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THETA Reports: Contents

  • THETA Report TR 2015.4
    Prostate-Specific Antigen (PSA)–Based Population Screening for Prostate Cancer: An Economic Analysis
  • THETA Report TR 2015.3
    Effect of Increased Intensity of Physiotherapy on Patient Outcomes After Stroke: An Economic Literature Review and Cost-Effectiveness Analysis
  • THETA Report TR 2015.2
    Pressure Ulcer Multi-disciplinary Teams via Telemedicine (PUMTT): A Pragmatic Randomised Controlled Trial in Long-Term Care
  • THETA Report TR 2015.1
    Pulmonary Rehabilitation for Postacute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): A Cost-Effectiveness and Budget Impact Analysis.
  • THETA Report TR 2014.2
    The Appropriate Use of Neuroimaging in the Diagnostic Workup of Dementia: An Economic Literature Review and Cost-Effectiveness Analysis
  • THETA Report TR 2014.1
    Turning for Ulcer Reduction (TURN) Study: Economic Analysis
  • THETA Report TR 2012.1
    Preventing Pressure Ulcers: A Multi-site RCT in Nursing Homes
  • THETA Report TR 2011.3
    Heart Failure (Multi-Disciplinary Community Care) Clinics Field Evaluation
  • THETA Report TR 2011.2
    Integrating Quantitative Preference-Related Evidence into HTA: The Case of Ventilation for COPD
  • THETA Report TR 2011.1
    Specialized Multidisciplinary Community-Based Care for Chronic Wounds: A Field Evaluation
  • THETA Report TR 2010.5
    Cost-Effectiveness of Oncotype-DX Guided Treatment in Early Breast Cancer
  • THETA Report TR 2010.4
    Cost-effectiveness of KRAS Genetic Testing for Anti-EGFR Therapy in Metastatic Colorectal Cancer
  • THETA Report TR 2010.3
    Cost-Effectiveness of Epidermal Growth Factor Receptor Gene Mutation Testing For Patients with Advanced Non-Small Cell Lung Cancer Living in Ontario.
  • THETA Report TR 2010.2
    Relative Cost-effectiveness of Five Non-invasive Cardiac Imaging Technologies for Diagnosing Coronary Artery Disease in Ontario
  • THETA Report TR 2010.1
    Ontario IMPACT Model
  • THETA Report TR 2009.4
    Cost-effectiveness of Biologic Response Modifiers Compared to Disease Modifying Anti-Rheumatic Drugs for Adults with Rheumatoid Arthritis: Systematic Review of Economic Evaluations
  • THETA Report TR 2009.3
    The Cost-Effectiveness of Pressure-Redistribution Mattresses for Early Prevention of Pressure Ulcers In Patients Admitted to Hospitals via the Emergency Department
  • THETA Report TR 2009.2
    Cost-Effectiveness of Specialized Multidisciplinary Heart Failure Clinics in Ontario, Canada
  • THETA Report TR 2009.1
    The cost-effectiveness of gel-filled overlays for the prevention of pressure ulcers in surgical patients
  • THETA Report TR 2008.1
    The cost-effectiveness of prevention strategies for pressure ulcers in longterm care homes in Ontario: Projections of the Ontario Pressure Ulcer Model
 

THETA Report TR 2015.4

Prostate-Specific Antigen (PSA)–Based Population Screening for Prostate Cancer: An Economic Analysis. - A Tawfik
Call Number: TR 2015.4
Publication Date: May 2015
Abstract

Background

The prostate-specific antigen (PSA) blood test has become widely used in Canada to test for prostate cancer (PC), the most common cancer among Canadian men. Data suggest that population-based PSA screening may not improve overall survival.

Objectives
This analysis aimed to review existing economic evaluations of population-based PSA screening, determine current spending on opportunistic PSA screening in Ontario, and estimate the cost of introducing a population-based PSA screening program in the province.

Methods
A systematic literature search was performed to identify economic evaluations of population-based PSA screening strategies published from 1998 to 2013. Studies were assessed for their methodological quality and applicability to the Ontario setting. An original cost analysis was also performed, using data from Ontario administrative sources and from the published literature. One-year costs were estimated for 4 strategies: no screening, current (opportunistic) screening of men aged 40 years and older, current (opportunistic) screening of men aged 50 to 74 years, and population-based screening of men aged 50 to 74 years. The analysis was conducted from the payer perspective.

Results
The literature review demonstrated that, overall, population-based PSA screening is costly and cost-ineffective but may be cost-effective in specific populations. Only 1 Canadian study, published 15 years ago, was identified. Approximately $119.2 million is being spent annually on PSA screening of men aged 40 years and older in Ontario, including close to $22 million to screen men younger than 50 and older than 74 years of age (i.e., outside the target age range for a population-based program). A population-based screening program in Ontario would cost approximately $149.4 million in the first year.

Limitations
Estimates were based on the synthesis of data from a variety of sources, requiring several assumptions and causing uncertainty in the results. For example, where Ontario-specific data were unavailable, data from the United States were used.

Conclusions
PSA screening is associated with significant costs to the health care system when the cost of the PSA test itself is considered in addition to the costs of diagnosis, staging, and treatment of screen-detected PCs.

 

THETA Report TR 2015.3

Effect of Increased Intensity of Physiotherapy on Patient Outcomes After Stroke: An Economic Literature Review and Cost-Effectiveness Analysis. - B Chan
Call Number: TR 2015.3
Publication Date: March 2015
Abstract

Background

Functional improvements have been seen in stroke patients who have received an increased intensity of physiotherapy. This requires additional costs in the form of increased physiotherapist time.

Objectives
The objective of this economic analysis is to determine the cost-effectiveness of increasing the intensity of physiotherapy (duration and/or frequency) during inpatient rehabilitation after stroke, from the perspective of the Ontario Ministry of Health and Long-term Care.

Data Sources
The inputs for our economic evaluation were extracted from articles published in peer-reviewed journals and from reports from government sources or the Canadian Stroke Network. Where published data were not available, we sought expert opinion and used inputs based on the experts’ estimates.

