The influence of bronchiolitisobliterans syndrome (BOS) on costs after lung transplantation wasinvestigated by comparing the costs of patients with and without thiscondition.
Follow-up costs were ...prospectivelyinvestigated in a medical technology assessment of the Dutch Lung Transplant Program, in relation to the development of the BOS. First, average follow-up costs per week per patient were compared betweenpatients who did or did not develop BOS. Second, in the BOS group, these costs were compared before and after the onset of BOS.
Dutch Lung Transplant Program, University Hospital of Groningen.
Data on 53 patients(37 patients without BOS and 16 with BOS) who underwent transplantationbetween November 1990 and April 1995 were available. The averagefollow-up time of these 53 patients was 1.5 years. The follow-up costsamounted to an average (in Dutch guilders Dfl) of 1,774/wk fornon-BOS patients, compared to 3,072/wk for BOS patients (+ 73%;p = 0.002; one Dfl = 50 cents US currency). This difference incosts was largely accounted for by an increase in used health-careresources, in particular hospitalization and medication. For the BOSpatients, the average costs per week before and after the onset of BOSwere 1,941 Dfl and 2,422 Dfl, respectively.
BOS is associated with substantial extra costs. These findings reemphasize the need to focus efforts on prevention of, BOS to enhance the cost-effectiveness of lungtransplantation.
Because of the poor outcome of hepatic retransplantation, it is still debated whether this procedure should be performed in an era of donor organ scarcity. The aim of this study was to analyze ...outcome of hepatic retransplantation in children, to identify risk factors influencing this outcome, and to assess morbidity and causes of death.
A series of 97 children after a single transplantation and 34 children with one retransplantation was analyzed.
The 1-, 3-, and 5-year survival of children with a retransplantation was 70, 63, and 52%, respectively, compared with 85, 82, and 78%, respectively, for children after a single transplantation (P=0.009). Survival of children with a retransplantation within 1 month after primary transplantation was worse (P=0.007) and survival of children with a late retransplantation was comparable (P=0.66) with single transplantation. In early retransplantations, the Child-Pugh score was higher, donors were older and weighed more, and more technical variant liver grafts were used compared with single transplantations. Biliary atresia and a high Child-Pugh score were associated with decreased patient survival after retransplantation. Sepsis was the most important complication and cause of death after retransplantation.
Retransplantation is a significant event after pediatric liver transplantation. Outcome after hepatic retransplantation in children is inferior compared with single transplantation. This difference is explained by low survival after early retransplantation and can be explained by the poor clinical condition of the children at time of retransplantation, especially in children with biliary atresia, and by the predominant use of technical variant liver grafts in retransplantations.
Most economic evaluations conducted in mental healthcare did not include widely recommended preference-based health outcomes like the QALY (Quality-Adjusted Life Years). Instead, studies have mainly ...been designed as cost-effectiveness analyses that include single outcome measures aimed at a (disease) specific aspect of health.
To raise awareness about the potential problems related to the selection of outcome measures for economic studies in patient populations with severe mental illness. Furthermore, to make suggestions that may prevent these problems in future economic evaluations.
Data of a previously conducted economic evaluation assessing the cost-effectiveness of the HIT (Hallucination focused Integrative Treatment) intervention in patients with schizophrenia were used for the analyses presented in the current paper. Economic analyses based on the results of the selected primary health outcome (Positive and Negative Syndrome Scale: PANSS) were compared with results based on various other health outcomes assessed during the study, including QALYs.
No relevant differences between groups were found on the single primary health outcome initially included in the cost-effectiveness analysis. In contrast, relevant and significant differences were identified on three of the four additionally assessed health outcomes. Conclusions based on the results of multiple cost-effectiveness analyses and acceptability curves were strongly in favour of the experimental intervention when including these three additional instruments. QALY results did not show differences between groups.
Selecting between outcome measures for cost-effectiveness analysis in the field of mental healthcare appears to be a complicated process, which may have considerable consequences for the results of economic studies and subsequent policy decisions. It was argued that inconsistent results across the selected primary health outcome and additionally assessed health outcomes should explicitly be presented to decision-makers. Until there is consensus on a preference-based instrument suited for severe mental illness, QoL instruments could be applied instead of instruments aimed at specific aspects of health.
Decision-makers in the field of mental healthcare should be careful when interpreting results of economic studies that included outcome measures aimed at a specific aspect of health. Such instruments may provide too narrow a view on relevant changes in health and findings may be difficult to generalise. Due to current reservations on the use of QALYs in mental healthcare, QALY outcomes should be considered in the context of the results of additionally assessed health outcomes.
Orthotopic liver transplantation has become the treatment of choice for children with end-stage liver disease. Although results have improved the last decades, still a considerable number of children ...die after transplantation. The aim of this study was to analyze long-term actual survival and to identify prognostic factors for such survival rates.
A consecutive series of 66 children receiving transplants who had or could have had a follow-up of at least 5 years was retrospectively analyzed. Actual survival and prognostic factors in relation to patient, donor, and operation related variables were assessed after multivariate analysis.
Actual 1-, 3-, and 5-year patient survival was 86%, 79%, and 73%, respectively. A high Child-Pugh (C-P) score or C-P class C, high donor age, high blood loss index, and retransplantation were predictive factors for actual patient survival. A high blood loss index was correlated with biliary atresia, low recipient age and weight, and with previous upper abdominal operations. The duration of stay of the donor at the intensive care unit (ICU) was a predictive factor for retransplantation.
Children with diseases eligible for liver transplantation should be seen early in the course of their disease in a transplantation center. All possible measures should be taken during the transplantation procedure to keep the blood loss at a minimum. Children with biliary atresia deserve special attention in this respect. The choice of donors has implications for survival.
