Analysis of uncertainty in health care cost-effectiveness studies: an introduction to statistical issues and methods

Cost-effectiveness analysis is now an integral part of health technology assessment and addresses the question of whether a new treatment or other health care program offers good value for money. In this paper we introduce the basic framework for decision making with cost-effectiveness data and then review recent developments in statistical methods for analysis of uncertainty when cost-effectiveness estimates are based on observed data from a clinical trial. Although much research has focused on methods for calculating confidence intervals for cost-effectiveness ratios using bootstrapping or Fieller’s method, these calculations can be problematic with a ratio-based statistic where numerator and=or denominator can be zero. We advocate plotting the joint density of cost and effect differences, together with cumulative density plots known as cost-effectiveness acceptability curves (CEACs) to summarize the overall value-for-money of interventions. We also outline the net-benefit formulation of the cost-effectiveness problem and show that it has particular advantages over the standard incremental cost-effectiveness ratio formulation

Net Health Benefits: A New Framework for the Analysis of Uncertainty in Cost-Effectiveness Analysis

In recent years, considerable attention has been devoted to the development of statistical methods for the analysis of uncertainty in cost-effectiveness analysis, with a focus on situations in which the analyst has patient-level data on the costs and health effects of alternative interventions. To date, discussions have focused almost exclusively on addressing the practical challenges involved in estimating confidence intervals for CE ratios. However, the general approach of using confidence intervals to convey information about uncertainty around CE ratio estimates suffers from theoretical limitations that render it inappropriate in many situations. We present an alternative framework for analyzing uncertainty in the economic evaluation of health interventions (termed the net health benefits' approach) that is more broadly applicable and that avoids some problems of prior methods. This approach offers several practical and theoretical advantages over the analysis of CE ratios, is straightforward to apply, and highlights some important principles in the theoretical underpinnings of CEA.

Mutagenesis of rat acyl-CoA synthetase 4 indicates amino acids that contribute to fatty acid binding

Although each of the five mammalian long-chain acyl-CoA synthetases (ACSL) can bind saturated and unsaturated fatty acids ranging from 12 to 22 carbons, ACSL4 prefers longer chain polyunsaturated fatty acids. In order to gain a better understanding of ACSL4 fatty acid binding, we based a mutagenesis approach on sequence alignments related to ttLC-FACS crystallized from Thermus thermophilus HB8. Four residues selected for mutagenesis corresponded to residues in ttLC-FACS that comprise the fatty acid binding pocket; the fifth residue aligned with a region thought to be involved in fatty acid selectivity of the Escherichia coli acyl-CoA synthetase, FadD. Changing an amino acid at the entry of the putative fatty acid binding pocket, G401L, resulted in an inactive enzyme. Mutating a residue near the pocket entry, L399M, did not significantly alter enzyme activity, but mutating a residue at the hydrophobic terminus of the pocket, S291Y, altered ACSL4’s preference for 20:5 and 22:6 and increased its apparent Km for ATP. Mutating a site in a region previously identified as important for fatty acid binding also altered activation of 20:4 and 20:5. These studies suggested that the preference of ACSL4 for long-chain polyunsaturated fatty acids can be modified by altering specific amino acid residues

Flight test investigation of the vortex wake characteristics behind a Boeing 727 during two-segment and normal ILS approaches (A joint NASA/FAA report)

Flight tests were performed to evaluate the vortex wake characteristics of a Boeing 727 aircraft during conventional and two-segment instrument landing approaches. Smoke generators were used for vortex marking. The vortex was intentionally intercepted by a Lear Jet and a Piper Comanche aircraft. The vortex location during landing approach was measured using a system of phototheodolites. The tests showed that at a given separation distance there are no readily apparent differences in the upsets resulting from deliberate vortex encounters during the two types of approaches. The effect of the aircraft configuration on the extent and severity of the vortices is discussed

On the probability of cost-effectiveness using data from randomized clinical trials

BACKGROUND: Acceptability curves have been proposed for quantifying the probability that a treatment under investigation in a clinical trial is cost-effective. Various definitions and estimation methods have been proposed. Loosely speaking, all the definitions, Bayesian or otherwise, relate to the probability that the treatment under consideration is cost-effective as a function of the value placed on a unit of effectiveness. These definitions are, in fact, expressions of the certainty with which the current evidence would lead us to believe that the treatment under consideration is cost-effective, and are dependent on the amount of evidence (i.e. sample size). METHODS: An alternative for quantifying the probability that the treatment under consideration is cost-effective, which is independent of sample size, is proposed. RESULTS: Non-parametric methods are given for point and interval estimation. In addition, these methods provide a non-parametric estimator and confidence interval for the incremental cost-effectiveness ratio. An example is provided. CONCLUSIONS: The proposed parameter for quantifying the probability that a new therapy is cost-effective is superior to the acceptability curve because it is not sample size dependent and because it can be interpreted as the proportion of patients who would benefit if given the new therapy. Non-parametric methods are used to estimate the parameter and its variance, providing the appropriate confidence intervals and test of hypothesis

Microstructural Alterations and Oligodendrocyte Dysmaturation in White Matter After Cardiopulmonary Bypass in a Juvenile Porcine Model.