Review Methods
The primary outcome we considered was cost per quality-adjusted life-year (QALY). We also evaluated functional strength training because of its similarities to physiotherapy. We used a 2-state Markov model to evaluate the cost-effectiveness of functional strength training and increased physiotherapy intensity for stroke inpatient rehabilitation. The model had a lifetime timeframe with a 5% annual discount rate. We then used sensitivity analyses to evaluate uncertainty in the model inputs.

Results
We found that functional strength training and higher-intensity physiotherapy resulted in lower costs and improved outcomes over a lifetime. However, our sensitivity analyses revealed high levels of uncertainty in the model inputs, and therefore in the results.

Limitations
There is a high level of uncertainty in this analysis due to the uncertainty in model inputs, with some of the major inputs based on expert panel consensus or expert opinion. In addition, the utility outcomes were based on a clinical study conducted in the United Kingdom (i.e., 1 study only, and not in an Ontario or Canadian setting).

Conclusions
Functional strength training and higher-intensity physiotherapy may result in lower costs and improved health outcomes. However, these results should be interpreted with caution.

 

THETA Report TR 2015.2

Pressure Ulcer Multi-disciplinary Teams via Telemedicine (PUMTT): A Pragmatic Randomised Controlled Trial in Long-Term Care - VE Rac, J Wong, AS Brooker, N Mitsakakis, M Paulden, B Pham, S Carcone, MD Krahn
Call Number: TR 2015.2
Publication Date: March 2015
ABSTRACT

Background
Pressure ulcers (PrUs) increase the risk of death among elderly patients by as much as 400%, increase the frequency and duration of hospitalization, and decrease quality of life. The cost of treating PrUs is substantial , about $9,000 CAD per patient per month in the community setting. There is limited evidence that expert multi disciplinary teams (EMDTs) are effective in the management of chronic wounds . A field evaluation was conducted to address the effectiveness of EMDTs in the treatment of PrUs in long - term care ( LTC ) settings.

Objective
The objective of this study was to evaluate the clinical effectiveness and cost - effectiveness of EMDTs versus “usual” care teams for the treatment of PrUs in LTC homes. Methods
A multi - method study was conducted that consisted of a pragmatic cluster stepped wedge randomized controlled trial, qualitative methods to increase the understanding of trial results, and an economic evaluation. The intervention consisted of 4 to 14 months of mentorship per home from an advanced practice nurse who communicated with an EMDT.

Results
One hundred thirty seven residents with 259 PrUs were recruited into the study. The primary outcome, rate of healing, was judged based on wound surface area. No difference was detected in healing rates before and after exposure to the intervention. Secondary outcomes showed a trend toward shortened healing times, an increased probability of healing, and decreased prevalence rates . The economic evaluation estimated that the use of EMDTs would reducedirect care costs by $651 per resident.

Limitations
The study was powered to detect a 40% difference in rate of healing between control and intervention periods . Healing rate calculations used in the study were based on s tage II PrUs ( less than 50% of all PrUs recruited ) . The dose of intervention may have been too low to allow for detection of an overall effect. Data were abstracted from residents’ charts upon study completion in order to evaluate resource use .

Conclusions
The use of EMDTs did not improve the rate of healing of PrUs in LTC homes.

Health Quality Ontario Special Reports

 

THETA Report TR 2015.1

Pulmonary Rehabilitation for Postacute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): A Cost-Effectiveness and Budget Impact Analysis. - X Xie, M Wang, A Schaink, M Krahn
Call Number: TR 2015.1
Publication Date: February 2015
ABSTRACT

Background
Pulmonary rehabilitation (PR) is a cornerstone treatment for chronic obstructive pulmonary disease (COPD) composed of supervised exercise, education, and psychosocial support. Objectives
We assessed the economic implications of PR programs for COPD patients after hospitalization for an acute exacerbation in 3 settings (outpatient hospital, community, and home) compared with usual care (i.e., no PR), considering both the costs of the PR programs and the potential savings from reduced COPD - related re-hospitalizations.

Methods
A decision analytic model was constructed for the cost - effectiveness analysis. A standardized PR program was developed through consulting with experts, considering pertinent clinical guidelines, and conducting a comprehensive literature search. Data from a recent PR survey in Ontario were also considered for empirical PR resource use. The theoretical and empirical resource use of PR was used to estimate the number of additional health care professionals needed to support the entire target population in Ontario. On the basis of the results of the cost - effectiveness analysis, a budget impact analysis was conducted to assess the potential economic impact of implementing PR programs for the target COPD population in Ontario.

Results
The total cost (professional time) per patient is $1,635 (Cdn) (29 hours) for the standardized outpatient hospital - or community - based PR and $3, 498 (62 hours) for home - based PR. Compared with usual care, outpatient hospital - or community - based PR dominates with cost savings of $1,098 per patient and reduced hospitalizations of 256 admissions in 1,000 patients in 1 year. Home - based PR is associated with incremental costs of $765 per patient , and the incremental cost per rehospitalization avoided is $ 2,989 . Factors influencing incremental cost include dPR setting, duration of PR, and COPD disease history. To deliver the standard PR program to COPD patients (where 90% of target patients receive outpatient hospital - or community - based PR, and 10% receive home - based PR) after discharge for an acute exacerbation, 155 additional health care professionals are needed in Ontario . Using empirical data increases the number of health care professionals required to 213 . The budget impact analysis shows that implementation of PR for the entire target population would lead to theoretical cost savings of approximately $7.7 million (Cdn) for fiscal year 2012 – 2013.

Limitations
Additional clinical benefits and resource use was not captured, nor were additional costs (such as capital investments, equipment costs, or costs incurred by patients and caregivers) .

Conclusions
Outpatient hospital or community PR costs approximately half of a home - based program and is preferred for access to equipment and psychosocial peer support. Outpatient hospital or community PR dominates usual care, while home - based PR costs more than usual care. Although post-discharge PR after an acute exacerbation can lead to substantial cost savings, actual cost savings largely depend on the expansion of current PR capacity in Ontario.

