Validation of the numerical rating scale for pain intensity and unpleasantness in pediatric acute postoperative pain: sensitivity to change over time

This study evaluates the construct validity (including sensitivity to change) of the numerical rating scale (NRS) for pain intensity (I) and unpleasantness (U) and participant pain scale preferences in children/adolescents with acute postoperative pain. Eighty-three children aged 8 to 18 years (mean = 13.8, SD = 2.4) completed 3 pain scales including NRS, Verbal Rating Scale (VRS), and faces scales (Faces Pain Scale-Revised [FPS-R] and Facial Affective Scale [FAS], respectively) for pain intensity (I) and unpleasantness (U) 48 to 72 hours after major surgery, and the NRS, VRS and Functional Disability Index (FDI) 2 weeks after surgery. As predicted, the NRSI correlated highly with the VRSI and FPS-R and the NRSU correlated highly with the VRSU and FAS 48 to 72 hours after surgery. The FDI correlated moderately with the NRS at both time points. Scores on the NRSI and NRSU at 48 to 72 hours were significantly higher than at 2 weeks after surgery. Children found the faces scales the easiest to use while the VRS was liked the least and was the hardest to use. The NRS has adequate evidence of construct validity including sensitivity for both pain intensity and unpleasantness. This study further supports the validity of the NRS as a tool to measure both intensity and unpleasantness of acute pain in children

Cost-Effectiveness of Genotypic Antiretroviral Resistance Testing in HIV-Infected Patients with Treatment Failure

BACKGROUND: Genotypic antiretroviral resistance testing (GRT) in HIV infection with drug resistant virus is recommended to optimize antiretroviral therapy, in particular in patients with virological failure. We estimated the clinical effect, cost and cost-effectiveness of using GRT as compared to expert opinion in patients with antiretroviral treatment failure. METHODS: We developed a mathematical model of HIV disease to describe disease progression in HIV-infected patients with treatment failure and compared the incremental impact of GRT versus expert opinion to guide antiretroviral therapy. The analysis was conducted from the health care (discount rate 4%) and societal (discount rate 2%) perspective. Outcome measures included life-expectancy, quality-adjusted life-expectancy, health care costs, productivity costs and cost-effectiveness in US Dollars per quality-adjusted life-year (QALY) gained. Clinical and economic data were extracted from the large Swiss HIV Cohort Study and clinical trials. RESULTS: Patients whose treatment was optimized with GRT versus expert opinion had an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and two weeks, respectively. Health care costs with and without GRT were $US 421,000 and$US 419,000, leading to an incremental cost-effectiveness ratio of $US 35,000 per QALY gained. In the analysis from the societal perspective, GRT versus expert opinion led to an increase in discounted life-expectancy and quality-adjusted life-expectancy of three and four weeks, respectively. Health care costs with and without GRT were$US 551,000 and $US 549,000, respectively. When productivity changes were included in the analysis, GRT was cost-saving. CONCLUSIONS: GRT for treatment optimization in HIV-infected patients with treatment failure is a cost-effective use of scarce health care resources and beneficial to the society at large

Cost effectiveness analysis of routine use of genotypic antiretroviral resistance testing after failure of antiretroviral treatment for HIV.

OBJECTIVES: Single use of genotypic antiretroviral resistance testing (GART) after first failure of highly active antiretroviral therapy (HAART) was reported to be cost effective; its use prior HAART initiation is unknown. Guidelines recommend GART after each treatment failure. We assessed the cost effectiveness of GART used routinely after first and subsequent treatment failures. Furthermore, we determined the minimum effectiveness required for GART prior to the first HAART to be as cost effective as after treatment failure. DESIGN AND METHODS: We developed a decision-analytic Markov model to estimate lifetime clinical and economic outcomes in a cohort of HIV patients starting HAART. Rates of treatment failure, estimates of GART effectiveness and data on disease progression were derived from published trials and observational studies. A cost effectiveness analysis was performed from the perspective of the healthcare system using cost data from a Central European healthcare setting. Deterministic and probabilistic sensitivity analyses using Monte Carlo technique were performed. RESULTS: GART after treatment failures increased life expectancy by 9 months and undiscounted life-time costs per case by 16,406 euros. The discounted incremental cost effectiveness ratio was 22,510 euros per life-year gained (euros/LY). Best- and worst-case scenarios yielded 16,512 euros/LY and 42,900 euros/LY, respectively. GART prior to the initiation of HAART would be equally cost effective if it could reduce the probability of first HAART failure by at least 36%. CONCLUSION: Routine use of GART after treatment failures is cost effective. GART prior to the first HAART would be equally cost effective if it could lower the probability of first HAART failure by approximately a third. &nbsp