BACKGROUND: Newly developed white matter (WM) injury is common after cardiopulmonary bypass (CPB) in severe/complex congenital heart disease. Fractional anisotropy (FA) allows measurement of macroscopic organization of WM pathology but has rarely been applied after CPB. The aims of our animal study were to define CPB-induced FA alterations and to determine correlations between these changes and cellular events after congenital heart disease surgery. METHODS AND RESULTS: Normal porcine WM development was first assessed between 3 and 7 weeks of age: 3-week-old piglets were randomly assigned to 1 of 3 CPB-induced insults. FA was analyzed in 31 WM structures. WM oligodendrocytes, astrocytes, and microglia were assessed immunohistologically. Normal porcine WM development resembles human WM development in early infancy. We found region-specific WM vulnerability to insults associated with CPB. FA changes after CPB were also insult dependent. Within various WM areas, WM within the frontal cortex was susceptible, suggesting that FA in the frontal cortex should be a biomarker for WM injury after CPB. FA increases occur parallel to cellular processes of WM maturation during normal development; however, they are altered following surgery. CPB-induced oligodendrocyte dysmaturation, astrogliosis, and microglial expansion affect these changes. FA enabled capturing CPB-induced cellular events 4 weeks postoperatively. Regions most resilient to CPB-induced FA reduction were those that maintained mature oligodendrocytes. CONCLUSIONS: Reducing alterations of oligodendrocyte development in the frontal cortex can be both a metric and a goal to improve neurodevelopmental impairment in the congenital heart disease population. Studies using this model can provide important data needed to better interpret human imaging studies

Are hospitals delivering appropriate VTE prevention? The venous thromboembolism study to assess the rate of thromboprophylaxis (VTE start)

The 7th conference of the American College of Chest Physicians (ACCP7) provides recommendations on the type, dose, and duration of thromboprophylaxis in hospitalized patients at risk of venous thromboembolism (VTE), but the extent to which hospitals follow these criteria has not been well studied. Discharge and billing records for patients admitted to any of 16 acute-care hospitals from January 2005 to December 2006 were obtained. Patients 18 years or older who had an inpatient stay ≥2 days and no apparent contraindications for thromboprophylaxis were grouped into the categories of critical care, surgery and medically ill before being assessed for additional VTE risk factors based on the diagnostic criteria outlined in ACCP7. For patients at risk, the recommended type (mechanical or pharmacologic), dose, and duration of thromboprophylaxis was identified based on the guidelines and compared to the regimen actually received, if any. Among the 258,556 hospitalized patients, 68,278 (26.4%) were determined to be at risk of VTE without apparent contraindications for thromboprophylaxis. The proportions of patients who received the appropriate type, dose, and duration of thromboprophylaxis were 10.5, 9.8, and 17.9% for critical care, medical, and surgical patients, respectively. Of those at risk, 36.8% received no thromboprophylaxis and an additional 50.2% received thromboprophylaxis deemed inappropriate for one or more reasons. The implementation of ACCP7 guidelines for type, dosage, and duration of thromboprophylaxis is low in patients at risk of VTE. There is a need for physicians and health systems to improve awareness and implementation of recommended thromboprophylaxis

Deposition and surface treatment with intense pulsed ion beams

Intense pulsed ion beams (500 keV, 30 kA, 0.5 {mu}s) are being investigated for materials processing. Demonstrated and potential applications include film deposition, glazing and joining, alloying and mixing, cleaning and polishing, corrosion improvement, polymer surface treatments, and nanophase powder synthesis. Initial experiments at Los Alamos have emphasized thin-film formation by depositing beam ablated target material on substrates. We have deposited films with complex stoichiometry such as YBa{sub 2}Cu{sub 3}O{sub 7-x}, and formed diamond-like-carbon films. Instantaneous deposition rates of 1 mm/sec have been achieved because of the short ion range (typically 1{mu}m), excellent target coupling, and the inherently high energy of these beams. Currently the beams are produced in single shot uncomplicated diodes with good electrical efficiency. High-voltage modulator technology and diodes capable of repetitive firing, needed for commercial application, are being developed