gained. Results were sensitive to the costs of oral antibiotics, missed work, special childcare, the societal cost of antibiotic resistance, and the quality of life associated with AOM. In probabilistic sensitivity analyses, medical management was favored in 66% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. Medical management was preferred in secondary analyses of low- and high-risk subgroups.For young children with recurrent AOM, the additional cost associated with tympanostomy tube placement outweighs the small improvement in quality of life. Medical management for these children is an economically reasonable strategy.

Objectives To evaluate the cost-effectiveness of abusive head trauma detection strategies in emergency department settings with and without rapid magnetic resonance imaging (rMRI) availability. Study design A Markov decision model estimated outcomes in well-appearing infants with high-risk chief complaints. In an emergency department without rMRI, we considered 3 strategies: clinical judgment, universal head computed tomography (CT) scan, or the Pittsburgh Infant Brain Injury Score (PIBIS) with a CT scan. In an emergency department with rMRI for brain availability, we considered additional strategies: universal rMRI, universal rMRI with a CT scan, PIBIS with rMRI, and PIBIS with rMRI followed by a CT scan. Correct diagnosis eliminated future risk; missed abusive head trauma led to reinjury risk with associated poor outcomes. Cohorts were followed for 1 year from a healthcare perspective. One-way and probabilistic sensitivity analyses were performed. The main outcomes evaluated in this study were abusive head trauma correctly identified and incremental cost per quality-adjusted life-year. Results Without rMRI availability, PIBIS followed by a CT scan was the most cost-effective strategy. Results were sensitive to variation of CT scan-induced cancer parameters and abusive head trauma prevalence. When rMRI was available, universal rMRI followed by a confirmatory CT scan cost $25 791 to gain 1 additional quality-adjusted life-year compared with PIBIS followed by rMRI with a confirmatory CT scan. In both models, clinical judgement was less effective than alternative strategies. Conclusions By applying CT scans to a more targeted population, PIBIS decreases radiation exposure and is more effective for the identification of abusive head trauma compared with clinical judgment. When rMRI is available, universal rMRI with a CT scan is more effective than PIBIS and is economically favorable.

Objective To assess whether antimicrobial therapy in young children with acute otitis media reduces time to resolution of symptoms, overall symptom burden, and persistence of otoscopic evidence of infection. We used a cost-utility model to evaluate whether immediate antimicrobial treatment seems to be worthwhile, and if so, which antimicrobial agent is most cost effective. Study design We compared the cost per quality-adjusted life-day of 5 treatment regimens in children younger than 2 years of age with acute otitis media: immediate amoxicillin/clavulanate, immediate amoxicillin, immediate cefdinir, watchful waiting, and delayed prescription (DP) for antibiotic. Results The 5 treatment regimens, listed in order from least effective to most effective were DP, watchful waiting, immediate cefdinir, immediate amoxicillin, and immediate amoxicillin/clavulanate. Listed in order from least costly to most costly, the regimens were DP, immediate amoxicillin, watchful waiting, immediate amoxicillin/clavulanate, and immediate cefdinir. The incremental cost-utility ratio of immediate amoxicillin compared with DP was $101.07 per quality-adjusted life-day gained. The incremental cost-utility ratio of immediate amoxicillin/clavulanate compared with amoxicillin was $2331.28 per quality-adjusted life-day gained. Conclusions In children younger than 2 years of age with acute otitis media and no recent antibiotic exposure, immediate amoxicillin seems to be the most cost-effective initial treatment.

To evaluate granulocyte colony-stimulating factor (G-CSF) as an early marker of bacterial or fungal infection in neonates.We measured G-CSF levels in infants of varying gestational and postnatal ages. We separated the infants into three groups: group 1, positive bacterial or fungal blood culture result; group 2, negative blood culture result but evidence of clinical sepsis; and group 3, negative blood culture result and no or weak evidence of sepsis. Comparison of mean G-CSF levels by group was accomplished by an analysis of variance.One hundred seventy-six evaluations for sepsis were done for 156 infants with gestational ages ranging from 24 to 43 weeks; 50% of these infants were less than 35 weeks of gestational age. The mean G-CSF levels of groups 1 and 2 were significantly higher than those of group 3. The mean G-CSF level of each group was 2278 pg/ml (group 1), 1873 pg/ml (group 2), and 280 pg/ml (group 3) (p0.001). On the basis of a cutoff level of 200 pg/ml, the sensitivity of the test was 95%, specificity 73%, positive predictive value 40%, and negative predictive value 99%.G-CSF levels represent a sensitive marker of infection in neonates of all gestational ages.

