Nederlands tijdschrift voor geneeskunde, Jan 19, 1998
There is a growing interest in developing clinical guidelines which support the efficiency of med... more There is a growing interest in developing clinical guidelines which support the efficiency of medical care by weighting the potential benefits against the costs of interventions. In the recently developed Dutch guideline on reduction of serum cholesterol concentration a formal cost-effectiveness analysis is included. Based on epidemiological arguments a cost-effectiveness ratio of 40,000 Dutch guilders per life year gained was found. In comparison with other preventive health care programmes this amount was considered acceptable. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. The results of the cost-effectiveness analysis vary particularly with the costs of the used statins. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. However, in view of the increase in health care expenditures, it has become the responsibility of physicians to take costs into account more...
Nederlands tijdschrift voor geneeskunde, Jan 13, 1993
The efficiency of prescribing HA-1A for sepsis patients is analysed by comparing direct medical c... more The efficiency of prescribing HA-1A for sepsis patients is analysed by comparing direct medical costs and effects. Effects are estimated on the basis of published data from a randomised clinical trial. Costs are analysed by combining data from the same trial with expectations about hospital days. Average costs per life year gained are estimated at DF1. 25,000. Sensitivity analysis is applied and the efficiency of treating patients with HA1A is shown to depend highly on the expected duration of survival after successful treatment. This leads to the advice to take epidemiologic knowledge into special account before setting the indication for using HA-1A.
Nederlands tijdschrift voor geneeskunde, Jan 12, 1994
The assessment of the cost-effectiveness of helicopter medical crews for patients with major trau... more The assessment of the cost-effectiveness of helicopter medical crews for patients with major trauma in the Dutch situation. A modelling approach, combining available information with plausible assumptions. Institute for Medical Technology Assessment, Rotterdam. First, a baseline scenario was developed, implementing information that was available in the literature and a few assumptions. The sensitivity of the cost-effectiveness for the various assumptions was evaluated in alternative scenarios. END-POINTS. The relation between the costs per life year gained and the expected increase in the number of patients surviving an accident is established for the separate scenarios. In the baseline scenario the number of victims with a trauma score < or = 12 is estimated at 4500 per year, it is assumed that victims who die at the scene of the accident are unsalvageable and that hospital treatment costs Dfl. 27,000.--per patient. As a result costs per life year saved are only under Dfl. 50,00...
Progress in clinical and biological research, 1994
The cost-effectiveness of prescribing HA-1A for sepsis patients was analyzed by comparing effecti... more The cost-effectiveness of prescribing HA-1A for sepsis patients was analyzed by comparing effectiveness and direct medical costs. Effectiveness was estimated on the basis of published data from a randomized clinical trial. Costs were determined by combining data from the same trial with expectations about hospital days. Average costs per life year gained were estimated at 25,000 Dutch guilders (1 Dutch guilder is approximately 53 US cents). Sensitivity analyses were applied and showed that the effectiveness and cost-effectiveness of treating patients with HA-1A depend a great deal on the expected duration of survival after successful treatment. If the objective is to maximize the cost-effectiveness of treatment, this means that the prognosis of the patient should be considered when deciding about the appropriateness of treatment with HA-1A. As one would expect, another way to increase cost-effectiveness would be to increase the proportion of gram-negative sepsis patients amongst tho...