Health Quality Ontario Special Reports

 

THETA Report TR 2014.2

The Appropriate Use of Neuroimaging in the Diagnostic Workup of Dementia: An Economic Literature Review and Cost-Effectiveness Analysis. - SL Bermingham
Call Number: TR 2014.2
Publication Date: February 2014
Abstract

Background

Structural brain imaging is often performed to establish the underlying causes of dementia. However, recommendations differ as to who should receive neuroimaging and whether computed tomography (CT) or magnetic resonance imaging (MRI) should be used.

Objectives
This study aimed to determine the cost-effectiveness in Ontario of offering structural imaging to all patients with mild to moderate dementia compared with offering it selectively according to guidelines from the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCC). We compared the cost-effectiveness of CT and MRI as first-line strategies.

Methods
We performed a systematic literature search (2000 to 2013) to identify cost-effectiveness studies of clinical prediction rules and structural imaging modalities. Studies were assessed for quality and applicability to Ontario. We also developed a model to evaluate the cost-effectiveness of clinical guidelines (image all versus according to CCC) and modalities (CT versus MRI). Transition probabilities, utilities, and costs were obtained from published literature or expert opinion. Results were expressed in terms of costs and quality adjusted life years (QALYs).

Results
No relevant cost-effectiveness analyses were identified in the published literature. According to the base-case results of our model, the most effective and cost-effective strategy is to image patients who meet CCC criteria with CT and to follow-up with MRI for suspected cases of space-occupying lesions (SOL). However, the results were sensitive to the specificity of MRI for detecting vascular causes of dementia. At a specificity of 64%, the most cost-effective strategy is CCC followed by MRI.

Limitations
Studies used to estimate diagnostic accuracy were limited by a lack of a gold standard test for establishing the cause of dementia. The model does not include costs to patients and their families, nor does it account for patient preferences about diagnostic information.

Conclusions
Given the relative prevalence of vascular dementia and SOLs, and the improvement in QALYs associated with treatment, the strategy with the greatest combined sensitivity (CCC with CT followed by MRI for patients with SOLs) results in the greatest number of QALYs and is the least costly. Due to limitations in the clinical data and challenges in the interpretation of this evidence, the model should be considered a framework for assessing uncertainty in the evidence base rather than providing definitive answers to the research questions.

 

THETA Report TR 2014.1

Turning for Ulcer Reduction (TURN) Study: Economic Analysis - M Paulden, N Bergstrom, S D Horn, M P Rapp, R Barrett, M Watkiss, B Pham, M Krahn
Call Number: TR 2014.1
Publication Date: October 2014
ABSTRACT

Background
The Turning for Ulcer Reduction (TURN) study was a multisite, randomized controlled trial that aimed to determine the optimal frequency of turning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer ( PrU ) development. Here we present data from the economic analysis.

Objectives
This economic analysis aims to estimate the economic consequences for Ontario of switching from a repositioning schedule of 2 - hour intervals to a schedule of 3 - hour or 4 - hour intervals.

Data Sources
Costs considered in the analysis included those associated with nursing staff time spent repositioning residents and with incontinent care supplies, which included briefs, barrier cream, and washcloths.

Results
The total economic benefit of switching to 3 - hour or 4 - hour repositioning is estimated to be $11.05 or $16.74 per day, respectively, for every resident at moderate or high risk of developing PrUs. For a typical facility with 123 residents, 41 (33%) of whom are at mode rate or high risk of developing PrUs, the total economic benefit is estimated to be $453 daily for 3 - hour or $686 daily for 4 - hour repositioning. For Ontario as a whole, assuming that there are 77,933 residents at 634 LTC facilities, 25,927 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefits of switching to 3 - hour or 4 - hour repositioning are estimated to be $286,420 or $433,913 daily, respectively, equivalent to $104. 5 million or $158.4 million per year.

Limitations
We did not consider the savings the Ontario Ministry of Health and Long - Term Care might incur should less frequent repositioning reduce the incidence of work - related injury among nursing staff, so our findings are potentially conservative .

Conclusions
A switch to 3 - hour or 4 - hour repositioning appears likely to yield substantial economic benefits to Ontario without placing residents at greater risk of developing PrUs.

Turning for Ulcer Reduction (TURN) Study: An Economic Analysis M Paulden, N Bergstrom, S D Horn, M P Rapp, R Barrett, M Watkiss, B Pham, M Krahn
Health Technology Assessment Series; Vol. 14: No. 12, pp. 1-24, October 2014



Ontario Health Technology Advisory Committee (OHTAC). Turning for the Prevention and Management of Pressure Ulcers: OHTAC recommendation.
Toronto: Queen's Printer for Ontario; 2014 October. 12 p.


 

THETA Report TR 2012.1

Cover Art
Preventing Pressure Ulcers: A Multi-site RCT in Nursing Homes - Nancy Bergstrom PhD, RN, FAAN, Susan D. Horn PhD, Mary Pat Rapp PhD, RN, Anita Stern PhD, RN, Ryan Barrett BS, Michael Watkiss BFA
Call Number: TR 2012.1
Publication Date: June 2012
Executive Summary

Context

Pressure at the interface between bony prominences and support surfaces, sufficient to occlude or reduce blood flow, is thought to cause pressure ulcers (PrUs). PrUs are prevented by providing support surfaces that redistribute pressure, and turning residents to reduce length of exposure. High density foam mattresses may reduce the frequency with which residents must be turned.

Objective
To determine optimal frequency of repositioning in Nursing Home (NH) residents at risk for PrUs when cared for on high density foam mattresses.

Design, Setting, and Participants
The Turning for Ulcer Reduction (TURN) Study, a Phase 3 Randomized, Controlled Trial, recruited residents from 20 United States and 7 Canadian NHs. Residents were >65 years, at moderate (scores 13-14) or high (scores 10-12) risk according to Braden Scale, and without PrUs.