Objective To address the cost-effectiveness of thrombophilia testing and treatment strategies among children with a first episode of thrombosis. Study design A 2-year Markov model was developed to evaluate the cost-utility of 3 strategies: (1) no testing, anticoagulate for 3 months, (2) no testing, anticoagulate for 6 months, and (3) testing, anticoagulate 3 or 6 months, based on results. We performed a literature search to estimate clinical probabilities and obtained quality-of-life and cost data from published sources. Results Total costs per patient were $7900 for no test, treat for 3 months; $8900 for test, treat based on results; and $12 100 for no test, treat for 6 months. Three months of treatment without testing was the least expensive strategy and also the most effective (1.74 quality-adjusted life-years) by 0.01 to 0.03 quality-adjusted life-years. Cost-utility ratios were sensitive to variation in hospitalization and medication costs, but 3 months, no testing, always remained the preferred choice. Conclusions Universal thrombophilia testing after a first episode of thrombosis is not cost-effective when used solely to determine anticoagulation duration. Therefore, a full panel of thrombophilia studies does not need to be an automatic response at the time of any deep venous thrombosis diagnoses.

Abstract 2476 Poster Board II-453 Introduction: It is unknown whether it is cost effective to screen adolescents with menorrhagia for von Willebrand disease (VWD) prior to starting oral contraceptive pills (OCPs). Because OCPs can mask a diagnosis of VWD, a woman is at risk for potential future traumatic or surgical bleeding, once OCPs are stopped. We, therefore, designed a decision analysis model to evaluate the cost utility of VWD testing in adolescents with menorrhagia. Methods: A 20-year Markov decision analytic model was constructed to evaluate the cost-utility of two strategies: testing or not testing for VWD. The hypothetical patient is a 15-year-old female presenting with menorrhagia and a decision regarding VWD testing is made. The model includes probabilities of remaining well, suffering an acute menorrhagia bleeding event, surgical complications, OCP complications or dying. Probabilities, costs and utilities were estimated from published literature. The prevalence of type 1 VWD in adolescent females with menorrhagia was estimated to be 13%. We assumed all patients were treated with OCPs regardless of whether hemostatic testing was performed. All patients were assumed to have mild type I VWD, the most common subtype, and all were responsive to intravenous DDAVP. Probabilities of surgical complications in patients with and without VWD were based on adenotonsillectomy hemorrhage rates in children. The probability of acute menorrhagia bleeding necessitating hospitalization or red blood cell transfusion was estimated to be 1% in an adolescent with VWD and 0% in an adolescent with normal hemostatic testing. The sole complication from OCPs incorporated into this decision analytic model was acute deep vein thrombosis. Results: The cost of testing adolescents with menorrhagia for VWD was $1,638, vs. $1,251 for not testing for VWD. The effectiveness of not testing in quality-adjusted life-year (QALY) gained (14.237 QALY) was similar to the VWD testing strategy (14.246 QALY). Compared to not testing for VWD, screening for VWD had an incremental cost-effectiveness ratio (ICER) per QALY of $45,061/QALY, a value typically considered economically reasonable. In one-way sensitivity analysis, the outcome and ICER were most sensitive to the probabilities of an acute bleeding event, surgical complication, and the prevalence of VWD. Monte Carlo probabilistic sensitivity analysis, substituting input distributions rather than a single point estimate for the probabilities, costs and utilities, was also performed. Under this assumption, testing for VWD is a cost-effective strategy approximately 60% of the time when the cost-effectiveness threshold is $100,000/QALY. Conclusions: It is cost effective to perform VWD testing in adolescents presenting with menorrhagia prior to initiating OCPs. This is related to avoiding cost from postoperative and other bleeding when the diagnosis is masked by OCPs. Disclosures: No relevant conflicts of interest to declare.