Background Cost-effectiveness analyses of blood safety interventions require estimates of the lif... more Background Cost-effectiveness analyses of blood safety interventions require estimates of the life expectancy after blood product transfusion. These are best derived from survival after blood transfusion, per age group and blood component type. Study design and methods In the PROTON (PROfiles of TransfusiON recipients) study transfusion recipient data was collected from a hospital sample covering 28% of the total blood use between 1996 and 2006 in the Netherlands. The dataset includes date of transfusion, blood component type transfused and recipient identification details. PROTON data were individually matched to mortality data of the Netherlands. Survival after first transfusion and after any transfusion was calculated, per blood component type and age group. PROTON mortality rates were compared to mortality rates in the general population. The results were used to estimate survival beyond the study period and to estimate life expectancy after transfusion. Results Of all 2 405 012 blood product transfusions in the PROTON dataset, 92% was matched to the national Dutch Municipal Population Register, which registers all deaths. After 1 year, survival after any transfusion was 65AE4%, 70AE4% and 53AE9% for RBC, FFP and PLT respectively. After 5 years, this was 46AE6%, 58AE8% and 39AE3% for RBC, FFP and PLT, respectively. Ten years after transfusion, mortality rates of recipients are still elevated in comparison with the general population. Conclusion Mortality rates of transfusion recipients are higher than those of the general population, but the increase diminishes over time. The mortality rates found for the Netherlands are lower than those found in comparable studies for other countries.
Background Transfusion recipient data are needed for correct estimation of costeffectiveness in t... more Background Transfusion recipient data are needed for correct estimation of costeffectiveness in terms of recipient outcomes after transfusion. Also, such data are essential for monitoring blood use, estimation of future blood use and benchmarking. Study Design and Methods A sample of 20 of 93 Dutch hospitals was selected. Datasets containing all blood product transfusions between 1996 and 2006 were extracted from hospital blood bank computer systems, containing transfusion date, blood product type and recipient characteristics such as gender, address, date of birth. The datasets were appended and matched to national hospitalization datasets including primary discharge diagnoses (ICD-9). Using these data, we estimated distributions of blood recipient characteristics in the Netherlands. Results The dataset contains information on 290 043 patients who received 2 405 012 blood products (1 720 075 RBC, 443 697 FFP, 241 240 PLT) from 1996 to 2006. This is 28% of total blood use in the Netherlands during this period. Comparable diagnosis and age distributions of all hospitalizations indicate included hospitals to be representative, per hospital category, for the Netherlands. Of all red blood cells (RBC), fresh-frozen plasma (FFP) and platelets (PLT), respectively 1AE7%, 2AE5% and 4AE5% were transfused to neonates. Recipients of 65 years or older received 57AE6% of RBC, 41AE4% of FFP and 29AE0% of PLT. Most of the blood products were transfused to patients with diseases of the circulary system (25AE1%) or neoplasms (22AE0%). Conclusion Transfusion data from a limited sample of hospitals can be used to estimate national distributions of blood recipient characteristics.
JAMA: The Journal of the American Medical Association, 1995
To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial i... more To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial infarction. Cost-effectiveness analysis, based on a randomized, double-blind, placebo-controlled trial. Sixty Dutch hospitals. A total of 3404 hospital survivors of acute myocardial infarction randomized within a median period of 4 days after discharge to either oral anticoagulant treatment or placebo. The mean follow-up was 37 months. Oral anticoagulant treatment aimed at a target international normalized ratio of 2.8 to 4.8. Costs of hospital stay during readmissions, costs related to major cardiologic interventions, and costs of oral anticoagulant treatment. The costs of oral anticoagulant treatment were estimated at 394 Dutch guilders (Dfl) per patient-year (Dfl 1 = US $0.58). Placebo patients stayed 18,830 days in the hospital compared with 15,083 days for anticoagulation patients. Average costs per patient of medical care during follow-up were estimated at Dfl 10,784 for placebo patients and Dfl 9878 for anticoagulation patients. Costs of long-term anticoagulant treatment are outweighed by the costs of prevented clinical events.