Interventions
Participants were randomly allocated by risk stratification group (moderate versus high risk) to one of three turning schedules (2- 3- or 4-hour intervals) when in bed. Participants continued daily activities. The study continued for 3 weeks with weekly risk and skin assessment completed by masked assessors

Main Outcome Measures
PrU on the coccyx/sacrum, trochanter or heels

Results
Participants were mostly female (731/942, 77.6%) and Caucasian (758/942, 80.5%), and had a mean age 85.1 (SD +7.66) years. The most common co-morbidities were cardiovascular disease (713/942, 76.9%) and dementia (672/942, 72.5%). Nineteen of 942 (2.02%) participants developed one superficial stage 1 (n=1) or stage 2 (n=19) ulcers; no full thickness ulcers developed. Overall, there was no significant difference in PrU incidence (p=0.68) between groups (2-hour, 8/321(2.49%) ulcers/group; 3-hour, 2/326 (0.61%); 4-hour, 9/295 (3.05%). PrUs among high (6/325, 1.85%) versus moderate (13/617, 2.11%) risk participants were not significantly different (p=0.79), nor was there a difference between moderate risk (p=0.68) or high risk allocation groups (p=0.90).

Conclusion
Overall, results of the TURN study support turning moderate and high risk residents at intervals of 2-, 3-, or 4- hours when they are cared for on high density foam replacement mattresses. Turning at 3- hour intervals may be superior to, and turning at 4-hour intervals no worse than, the current practice of turning every 2-hours. Less frequent turning may increase sleep, improve quality of life, reduce staff injury and save time for other activities such as feeding, walking and toileting. Careful monitoring of skin is recommended as always.



 

THETA Report TR 2011.3

Cover Art
Heart Failure (Multi-Disciplinary Community Care) Clinics Field Evaluation - THETA Cardiac Group
Call Number: TR 2011.3
Publication Date: November, 2011
Despite advances in pharmacologic and device therapy, the prognosis for patients with heart failure (HF) remains poor. Alternative models of care delivery, such as multi-disciplinary HF clinics have been shown to reduce mortality.

The systematic review determined that HF clinics were associated with a 29% reduction in all-cause mortality but a 12% increase in hospitalizations. The cost of care in HF clinics was $52 per 30 patient-days. Projected life- expectancy of HF clinic patients was 3.91 years, compared to 3.21 years for standard care. The 12 year cumulative cost per patient in the HF clinic group was $66,532 versus $53,638 in the standard care group. The ICER was $18,259/life year gained. The average annual cost for HF clinic implementation was $17 million in Ontario.

Multi-disciplinary HF clinics reduce mortality and increase life expectancy. Despite increasing overall costs due to increased late hospitalizations, HF clinics appear to be a cost effective way of delivering ambulatory care to HF patients.



 

THETA Report TR 2011.2

Cover Art
Integrating Quantitative Preference-Related Evidence into HTA: The Case of Ventilation for COPD - Ann-Sylvia Brooker, PhD Steven Carcone, MSc William Witteman, MISt Murray Krahn, MD
Call Number: TR 2011.2
Publication Date: October 07, 2011
EXECUTIVE SUMMARY

Background
Recently, there has been increased effort to formally consider patient values and preferences in health technology assessment (HTA). Incorporating systematic reviews on patient preferences is one way of achieving this goal.

Purpose
To explore and discuss the feasibility of including systematic literature reviews on patient preferences within HTA; ii. To develop an appropriate search strategy for finding quantitative research on patient preferences; iii. To summarize the literature on patient preferences for ventilation among COPD patients; and iv. To discuss the advantages and disadvantages of including patient preference data within HTA.

Data Sources
Medical and economic databases were searched for studies published in English from 1990 through March 4, 2011 for preference-relevant studies.

Study Selection
Studies were selected based on title and abstract according to four main criteria.

Data Extraction
Two authors (A.B. and S.C.) independently extracted data using a standardized extraction table. Disagreement was resolved by discussion or consensus with a third party (M.K.).

Conclusions
A significant proportion of COPD patients were willing to forgo a potentially life-saving intervention, particularly when it was framed as an indefinite procedure. COPD patients who were willing to forgo either MV or NIV cannot be reliably predicted by known covariates (such as age, quality of life). COPD patient preferences for ventilation are not stable, but can vary depending on how the intervention is described. One study showed that COPD patients can also alter their preferences when they are asked to consider ventilation under different hypothetical health states. Finally, a systematic review of the patient preference literature offers many insights. However, the process is time-consuming due to the heterogeneity of study designs, outcomes measures and terminology.

Please check the summary of this work in the March 2012 report from the Health Quality Ontario (HQO):

Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework - Ontario Health Technology Assessment Series (OHTAS) Volume 12, Number 2
Publication Date: March 2012
The objective of this report series is to create an evidentiary base and economic analysis that will guide investment in the treatment of chronic obstructive pulmonary disease (COPD) in a way that optimizes patient outcomes and system efficiencies. This evidentiary platform concerning the effectiveness and cost-effectiveness of treatment strategies for patients with COPD will be used to build a provincial COPD strategy.

 

THETA Report TR 2011.1

Cover Art
Specialized Multidisciplinary Community-Based Care for Chronic Wounds: A Field Evaluation - Gina Trubiani, Ba Pham, Anita Stern, Steven Carcone, Laura Rosen, Murray Krahn
Call Number: TR 2011.1
Publication Date: August, 2011
Background

In view of the increasing prevalence, complexity and cost of chronic wounds, Ontario Health Technology
Advisory Committee recommended an intermediate care model for chronic disease management
(OHTAC 2009). In 2010, OHTAC and the Medical Advisory Secretariat (MAS) commissioned THETA
Collaborative to conduct a field evaluation to assess the effectiveness and cost-effectiveness of
specialized multidisciplinary wound care teams for community based patients with chronic wounds in
Ontario.

Research Objectives

The field evaluation was conducted in three phases with specific objectives described below:

Phase 1:
Identify specialized multidisciplinary wound care teams in Ontario.

Phase 2:
Describe the characteristics and service models of the identified specialized multi-disciplinary
wound care teams in Ontario.

Phase 3:
Evaluate the clinical effectiveness and cost-effectiveness of specialized multi-disciplinary
wound care teams in Ontario. This is an on-going pragmatic randomized controlled trial and will be in of
a separate report.

The current report describes the methods and results of Phases 1 and 2.

Methods

Phase 1:
Systematic survey and snowball sampling to identify all the specialized multidisciplinary wound
care teams in Ontario.