Objectives: In cost-minimization studies, it is important to establish noninferiority in the clinical effect of the treatments under investigation. The relationship between the proportion of patients ...reaching the end point in a study, equivalence limit (δ), and power is investigated in the context of cost-minimization studies with dichotomous clinical end points. Two formulations of the null-hypothesis, absolute and relative formulations of δ, will be explored. Methods: Sensitivity analysis was performed, in which the effect of the predicted proportions and δ on the power in a noninferiority setting was investigated. The patterns found are discussed in terms of the practical relevance within the cost-minimization framework. Results: Sensitivity analyses show different patterns of results for both null-hypotheses. The differences in these results originate from the way δ is expressed. By expressing δ as absolute difference, power grows quite fast when sample proportions are smaller than expected. In the case of a proportional δ at small sample proportions, the power to establish noninferiority remains low. Conclusions: To obtain valid results from a cost-minimization study, care has to be taken to adapt the correct methodology for noninferiority testing in clinical outcomes. Defining δ in terms of absolute differences between treatments can lead to obscured results. Although conservative, the expression of δ as a proportion of the effectiveness of the treatment as usual is found to be closer to clinical practice. The inflated δ, resulting from smaller clinical effects than expected when absolute formulation is applied, thus can be avoided.
: Between November 1982 and March 2006, 67 children with body weight ≤10 kg had a primary liver transplantation from deceased donors in our unit. The aim of this study was to analyze the outcome in ...terms of patient and graft survival and to search for factors affecting this outcome. Overall, one‐, three‐, five‐, and 10‐yr primary patient and graft survival rates were 73%, 71%, 66%, 63% and 59%, 56%, 53%, 48%, respectively. Twenty‐four of 67 (36%) children died and in the remaining 22 (33%), the first grafts failed and they were retransplanted. Cox regression analysis revealed that a need for retransplantation and urgent transplantation were important predictors for patient survival (p = 0.04 and p = 0.001, respectively). To assess whether the need for retransplantation can be influenced, all study variables were compared between surviving grafts and failed grafts. Cox regression analysis showed that only donor/recipient (D/R) weight ratio proved to be independent predictor for graft survival (p = 0.004). After comparison of graft survival with the long rank test according to different D/R weight ratios (3.0–7.0), the cut‐off point for significantly different graft survival approached 4.0. The one‐, three‐, five‐, and 10‐yr graft survival for technical variant grafts with a D/R weight ratio <4.0 was 85%, 68%, 68%, and 68% compared with a D/R weight ratio >4.0 was 44%, 38%, 38%, and 30%, respectively (p = 0.02). In summary, patient survival in children with body weight ≤10 kg is determined by urgent transplantation and the need for retransplantation. Graft loss and retransplantation in small children can be prevented by adequate size matching of donor and recipient whereby a D/R weight ratio <4.0 seems to offer the favorable outcome.
To describe the epidemiology and causes of graft loss after pediatric liver transplantation and to identify risk factors.
Graft failure after transplantation remains an important problem. It results ...in patient death or retransplantation, resulting in lower survival rates.
A series of 157 transplantations in 120 children was analyzed. Graft loss was categorized as early (within 1 month) and late (after 1 month). Risk factors were identified by analyzing recipient, donor, and transplantation variables.
Kaplan-Meier 1-month and 1-, 3-, and 5-year patient survival rates were 85%, 82%, 77%, and 71%, respectively. Graft survival rates were 71%, 64%, 59%, and 53%, respectively. Seventy-one of 157 grafts (45%) were lost: 18 (25%) by death of patients with functioning grafts and 53 (75%) by graft-related complications. Forty-five grafts (63%) were lost early after transplantation. Main causes of early loss were vascular complications, primary nonfunction, and patient death. Main cause of late graft loss was fibrosis/cirrhosis, mainly as a result of biliary complications or unknown causes. Child-Pugh score, anhepatic phase, and urgent transplantation were risk factors for early loss. Donor age, donor/recipient weight ratio, blood loss, and technical-variant liver grafts were risk factors for late loss.
To prevent graft loss after pediatric liver transplantation, potential recipients should be referred early so they can be transplanted in an earlier phase of their disease. Technical-variant liver grafts are risk factors for graft survival. The logistics of the operation need to be optimized to minimize the length of the anhepatic phase.
To assess the cost effectiveness of selective decontamination of the digestive tract (SDD) in liver transplant patients.
Randomised, placebo-controlled, double-blind trial with an integrated economic ...evaluation.
Two university hospitals in The Netherlands. Cost effectiveness was assessed from a societal perspective.
58 patients who underwent liver transplantation and received SDD (n = 29) or placebo (n = 29) pre- and postoperatively.
SDD medication and placebo.
Infection episodes, days of infection, costs of SDD and routine cultures, mean other direct medical costs per patient and additional costs of severe infection.
Costs of SDD medicine and routine cultures were on average 3,100 US dollars ($US; 1997 values) per patient who underwent SDD. Both preoperatively and postoperatively, costs other than SDD and cultures did not significantly differ between the SDD and the placebo groups (preoperative, $US2,370 vs $US2,590; postoperative, $US25,455 vs $US24,915). Additional postoperative costs of severe infections were $US250 per day per patient. There were no significant differences in the mean number of infection episodes between groups.
SDD leads to the additional costs of SDD medication and routine cultures, whereas no savings in other costs and no improvement in infection episodes are realised. Consequently, SDD may be considered as a nonefficient approach in patients undergoing liver transplantation. The additional costs of severe infection are considerable.
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