Using a simple societal utility function-giving equal weight to current and future generations-it... more Using a simple societal utility function-giving equal weight to current and future generations-it is concluded that costs need to be discounted on the basis of the expected increase in income and the marginal utility of consumption, and that effects need to be discounted on the basis of the expected increase in health and the marginal utility of health. It is derived that both rates need to be equal when assuming a kind of perfect market, where growth rates are determined by the societal utility function. It is argued that this is an extremely heroic assumption and that different discount rates may be needed. Additionally, the traditional 'inconsistency arguments' of Weinstein and Stason and of Keeler and Cretin are reconsidered. Within the context presented earlier, the first inconsistency only emerges when a growth equilibrium is assumed, reinforcing the arguments put forward before. The Keeler and Cretin paradox is reconsidered by showing that absolutely no paradox emerges when programs are not supposed to stop after a year but are supposed to continue indefinitely. The conclusion is drawn that non-believers in market mechanisms assuring an optimal social policy, need to reconsider the use of their discount rates.
Summary. Background: The need for clearly reported studies evaluating the cost of prophylaxis an... more Summary. Background: The need for clearly reported studies evaluating the cost of prophylaxis and its overall outcomes has been recommended from previous literature. Objectives: To establish minimal ‘‘core standards’’ that can be followed when conducting and reporting economic evaluations of hemophilia prophylaxis. Methods: Ten members of the IPSG Economic Analysis Working Group participated in a consensus process using the Nominal Groups Technique (NGT). The following topics relating to the economic analysis of prophylaxis studies were addressed; Whose perspective should be taken? Which is the best methodological approach? Is micro‐ or macro‐costing the best costing strategy? What information must be presented about costs and outcomes in order to facilitate local and international interpretation? Results: The group suggests studies on the economic impact of prophylaxis should be viewed from a societal perspective and be reported using a Cost Utility Analysis (CUA) (with considerat...
European Journal of Gastroenterology & Hepatology, 1999
Whereas soluble interleukin-I receptor type II (slL-1RII) reflects potent anti-interleukin-1 (IL-... more Whereas soluble interleukin-I receptor type II (slL-1RII) reflects potent anti-interleukin-1 (IL-1)/anti-inflammatory strategies, soluble interleukin-1 receptor type I (slL-1RI) exerts predominantly proinflammatory activities. Serum levels of slL-1RI, slL-1RII and IL-IRa were investigated in patients with chronic liver disease (CLD) of different etiologies. A group of 12 healthy volunteers served as a control group. 126 patients with CLD were studied. 80 cases presented with cirrhosis. Whereas slL-1RII serum levels were not significantly elevated in patients with CLD (mean _+ SEM; control group: 4.76 + 0.16 ng/ml, n=12; CLD patients: 5.34 + 0.11 ng/ml, n=126), slL-IRI levels were significantly higher in the CLD group compared with control patients (controls: 1.38 + 0.2 ng/ml; CLD: 3.90 5: 0.21; P<0.001). In addition, patients in the cirrhotic stage of CLD showed significantly higher levels of slL-1RI than those with non-cirrhotic CLD (non-cirrhotic CLD: 2.00 +/-0.1 ng/ml, n=46; cirrhotic CLD: 4.98 +/-0.26 ng/ml, n=80, P<0.001). IL-1Ra serum levels were also significantly increased in patients with CLD (controls: 0.23 + 0.02 ng/ml, CLD: 0.82 + 0.08 ng/ml; P<0.05). The present findings of increased levels of slL-1RI may reflect the proinflammatury nature of CLD. A lack of increase in the natural occurring IL-1 antagonist, slL-1RII, indicates that CLD might be characterized by an imbalance of inflammatory and antiinflammatory cytokines, which may contribute to disease progression.