Phase 2:
A survey to capture the characteristics and service model of the identified teams was
administered in consultation with content experts representing various disciplines across the province.

Results

Phase 1:
49 wound care teams across the 14 CCACs were identified with an average of 41,000 senior
residents (>65 yr old)/ team.

Phase 2:

- 66% teams established for more than 5 years
- 56% led by a physician, 31% led by a nurse
- 61% located within out-patient departments and funded by hospitals
- An average of 579 unique patients seen per year per team
- 75% of the team service is for chronic wounds (45% diabetic ulcers, 15% pressure ulcers, 13%
venous leg ulcers, 7% arterial leg ulcers and 6% surgical wounds).
- 43% use telemedicine, mainly video link for wound treatment, patient management and
clinician education.
- 34% referrals from MD, 16% from CCAC and 16% from community nurses

Discussion

There is wide variation in the number, characteristics, and service models of specialized multidisciplinary
wound care teams across the province. Some regions of the province may be underserved. Care
coordination is a key problem in supporting patients with chronic wounds. The role of telemedicine to
extend the reach of specialty teams may require further exploration.

 

THETA Report TR 2010.5

Cover Art
Cost-Effectiveness of Oncotype-DX Guided Treatment in Early Breast Cancer - MikePaulden, Jacob Franek, Ba’ Pham and Murray Krahn
Call Number: TR 2010.5
Publication Date: November 10, 2010
Background
Adjuvant chemotherapy decisions for women with early-stage breast cancer are complex. Oncotype DX is validated at predicting distant recurrence-free response in patients with ER+ LN early-stage breast cancer. This enables chemotherapy to be better targeted at higher risk patients than is possible through the use of Adjuvant! Online (AOL) or clinical judgement alone. However, existing cost-effectiveness analyses of Oncotype DX have numerous limitations: In particular, they consider a limited range of strategies and do not separately consider intermediate risk.

Methods
We present an Ontario-based cost-effectiveness analysis which comprehensively addresses these limitations. We build upon a Markov model developed by Tsoi and colleagues, using data from the NSABP B-14 and B-20 clinical trials. We assume that AOL and Oncotype DX may be provided separately or sequentially and consider chemotherapy for each risk group, resulting in 1,000 unique strategies for the provision of AOL, Oncotype DX, and chemotherapy.

Results
Oncotype DX is cost-effective in all patients regardless of AOL risk. The highest ICER is in patients at low AOL risk ($29,000 per QALY), while Oncotype DX dominates in patients at high AOL risk. Chemotherapy is cost-effective only in patients at intermediate or high Oncotype DX risk. The highest ICER is in patients at low AOL and intermediate Oncotype DX risk ($64,000 per QALY). Chemotherapy is dominated in patients at low Oncotype DX risk.

Conclusion
Oncotype DX appears to be cost-effective regardless of a patient's AOL risk. These results have informed the Ontario Health Technology Advisory Committee's recent deliberations regarding the funding of Oncotype DX in Ontario.

Please check the summary of this work in the December 2010 report from the Health Quality Ontario (HQO)

Gene Expression Profiling for Guiding Adjuvant Chemotherapy Decisions in Women with Early Breast Cancer - Ontario Health Technology Assessment Series (OHTAS) Volume 10, Number 23
Publication Date: December 2010
To review and synthesize the available evidence regarding the laboratory performance, prognostic value, and predictive value of Oncotype1DX for the target population.

 

THETA Report TR 2010.4

Cover Art
Cost-effectiveness of KRAS Genetic Testing for Anti-EGFR Therapy in Metastatic Colorectal Cancer - Luciano Ieraci
Call Number: TR 2010.4
Publication Date: November 8, 2010
Objectives
To evaluate the cost-effectiveness of KRAS genetic testing in the (third-line) treatment of metastatic colorectal cancer (mCRC) with two anti-EGFR agents used as monotherapies; cetuximab and panitumumab, and the combination therapy of cetuximab with irinotecan (chemotherapy). The cost-effectiveness of KRAS testing for each of the three treatment options was assessed individually, and the relative cost-effectiveness of all treatments when compared to each other was also examined.

Methods
The economic analysis consisted of: 1) a systematic review of existing literature examining economic evaluations of KRAS genetic testing for mCRC; 2) a cost-utility analysis and decision analytic (Markov) model evaluating genetic testing strategies for three treatment options of mCRC (cetuximab, panitumumab and cetuximab with irinotecan chemotherapy); and 3) a budget impact analysis assessing the cost effect from the perspective of the Ministry of Health and Long-Term Care (MOHLTC).

Results
For each of the three treatment options considered individually (cetuximab, panitumumab and cetuximab with irinotecan chemotherapy), KRAS genetic testing was considered cost-effective at a willingness-to-pay (WTP) threshold of $50-$60K CAD. When all treatment options and strategies were considered together and compared in a relative cost-effectiveness analysis, KRAS testing for cetuximab with irinotecan chemotherapy was the most cost- effective option; with the highest lifetime gain in quality-adjusted life years (QALYs) and lowest calculated ICER (~$43K per QALY). Probabilistic sensitivity analysis indicated that strategies with KRAS testing were 44% (panitumumab), 42% (cetuximab with irinotecan), and 14% (cetuximab) cost- effective for a WTP threshold of $50K per QALY. The average annual increase in budget (cost) of having 50% of mCRC patients seeking third-line treatment with cetuximab, panitumumab and cetuximab with irinotecan chemotherapy was calculated respectively as: $0.07M, -$1.76M (cost saving), and $1.63M.

Conclusions
KRAS genetic testing is cost-effective for currently available anti-EGFR therapies for the treatment of mCRC. Specifically, providing KRAS testing for treatment with cetuximab and panitumumab monotherapies, and cetuximab with irinotecan chemotherapy is cost-effective at a WTP threshold of $50-$60K. Current indications by Health Canada (and Cancer Care Ontario) require KRAS testing for patients to gain access to the three anti-EGFR therapies evaluated in the current analysis. While not all KRAS testing strategies were found be equally cost-effective in the comparative analysis, KRAS testing should continue to provide benefit (in both cost and lifetime QALYs) for all three treatment therapies.

