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Objectives: To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction.Methods: An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated.Results: On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY.Conclusions: Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate how the optimal decision and level of uncertainty associated with that decision, can be presented when assessing the cost-effectiveness of multiple options. To explore and explain potentially counterintuitive results that can arise when analyzing multiple options. Methods: A template was created, based on the assumption of multivariate normality, in order to replicate a previous analysis that compared the cost-effectiveness of multiple options. We used this template to explain some of the different shapes that the cost-effectiveness acceptability curve (CEAC), cost-effectiveness acceptability frontier (CEAF), and expected value of perfection information (EVPI) may take, with changing correlation structure and variance between the multiple options. Results: We show that it is possible for 1) an option that is subject to extended dominance to have the highest probability of being cost-effective for some values of the cost-effectiveness threshold; 2) the most cost-effective (optimal) option to never have the highest probability of being cost-effective; and 3) the EVPI to increase when the probability of making the wrong decision decreases. Changing the correlation structure between multiple options did not change the presentation of results on the cost-effectiveness plane. Conclusion: The cost-effectiveness plane has limited use in representing the uncertainty surrounding multiple options as it cannot represent correlation between the options. CEACs can represent decision uncertainty, but should not be used to determine the optimal decision. Instead, the CEAF shows the decision uncertainty surrounding the optimal choice and this can be augmented by the EVPI to show the potential gains to further research. [ABSTRACT FROM AUTHOR]

Summary: Objective: To examine what factors are associated with EuroQol EQ-5D scores in children after unilateral cochlear implantation and to explore parental conceptualisations of health-related quality of life (HRQL) and quality of life (QoL). Methods: Face to face interviews were conducted with the parents of 222 implanted children, in an attempt to elicit information on their child''s HRQL and QoL. Post-implant, the child''s HRQL was measured using the EQ-5D, completed by parental proxy. Regression analysis was undertaken in order to estimate the association between the child EQ-5D score and child characteristics, child performance, and parental characteristics, in order to assess the construct validity of the EQ-5D. HRQL was also measured using the EuroQol visual analogue scale (VAS), where the endpoints were the best and worst imaginable health state, and a VAS was also used to measure QoL (endpoints: best/worst imaginable QoL). Parents were asked to estimate scores on both these VAS measures both post-implantation and (retrospectively) pre-implantation. Throughout the HRQL and QoL elicitation process, subjects’ comments, and observations were noted. Results: Children who had an additional disability (p <0.001), were male (p <0.05) or had a lower level of auditory perception (p <0.001) were estimated to have lower EQ-5D scores, as were children whose parents who left school before age 18 years (p <0.05). According to the EuroQol VAS the mean difference between pre- and post-implantation score was 0.14, compared to 0.35 for the QoL VAS, demonstrating that parents tended not to see HRQL and QoL as equivalent. As 67% of parents deemed there to be no difference between the pre- and post-implant EuroQol VAS scores we also infer that the majority of parents rejected the notion of deafness being a HRQL issue. Conclusion: The evidence relating to the construct validity of the EQ-5D is variable—though it was able to discriminate between children with certain levels of auditory performance, it could not discriminate between children who differed in other ways. By limiting outcome from cochlear implantation to HRQL, as opposed to QoL, the benefits of cochlear implants are likely to be underestimated. [Copyright &y& Elsevier]

Objective: Pediatric cochlear implantation (CI) entails surgery followed by lifetime maintenance, and hence incurs both initial and ongoing costs. Previous assessments of these costs were either undertaken early in the evolution of services, or were based on single hospitals, or estimated costs largely from hospital charges. The aim was to overcome these limitations by conducting a multi-center evaluation of the costs of providing unilateral CI to children in the United Kingdom (UK). Methods: Annual numbers of implantations in all UK pediatric CI programs were monitored prospectively from 1991. Resource use was measured in 12 programs in 1998/1999 and retrospectively back to the year of inception of each program. The profile of outpatient and outreach visits was assessed in the 12 programs. Together these variables were used to estimate health-service costs for four phases of management: pre-operative assessment, implantation, tuning, and subsequent maintenance, using economic micro-costing methods. Costs were subsequently estimated for all children implanted in 1998/1999 (N=199) and were aggregated over 1, 15, and 73 years following implantation. To assess the robustness of cost estimates, parameter values were varied over plausible ranges and costs re-estimated. Total UK health-service costs were also estimated. All costs are presented in euros (€1=US$0.98=£0.65, 1st July 2002), inflated to 2000/2001 financial-year levels, and discounted at 6% per annum. Results: Per-child average costs were €42 972 (1-year), €73 763 (15-years), and €95 034 (73-years). Cost estimates were not overly sensitive to the value of any one cost component nor to the relative cost of outpatient and outreach visits. When these parameters were varied, costs ranged between €30 000 and €47 000 (1-year), €61 000 and €83 000 (15-years), and €82 000 and €108 000 (73-years). The total UK health-service cost of unilateral pediatric CI was estimated to be €14 million in 2000/2001 and is predicted to rise to €23 million in 2015/2016, if the present model of service-delivery continues. The cost of maintaining implanted children was estimated to account for 22% of the total in 2000/2001 and is predicted to rise to 63% by 2015/2016. Conclusions: Ongoing costs of maintaining implanted children and their implant systems are significant and should be factored into resource-allocation decisions. [Copyright &y& Elsevier]

This review assesses the cost effectiveness of cochlear implantation (CI) for children and adults. Two arguments are offered: (i) an appropriate approach to estimating the cost effectiveness of CI is to use cost–utility analysis to estimate the cost of gaining a time-integrated unit of quality of life, expressed as a quality-adjusted life year (QALY). (ii) The Mark III Health Utilities Index is an appropriate self-report instrument for assessing the gain in quality of life associated with CI, provided that “quality of life” is interpreted as a measure of society''s usual preference for better hearing rather than as an indication that impaired hearing equates to poor health. Cost–utility analysis shows that, for most groups of candidates, unilateral CI gains a QALY for significantly less than the value of €50,000 that has been inferred to define the upper limit of acceptability for the National Health Service in the United Kingdom (UK). Cost–utility ratios estimated for bilateral CI fall significantly above this limit, but could be acceptable in some countries that devote a higher percentage of their Gross Domestic Product to health care than the UK does at present. [Copyright &y& Elsevier]