Previous analyses have shown that long-acting risperidone (LAR) is cost-effective in several West... more Previous analyses have shown that long-acting risperidone (LAR) is cost-effective in several Western countries. In Portugal, however, the costs of key services are lower. Therefore, available evidence in other countries may have limited relevance. To estimate costs and effects of LAR versus a conventional depot and a short-acting oral atypical antipsychotic over a 5-year period in Portugal. An existing discrete event model was adapted to reflect the Portuguese healthcare setting, based on expert opinion, clinical, epidemiological, and cost data. The model compares three scenarios. In scenario 1, patients start with a conventional depot; in scenario 2, with LAR; and in scenario 3, with oral risperidone. The model simulates individual patient histories while taking into account patient characteristics such as risk to society and side-effects. Subsequently, the model simulates patient histories in terms of outpatient appointments, psychotic episodes, treatment, compliance, symptom scores, lack of ability to take care presenting an actual risk, and treatment setting. Outcomes were number of psychotic episodes, cumulative symptom score and direct medical costs. Univariate sensitivity analyses were carried out. Compared to a conventional depot and an oral atypical, LAR was estimated to save approximately euro 3603 and euro 4682 per patient (respectively) and avoid 0.44 and 0.59 relapses per patient in 5 years. Sensitivity analyses showed that the outcome of dominance was only sensitive to estimates about unit costs of hospital/institutionalization, potential risk, and to the reduction in symptoms by use of atypicals. Based on this modeling exercise, it could be expected that LAR may be a cost-effective treatment with limited budget impact in Portugal. However, further studies are required to test the generalizability of the results of the present modeling study to the larger population of Portugal.
The present study indicates that primary coronary angioplasty is effective with regard to mortali... more The present study indicates that primary coronary angioplasty is effective with regard to mortality, morbidity, and functional status in patients with acute myocardial infarction. The concern that this new approach is far more expensive than conservative thrombolytic therapy ...
The advent of platelet membrane glycoprotein (GP) IIb/IIIa inhibitors has changed the landscape o... more The advent of platelet membrane glycoprotein (GP) IIb/IIIa inhibitors has changed the landscape of interventional cardiology. Given the commercial availability of abciximab and expected regulatory approvals for other receptor blockers, defining appropriate use of these agents in the interventional setting is mandated. One key issue is selection of patients who may benefit from GP IIb/IIIa receptor blockade. Focusing specifically on abciximab, data from three large-scale, randomized trials demonstrate that abciximab is appropriate for all patients undergoing percutaneous transluminal coronary angioplasty, regardless of risk stratum. Other important issues to consider when prescribing this therapy include benefits in conjunction with stents and new devices, dosing and timing of administration, and the role of prophylactic versus &amp;amp;amp;amp;amp;amp;quot;bailout&amp;amp;amp;amp;amp;amp;quot; administration. This article reflects a distillation of the views and consensus regarding the use of GP IIb/IIIa inhibitors in patients undergoing coronary intervention expressed by a group of international experts convened in Davos, Switzerland, February 16, 1997. This report attempts to review clinical progress to date, formulate recommendations, and map out potentially fruitful lines of inquiry for future investigation.
Purpose: To assess and quantify the association of haemophilic arthropathy, measured by the radio... more Purpose: To assess and quantify the association of haemophilic arthropathy, measured by the radiological Pettersson score, with the number of joint bleeds suffered by the patient. Material and Methods: In order to quantify the effect of the cumulative number of joint bleeds on the Pettersson score, a study was performed using 295 Pettersson scores obtained in 117 patients with severe haemophilia. The patients were born between 1965 and 1994, and had no history of inhibitors. The number of joint bleeds was determined annually from the entry in the clinic and onwards. The localization of bleeds was not assessed. The patients entered the clinic at a median age of 3.6 years, and received intermediate dose prophylaxis, starting at a median age of 5.3 years. Evaluation of 1643 treatment years showed a mean of 6.8 joint bleeds/year. Pettersson scores were obtained at a mean age of 15.9 years (range 1.7–32.9) and had a median value of 4 points (range 0–50). Results and Conclusion: The Pette...
Taking the right decision in health care may be as much an art as a science. However, without exc... more Taking the right decision in health care may be as much an art as a science. However, without exception and whatever the decision, usage is made of scarce resources and they may be used in an alternative way. This implies costs and there comes a time at which the various options have to be assessed in comparison with their effects. Cost-effectiveness aims at informing decision-makers about the balance between the costs and effects of alternative therapies.