Please check the summary of this work in the December 2010 report from the Health Quality Ontario (HQO)

KRAS Testing for Anti-EGFR Therapy in Advanced Colorectal Cancer - Ontario Health Technology Assessment Series (OHTAS) Volume 10, Number 25
Publication Date: December 2010
The objective of this systematic review is to determine the predictive value of KRAS testing in the treatment of metastatic colorectal cancer (mCRC) with two anti-EGFR agents, cetuximab and panitumumab. Economic analyses are also being conducted to evaluate the cost-effectiveness of KRAS testing

 

THETA Report TR 2010.3

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Cost-Effectiveness of Epidermal Growth Factor Receptor Gene Mutation Testing For Patients with Advanced Non-Small Cell Lung Cancer Living in Ontario. - Wendong Chen
Call Number: TR 2010.3
Publication Date: November 3, 2010
Executive Summary
Background:

About 20% of patients with non-small cell lung cancer (NSCLC) have an epidermal growth factor receptor (EGFR) gene mutation on exon 19 to 21. Recently, NSCLC patients with an EGFR gene mutation were found to respond to EGFR tyrosine kinase inhibitors (TKIs), including gefitinib and erlotinib. EGFR gene mutation testing has been suggested to guide the treatment with TKIs.
Objective:

The purpose of this study is to assess the cost-effectiveness of EGFR gene mutation testing for the selection of gefitinib as first-line therapy in patients with advanced NSCLC who are residents in Ontario.
Methods:

A decision analytic model was developed to compare the lifetime benefits (life years and quality-adjusted life years (QALY)) and direct medical costs in 2010 Canadian dollars between the strategy of EGFR gene mutation testing and the strategy of no EGFR gene mutation testing in patients with advanced NSCLC (stage 3b or 4). Under the strategy of EGFR gene mutation testing, tumour tissues taken by biopsy were assessed to detect any mutation of EGFR gene from exon 19 to 21. Patients with EGFR gene mutations would receive gefitinib daily as first-line therapy, platinum based chemotherapy (cisplatin plus gemcitabine) as second-line therapy, and docetaxel or pemetrexed as third-line therapy before BSC. Patients without EGFR gene mutation would receive cisplatin plus gemcitabine as first-line therapy, docetaxel or pemetrexed as second-line therapy, and best supportive care (BSC). The other patients whose EGFR gene mutation status remained unknown after the testing (due to inadequate tissue or other technical limitations) would be treated with the combination of cisplatin and gemcitabine as first-line, docetaxel or pemetrexed as second-line, and erlotinib as third-line before BSC. For the no testing strategy, all patients would not be assessed for EGFR gene mutations. Patients would receive cisplatin and gemcitabine as first-line, docetaxel or pemetrexed as second-line, and erlotinib as third-line before BSC. The Markov cohort model was constructed to reflect the natural history of advanced NSCLC and the patterns of care for patients with advanced NSCLC in Ontario starting from first-line therapy. The cycle length of the Markov cohort model was 3 weeks. Literature review was conducted to estimate probability variables including distribution of squamous cell carcinoma, prevalence of EGFR gene mutation, failure rate of EGFR gene mutation testing, efficacy of treatments (gefitinib as first-line therapy, cisplatin and gemcitabine as first-line therapy, docetaxel as second-line therapy, pemetrexed as second-line therapy in patients with non-squamous cell carcinoma, erlotinib as third-line therapy, and BSC). A formula derived from a multivariate linear regression analysis was applied to estimate the utility of patients with advanced NSCLC according to the distributions of clinical responses after treatment and side-effects associated with treatment. Two cost studies estimating direct medical costs for patients with advanced NSCLC in Ontario were the data source for the cost variables. The analytic perspective in this study was the Ontario Ministry of Health and Long-Term Care (MOHLTC). Both benefits and costs (Canadian dollars in 2010) were discounted at 5% per annum. The base case analysis was conducted by using the baseline values of the variables in the model. One-way sensitivity analyses were conducted to identify the main variables affecting the cost-effectiveness of EGFR gene mutation testing. Probabilistic sensitivity analyses were also conducted to assess the relative percentage cost-effectiveness of EGFR gene mutation testing under different willingness to pay (WTP) values. A budget impact analysis was also performed to illustrate the changes of future health care expenditure on patients with advanced NSCLC in Ontario after the adaption of EGFR gene mutation testing.
Results:

Under the strategy of no EGFR gene mutation testing, the average lifetime benefit associated with patients with advanced NSCLC was 0.4842 life years or 0.2881 QALY; the average lifetime direct medical cost spent on patients was $14,368. Under the strategy of EGFR gene mutation testing, the average lifetime benefit collected for patients with advanced NSCLC was 0.5383 life years or 0.3188 QALY; the average lifetime direct medical cost consumed by patients was $16,857. Compared to the strategy of no testing, the incremental cost-effectiveness ratio (ICER) for EGFR gene mutation testing was $46,021 per life year or $81,071 per QALY. The one-way sensitivity analyses indicated that cost of care, cost of gefitinib, transition probability per cycle to progressive disease, and transition probability to death per cycle for patients under the treatment with gefitinib could increase the ICER of EGFR gene mutation testing over $10,000 per QALY; Daily cost of erlotinib and the cost of care for patients under the treatment with cisplatin and gemcitabine could decrease the ICER of EGFR gene mutation testing over $10,000 per QALY. Probabilistic sensitivity analysis suggested that the proportions of simulations in which EGFR gene mutation testing was cost-effective under the WTP of $50,000 and $100,000 were 5.2% and 56.1% respectively. Budget impact analysis projected that EGFR gene mutation testing in Ontario would cost MOHLTC $4.6M, $7.0M, $7.9M, $8.1M, and $8.1M more a year from 2011 to 2015, respectively, when compared to the current practices without testing.
Conclusion:

Applying EGFR gene mutation testing to guide the use of gefitinib as first- line therapy for patients with advanced NSCLC will be cost-effective if WTP is above $81,000 per QALY. The cost-effectiveness of EGFR gene mutation testing is sensitive to the efficacy and cost of gefitinib.