Nederlands tijdschrift voor geneeskunde, Jan 19, 1998
There is a growing interest in developing clinical guidelines which support the efficiency of med... more There is a growing interest in developing clinical guidelines which support the efficiency of medical care by weighting the potential benefits against the costs of interventions. In the recently developed Dutch guideline on reduction of serum cholesterol concentration a formal cost-effectiveness analysis is included. Based on epidemiological arguments a cost-effectiveness ratio of 40,000 Dutch guilders per life year gained was found. In comparison with other preventive health care programmes this amount was considered acceptable. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. The results of the cost-effectiveness analysis vary particularly with the costs of the used statins. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. However, in view of the increase in health care expenditures, it has become the responsibility of physicians to take costs into account more...
Nederlands tijdschrift voor geneeskunde, Jan 13, 1993
The efficiency of prescribing HA-1A for sepsis patients is analysed by comparing direct medical c... more The efficiency of prescribing HA-1A for sepsis patients is analysed by comparing direct medical costs and effects. Effects are estimated on the basis of published data from a randomised clinical trial. Costs are analysed by combining data from the same trial with expectations about hospital days. Average costs per life year gained are estimated at DF1. 25,000. Sensitivity analysis is applied and the efficiency of treating patients with HA1A is shown to depend highly on the expected duration of survival after successful treatment. This leads to the advice to take epidemiologic knowledge into special account before setting the indication for using HA-1A.
Nederlands tijdschrift voor geneeskunde, Jan 12, 1994
The assessment of the cost-effectiveness of helicopter medical crews for patients with major trau... more The assessment of the cost-effectiveness of helicopter medical crews for patients with major trauma in the Dutch situation. A modelling approach, combining available information with plausible assumptions. Institute for Medical Technology Assessment, Rotterdam. First, a baseline scenario was developed, implementing information that was available in the literature and a few assumptions. The sensitivity of the cost-effectiveness for the various assumptions was evaluated in alternative scenarios. END-POINTS. The relation between the costs per life year gained and the expected increase in the number of patients surviving an accident is established for the separate scenarios. In the baseline scenario the number of victims with a trauma score < or = 12 is estimated at 4500 per year, it is assumed that victims who die at the scene of the accident are unsalvageable and that hospital treatment costs Dfl. 27,000.--per patient. As a result costs per life year saved are only under Dfl. 50,00...
Progress in clinical and biological research, 1994
The cost-effectiveness of prescribing HA-1A for sepsis patients was analyzed by comparing effecti... more The cost-effectiveness of prescribing HA-1A for sepsis patients was analyzed by comparing effectiveness and direct medical costs. Effectiveness was estimated on the basis of published data from a randomized clinical trial. Costs were determined by combining data from the same trial with expectations about hospital days. Average costs per life year gained were estimated at 25,000 Dutch guilders (1 Dutch guilder is approximately 53 US cents). Sensitivity analyses were applied and showed that the effectiveness and cost-effectiveness of treating patients with HA-1A depend a great deal on the expected duration of survival after successful treatment. If the objective is to maximize the cost-effectiveness of treatment, this means that the prognosis of the patient should be considered when deciding about the appropriateness of treatment with HA-1A. As one would expect, another way to increase cost-effectiveness would be to increase the proportion of gram-negative sepsis patients amongst tho...
Background Cost-effectiveness analyses of blood safety interventions require estimates of the lif... more Background Cost-effectiveness analyses of blood safety interventions require estimates of the life expectancy after blood product transfusion. These are best derived from survival after blood transfusion, per age group and blood component type. Study design and methods In the PROTON (PROfiles of TransfusiON recipients) study transfusion recipient data was collected from a hospital sample covering 28% of the total blood use between 1996 and 2006 in the Netherlands. The dataset includes date of transfusion, blood component type transfused and recipient identification details. PROTON data were individually matched to mortality data of the Netherlands. Survival after first transfusion and after any transfusion was calculated, per blood component type and age group. PROTON mortality rates were compared to mortality rates in the general population. The results were used to estimate survival beyond the study period and to estimate life expectancy after transfusion. Results Of all 2 405 012 blood product transfusions in the PROTON dataset, 92% was matched to the national Dutch Municipal Population Register, which registers all deaths. After 1 year, survival after any transfusion was 65AE4%, 70AE4% and 53AE9% for RBC, FFP and PLT respectively. After 5 years, this was 46AE6%, 58AE8% and 39AE3% for RBC, FFP and PLT, respectively. Ten years after transfusion, mortality rates of recipients are still elevated in comparison with the general population. Conclusion Mortality rates of transfusion recipients are higher than those of the general population, but the increase diminishes over time. The mortality rates found for the Netherlands are lower than those found in comparable studies for other countries.
Background Transfusion recipient data are needed for correct estimation of costeffectiveness in t... more Background Transfusion recipient data are needed for correct estimation of costeffectiveness in terms of recipient outcomes after transfusion. Also, such data are essential for monitoring blood use, estimation of future blood use and benchmarking. Study Design and Methods A sample of 20 of 93 Dutch hospitals was selected. Datasets containing all blood product transfusions between 1996 and 2006 were extracted from hospital blood bank computer systems, containing transfusion date, blood product type and recipient characteristics such as gender, address, date of birth. The datasets were appended and matched to national hospitalization datasets including primary discharge diagnoses (ICD-9). Using these data, we estimated distributions of blood recipient characteristics in the Netherlands. Results The dataset contains information on 290 043 patients who received 2 405 012 blood products (1 720 075 RBC, 443 697 FFP, 241 240 PLT) from 1996 to 2006. This is 28% of total blood use in the Netherlands during this period. Comparable diagnosis and age distributions of all hospitalizations indicate included hospitals to be representative, per hospital category, for the Netherlands. Of all red blood cells (RBC), fresh-frozen plasma (FFP) and platelets (PLT), respectively 1AE7%, 2AE5% and 4AE5% were transfused to neonates. Recipients of 65 years or older received 57AE6% of RBC, 41AE4% of FFP and 29AE0% of PLT. Most of the blood products were transfused to patients with diseases of the circulary system (25AE1%) or neoplasms (22AE0%). Conclusion Transfusion data from a limited sample of hospitals can be used to estimate national distributions of blood recipient characteristics.
JAMA: The Journal of the American Medical Association, 1995
To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial i... more To investigate the costs and effects of long-term oral anticoagulant treatment after myocardial infarction. Cost-effectiveness analysis, based on a randomized, double-blind, placebo-controlled trial. Sixty Dutch hospitals. A total of 3404 hospital survivors of acute myocardial infarction randomized within a median period of 4 days after discharge to either oral anticoagulant treatment or placebo. The mean follow-up was 37 months. Oral anticoagulant treatment aimed at a target international normalized ratio of 2.8 to 4.8. Costs of hospital stay during readmissions, costs related to major cardiologic interventions, and costs of oral anticoagulant treatment. The costs of oral anticoagulant treatment were estimated at 394 Dutch guilders (Dfl) per patient-year (Dfl 1 = US $0.58). Placebo patients stayed 18,830 days in the hospital compared with 15,083 days for anticoagulation patients. Average costs per patient of medical care during follow-up were estimated at Dfl 10,784 for placebo patients and Dfl 9878 for anticoagulation patients. Costs of long-term anticoagulant treatment are outweighed by the costs of prevented clinical events.