Some of the contents of this report are currently available in the Economic Analysis section of Health Quality Ontario (HQO) found here.

Epidermal Growth Factor Receptor Mutation (EGFR) Testing for Prediction of Response to EGFR- Targeting Tyrosine Kinase Inhibitor (TKI) Drugs in Patients with Advanced Non-Small-Cell Lung Cancer - Ontario Health Technology Assessment Series (OHTAS) Volume 10, Number 24
Publication Date: December 2010
The Medical Advisory Secretariat undertook a systematic review of the evidence on the clinical effectiveness and cost,effectiveness of epidermal growth factor receptor (EGFR) mutation testing compared with no EGFR mutation testing to predict response to tyrosine kinase inhibitors (TKIs), gefitinib (Iressa®) or erlotinib (Tarceva®) in patients with advanced non,small cell lung cancer (NSCLC).

 

THETA Report TR 2010.2

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Relative Cost-effectiveness of Five Non-invasive Cardiac Imaging Technologies for Diagnosing Coronary Artery Disease in Ontario - Toronto Health Economics and Technology Assessment Collaborative
Call Number: TR 2010.2
Publication Date: March, 2010
Objectives
The objective of this report was to determine the relative cost-effectiveness of five cardiac imaging technologies for the diagnosis of patients with suspected coronary artery disease (CAD) in two patient populations: out-patients presenting with stable chest pain with an intermediate risk of CAD following physical examination and a graded exercise test (stable outpatients); and patients presenting to emergency and subsequently admitted to hospital with an acute chest pain syndrome, low- intermediate risk of CAD, with a normal ECG and negative cardiac biomarker (acute inpatients).

The five cardiac imaging technologies are: stress echocardiography (stress ECHO); stress echocardiography with the use of contrast agent if necessary for interpretation (stress contrast ECHO); single photon emission computed tomography (SPECT); cardiac magnetic resonance imaging (cardiac MRI); and cardiac computed tomography (CT angiography).

Results
The results of this analysis is that new options for non-invasive cardiac diagnostic imaging (CT angiography, stress contrast ECHO) appear to have broadly similar sensitivity and specificity values in comparison to widely used current technologies (e.g. SPECT). CT angiography and stress contrast ECHO are consistently more economically attractive than competing technologies, and offer the potential for significant cost savings if they were used as replacement technologies for current, widely used tests. Clinical policy regarding implementation and wider use of these tests must also consider issues of radiation- related risk, long-term clinical and economic consequences of diagnostic imaging strategies (not considered here), the extent to which these tests may be used as complementary rather than replacement tests, and quality standards in the performance and interpretation of imaging technologies.

Non-invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease
Call Number: Ontario Health Technology Assessment Series 2010; Vol. 10, No. 7

 

THETA Report TR 2010.1

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Ontario IMPACT Model - Harindra C. Wijeysundera, Márcio Machado, Farah Farahati, Xuesong Wang, William Witteman, Gabrielle van der Velde, Jack V. Tu, Douglas S. Lee, Shaun G. Goodman, Robert Petrella, Martin O’Flaherty, Murray Krahn, Simon Capewell
Call Number: THETA Report TR 2010.1
Publication Date: January, 2010
Coronary heart disease (CHD) mortality has declined substantially in Canada over recent decades. Our objective was to determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments.

The validated IMPACT model was used for all analyses, integrating data on population size, CHD mortality, in addition to risk factor and treatment uptake changes in adults 25 years and older between 1994 and 2005 in Ontario. Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and a) evidence-based therapies in 8 distinct CHD sub-populations and b) population trends in 6 risk factors. The outcome of interest was the number of deaths prevented or postponed.

From 1994-2005, the age-adjusted CHD mortality rate in Ontario fell 35% from 190.9 to 124.8 deaths per 100,000 inhabitants, translating to an estimated 7585 fewer CHD deaths in 2005. Improvements in medical treatments accounted for approximately 43% of the total mortality decrease. Trends in risk factors explained approximately 48% of the total mortality decrease. Increasing diabetes prevalence and body mass index had a negative impact, increasing CHD mortality by approximately 6% and 2%, respectively.


 

THETA Report TR 2009.4

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Cost-effectiveness of Biologic Response Modifiers Compared to Disease Modifying Anti-Rheumatic Drugs for Adults with Rheumatoid Arthritis: Systematic Review of Economic Evaluations - Gabrielle van der Velde, Claire Bombardier, Luciano Ieraci, Murray Krahn, Marcio Machado, Ba' Pham, William Witteman
Call Number: TR 2009.4
Publication Date: December 12, 2009
Biologic response modifiers (biologics) have a greater potential to slow the course of rheumatoid arthritis (RA) but cost more than disease-modifying anti-rheumatic drugs (DMARDs). We systematically reviewed the literature to determine the cost-effectiveness of biologics compared to DMARDs for RA in adults.

The cost-effectiveness of biologics for the treatment of RA has not been widely demonstrated at the commonly cited CAD 50,000/QALY threshold; but there is evidence for cost-effectiveness at the CAD 100,000/QALY threshold. Economic evaluations of biologics are limited by lack of long-term response data in patients taking biologics and other important gaps in the literature.


 

THETA Report TR 2009.3

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The Cost-Effectiveness of Pressure-Redistribution Mattresses for Early Prevention of Pressure Ulcers In Patients Admitted to Hospitals via the Emergency Department - PhamB. MSc, PhD (c); Teague L. RN-EC, NP, MN; Mahoney J. MD; Goodman L. RN, BA; Poss J. PhD; Li J. PhD; Sikich N.J. RN, MSc; Lourenco R. CHIM, IMS; Ieraci L. MSc; Witteman W. MIS; Carcone S. MSc; Krahn M. MD, MSc
Call Number: TR 2009.3
Publication Date: December, 2009
This project evaluates the cost-effectiveness of pressure- redistribution mattresses (PRMs) compared to standard mattresses (SMs) on emergency room stretchers and beds for the prevention of pressure ulcers (PrUs) in patients admitted to hospitals via emergency departments.