Using a simple societal utility function-giving equal weight to current and future generations-it... more Using a simple societal utility function-giving equal weight to current and future generations-it is concluded that costs need to be discounted on the basis of the expected increase in income and the marginal utility of consumption, and that effects need to be discounted on the basis of the expected increase in health and the marginal utility of health. It is derived that both rates need to be equal when assuming a kind of perfect market, where growth rates are determined by the societal utility function. It is argued that this is an extremely heroic assumption and that different discount rates may be needed. Additionally, the traditional 'inconsistency arguments' of Weinstein and Stason and of Keeler and Cretin are reconsidered. Within the context presented earlier, the first inconsistency only emerges when a growth equilibrium is assumed, reinforcing the arguments put forward before. The Keeler and Cretin paradox is reconsidered by showing that absolutely no paradox emerges when programs are not supposed to stop after a year but are supposed to continue indefinitely. The conclusion is drawn that non-believers in market mechanisms assuring an optimal social policy, need to reconsider the use of their discount rates.
Summary. Background: The need for clearly reported studies evaluating the cost of prophylaxis an... more Summary. Background: The need for clearly reported studies evaluating the cost of prophylaxis and its overall outcomes has been recommended from previous literature. Objectives: To establish minimal ‘‘core standards’’ that can be followed when conducting and reporting economic evaluations of hemophilia prophylaxis. Methods: Ten members of the IPSG Economic Analysis Working Group participated in a consensus process using the Nominal Groups Technique (NGT). The following topics relating to the economic analysis of prophylaxis studies were addressed; Whose perspective should be taken? Which is the best methodological approach? Is micro‐ or macro‐costing the best costing strategy? What information must be presented about costs and outcomes in order to facilitate local and international interpretation? Results: The group suggests studies on the economic impact of prophylaxis should be viewed from a societal perspective and be reported using a Cost Utility Analysis (CUA) (with considerat...
European Journal of Gastroenterology & Hepatology, 1999
Whereas soluble interleukin-I receptor type II (slL-1RII) reflects potent anti-interleukin-1 (IL-... more Whereas soluble interleukin-I receptor type II (slL-1RII) reflects potent anti-interleukin-1 (IL-1)/anti-inflammatory strategies, soluble interleukin-1 receptor type I (slL-1RI) exerts predominantly proinflammatory activities. Serum levels of slL-1RI, slL-1RII and IL-IRa were investigated in patients with chronic liver disease (CLD) of different etiologies. A group of 12 healthy volunteers served as a control group. 126 patients with CLD were studied. 80 cases presented with cirrhosis. Whereas slL-1RII serum levels were not significantly elevated in patients with CLD (mean _+ SEM; control group: 4.76 + 0.16 ng/ml, n=12; CLD patients: 5.34 + 0.11 ng/ml, n=126), slL-IRI levels were significantly higher in the CLD group compared with control patients (controls: 1.38 + 0.2 ng/ml; CLD: 3.90 5: 0.21; P<0.001). In addition, patients in the cirrhotic stage of CLD showed significantly higher levels of slL-1RI than those with non-cirrhotic CLD (non-cirrhotic CLD: 2.00 +/-0.1 ng/ml, n=46; cirrhotic CLD: 4.98 +/-0.26 ng/ml, n=80, P<0.001). IL-1Ra serum levels were also significantly increased in patients with CLD (controls: 0.23 + 0.02 ng/ml, CLD: 0.82 + 0.08 ng/ml; P<0.05). The present findings of increased levels of slL-1RI may reflect the proinflammatury nature of CLD. A lack of increase in the natural occurring IL-1 antagonist, slL-1RII, indicates that CLD might be characterized by an imbalance of inflammatory and antiinflammatory cytokines, which may contribute to disease progression.
Previous analyses have shown that long-acting risperidone (LAR) is cost-effective in several West... more Previous analyses have shown that long-acting risperidone (LAR) is cost-effective in several Western countries. In Portugal, however, the costs of key services are lower. Therefore, available evidence in other countries may have limited relevance. To estimate costs and effects of LAR versus a conventional depot and a short-acting oral atypical antipsychotic over a 5-year period in Portugal. An existing discrete event model was adapted to reflect the Portuguese healthcare setting, based on expert opinion, clinical, epidemiological, and cost data. The model compares three scenarios. In scenario 1, patients start with a conventional depot; in scenario 2, with LAR; and in scenario 3, with oral risperidone. The model simulates individual patient histories while taking into account patient characteristics such as risk to society and side-effects. Subsequently, the model simulates patient histories in terms of outpatient appointments, psychotic episodes, treatment, compliance, symptom scores, lack of ability to take care presenting an actual risk, and treatment setting. Outcomes were number of psychotic episodes, cumulative symptom score and direct medical costs. Univariate sensitivity analyses were carried out. Compared to a conventional depot and an oral atypical, LAR was estimated to save approximately euro 3603 and euro 4682 per patient (respectively) and avoid 0.44 and 0.59 relapses per patient in 5 years. Sensitivity analyses showed that the outcome of dominance was only sensitive to estimates about unit costs of hospital/institutionalization, potential risk, and to the reduction in symptoms by use of atypicals. Based on this modeling exercise, it could be expected that LAR may be a cost-effective treatment with limited budget impact in Portugal. However, further studies are required to test the generalizability of the results of the present modeling study to the larger population of Portugal.
The present study indicates that primary coronary angioplasty is effective with regard to mortali... more The present study indicates that primary coronary angioplasty is effective with regard to mortality, morbidity, and functional status in patients with acute myocardial infarction. The concern that this new approach is far more expensive than conservative thrombolytic therapy ...
The advent of platelet membrane glycoprotein (GP) IIb/IIIa inhibitors has changed the landscape o... more The advent of platelet membrane glycoprotein (GP) IIb/IIIa inhibitors has changed the landscape of interventional cardiology. Given the commercial availability of abciximab and expected regulatory approvals for other receptor blockers, defining appropriate use of these agents in the interventional setting is mandated. One key issue is selection of patients who may benefit from GP IIb/IIIa receptor blockade. Focusing specifically on abciximab, data from three large-scale, randomized trials demonstrate that abciximab is appropriate for all patients undergoing percutaneous transluminal coronary angioplasty, regardless of risk stratum. Other important issues to consider when prescribing this therapy include benefits in conjunction with stents and new devices, dosing and timing of administration, and the role of prophylactic versus &amp;amp;amp;amp;amp;amp;quot;bailout&amp;amp;amp;amp;amp;amp;quot; administration. This article reflects a distillation of the views and consensus regarding the use of GP IIb/IIIa inhibitors in patients undergoing coronary intervention expressed by a group of international experts convened in Davos, Switzerland, February 16, 1997. This report attempts to review clinical progress to date, formulate recommendations, and map out potentially fruitful lines of inquiry for future investigation.
Purpose: To assess and quantify the association of haemophilic arthropathy, measured by the radio... more Purpose: To assess and quantify the association of haemophilic arthropathy, measured by the radiological Pettersson score, with the number of joint bleeds suffered by the patient. Material and Methods: In order to quantify the effect of the cumulative number of joint bleeds on the Pettersson score, a study was performed using 295 Pettersson scores obtained in 117 patients with severe haemophilia. The patients were born between 1965 and 1994, and had no history of inhibitors. The number of joint bleeds was determined annually from the entry in the clinic and onwards. The localization of bleeds was not assessed. The patients entered the clinic at a median age of 3.6 years, and received intermediate dose prophylaxis, starting at a median age of 5.3 years. Evaluation of 1643 treatment years showed a mean of 6.8 joint bleeds/year. Pettersson scores were obtained at a mean age of 15.9 years (range 1.7–32.9) and had a median value of 4 points (range 0–50). Results and Conclusion: The Pette...
Taking the right decision in health care may be as much an art as a science. However, without exc... more Taking the right decision in health care may be as much an art as a science. However, without exception and whatever the decision, usage is made of scarce resources and they may be used in an alternative way. This implies costs and there comes a time at which the various options have to be assessed in comparison with their effects. Cost-effectiveness aims at informing decision-makers about the balance between the costs and effects of alternative therapies.
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Papers by B. Van Hout