Approximately 1 in 6 emergency-admitted patients experienced H-A PrUs. PRMs reduced the prevalence of H-A PrUs by 2.2% on average, 47 patients need to be on PRMs to prevent one H-A PrU. The mean cost saving associated with PRMs was $74 per patient for the 258,000 targeted cases per year in Ontario. PRMs had a 68% chance of improving health while saving costs. The aggregate direct cost saving to hospitals'' budgets would be $17 million per year.

The use of PRMs for ER stretchers and beds reduces the incidence of PrUs, alleviates the associated morbidity, saves direct costs to hospitals, and has a modest preventive effect on a large volume of patients at perhaps one of the highest risk periods of their hospital experience.


 

THETA Report TR 2009.2

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Community-Based Care for the Specialized Management of Heart Failure: A Cost-Effectiveness and Budget Impact Analysis - Harindra C. Wijeysundera, Márcio Machado, Xuesong Wang, Gabrielle van der Velde, Nancy Sikich, William Witteman, Jack V. Tu, Douglas S. Lee, Shaun G. Goodman, Robert Petrella, Martin O’Flaherty, Simon Capewell, Murray Krahn.
Call Number: TR 2009.2
Publication Date: November 20, 2009
Despite advances in pharmacologic and device therapy, the prognosis for patients with heart failure (HF) remains poor. Alternative models of care delivery, such as multi-disciplinary HF clinics have been shown to reduce mortality.

The systematic review determined that HF clinics were associated with a 29% reduction in all-cause mortality but a 12% increase in hospitalizations. The cost of care in HF clinics was $52 per 30 patient-days. Projected life- expectancy of HF clinic patients was 3.91 years, compared to 3.21 years for standard care. The 12 year cumulative cost per patient in the HF clinic group was $66,532 versus $53,638 in the standard care group. The ICER was $18,259/life year gained. The average annual cost for HF clinic implementation was $17 million in Ontario.

Multi-disciplinary HF clinics reduce mortality and increase life expectancy. Despite increasing overall costs due to increased late hospitalizations, HF clinics appear to be a cost effective way of delivering ambulatory care to HF patients.

 

THETA Report TR 2009.1

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The cost-effectiveness of gel-filled overlays for the prevention of pressure ulcers in surgical patients - Pham B. MSc PhD (c); Teague L. RN-EC NP MN; Mahone J. MD; Goodman L. RN BA; Stern A. RN PhD; Poss J. PhD; Li J. PhD; Sikich N. RN MSc; Lourenco R. CHIM IMS; Ieraci L. MSc; Witteman W. MIS; Carcone S. MSc; Krahn M. MD MSc
Call Number: TR 2009.1
Publication Date: November, 2009
Pressure ulcers are localized tissue destruction caused by skin compression at bony prominences. Surgical patients are at particularly high risk. Prolonged immobility during surgery is associated with pressure-related tissue injuries to vulnerable bony areas, including the back, heels, hip, spine, elbows, shoulders, and back of the head, among others. Gel-filled overlays on operating tables have been shown to reduce new pressure ulcers but are not widely used. Commissioned by the Ontario Health Technology Assessment Committee (OHTAC), this study evaluates the cost-effectiveness of adding gel-filled overlays to standard operating tables for the prevention of pressure ulcers in hospitalized patients undergoing planned major surgical procedures.

Gel-filled overlays are currently used in 8 to 20% of OR departments in Ontario (an estimated 2,205 OR tables). The expanded use of gel-filled overlays to cover all OR tables would cost approximately $2 million and result in the prevention of 4,233 to 4,868 cases with pressure ulcers per year. The aggregate health impact would be a gain of approximately 3.8 to 4.4 QALYs over the 122,000 to 144,000 targeted surgical patients per year. Direct healthcare costs would be reduced by $26 to $29 million per year. The direct cost saving to hospitals' annual budgets would be $25 to $28 million (equivalent to approximately 393 to 453 full-time equivalents of registered nurse time).


 

THETA Report TR 2008.1

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The cost-effectiveness of prevention strategies for pressure ulcers in longterm care homes in Ontario: Projections of the Ontario Pressure Ulcer Model - Ahmed Bayoumi, MD, MSc; Ava John-Baptiste, MSc, PhD candidate; Maggie Hong Chen, MMath, PhD candidate; Farah Farahati, PhD; Murray Krahn, MD, MSc; Márcio Machado, PharmD, PhD; Ba’ Pham, MMath, PhD candidate; Beate Sander, RN, MBA, MEcDev, PhD; candidat
Call Number: TR 2008.1
Publication Date: December 2008
Pressure ulcers (PUs), commonly known as bedsores, are lesions caused by many factors such as unrelieved pressure over bony prominences, friction, humidity, and shearing forces to any part of the body. PUs are common among residents of long-term care (LTC) homes in Ontario.

Although treatable if found early, PUs can become life-threatening, and in rare instances, lead to fatal infections. PUs impose a significant health and economic burden, costing the Canadian health care system approximately $2.1 billion annually.

The clinical evidence and cost-effectiveness data suggests that some of the prevention strategies considered above lead to substantial improvement in health compared to standard care in LTC homes across Ontario. The prevention strategies with AF mattresses with or without 4-hourly turning/repositioning were somewhat attractive, and were supported by moderate to high quality evidence. These two strategies are economically attractive at an incremental cost-effectiveness ratio (ICER) below $50,000 per QALY gained. In addition, they were associated with lower implementation costs compared to other alternatives. Nutritional supplementation, skin care protocol, and RN time increase strategies cannot be considered cost-effective under the conventional threshold of $50,000 per QALY.

The clinical and economic evidence supports implementation of AF mattresses in LTC homes in Ontario. Reducing the frequency of turning to 4 hourly intervals, in conjunction with implementation of AF mattresses also appears to be economically attractive, but significant uncertainty remains regarding the clinical equivalence of 2-hourly and 4-hourly turning in high risk groups. However, because of the potential for very significant impacts on labor requirements for long-term care facilities (i.e., potential cost savings, or potential allocation of work-time to other effective interventions), this strategy should be evaluated in future research studies.


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