Direct costs of radiotherapy for rectal cancer: A microcosting study

Background: Radiotherapy provides significant benefits in terms of reducing risk of local recurrence and death from rectal cancer. Despite this, up-to-date cost estimates for radiotherapy are lacking, potentially inhibiting policy and decision-making. Our objective was to generate an up-to-date estimate of the cost of traditional radiotherapy for rectal cancer and model the impact of a range of potential efficiency improvements. Methods: Microcosting methods were used to estimate total direct radiotherapy costs for long- (assumed at 45-50 Gy in 25 daily fractions over a 5 week period) and short-courses (assumed at 25 Gy in 5 daily fractions over a one week period). Following interviews and on-site visits to radiotherapy departments in two designated cancer centers, a radiotherapy care pathway for a typical rectal cancer patient was developed. Total direct costs were derived by applying fixed and variable unit costs to resource use within each care phase. Costs included labor, capital, consumables and overheads. Sensitivity analyses were performed. Results: Radiotherapy treatment was estimated to cost between €2,080 (5-fraction course) and €3,609 (25-fraction course) for an average patient in 2012. Costs were highest in the treatment planning phase for the short-course (€1,217; 58% of total costs), but highest in the radiation treatment phase for the long-course (€1,974: 60% of total costs). By simultaneously varying treatment time, capacity utilization rates and linear accelerator staff numbers, the base cost fell by 20% for 5-fractions: (€1,660) and 35% for 25-fractions: (€2,354). Conclusions: Traditional radiotherapy for rectal cancer is relatively inexpensive. Moreover, significant savings may be achievable through service organization and provision changes. These results suggest that a strong economic argument can be made for expanding the use of radiotherapy in rectal cancer treatment

A decade of Clostridioides Difficile infection – An in-depth analytical retrospective review of a single centres experience

Background: Clostridioides difficile infection (CDI) is the leading cause of hospital-acquired infectious diarrhoea. CDI is potentially preventable and can disrupt hospital services. The Beaumont Hospital Department of Clinical Microbiology provides daily onsite C. difficile laboratory testing and has a comprehensive CDI prevention and control programme for over a decade. This has included a CDI surveillance programme which has not been appraised since its development.  Objectives: 1. To investigate CDI trends using an observational retrospective cohort study of hospitalised patients attending Beaumont Hospital over ten years and to investigate patient factors predicting first episode of CDI and recurrence.  2. To evaluate the attributes and continued feasibility of the current CDI surveillance approach in Beaumont hospital. Methods: C. difficile is a standing agenda item at the weekly infection prevention and control team meeting with multi-disciplinary input and reporting to key stakeholders in real time. C. difficile data from 1st January 2012 to 31st December 2021 was extracted. Data included patient demographics, admission details, C. difficile testing and CDI case details, C. difficile ribotyping (RT) and CDI outbreak data. Data on antimicrobial exposure before CDI onset and specific antimicrobial CDI treatment were captured since 2016. All laboratory samples tested for C. difficile, irrespective of case type were analysed initially. Subsequent analysis explored the sub-groups of new onset inpatient using ꭓ2 analyses with unadjusted odds ratios (ORs) presented, new and recurrent CDI by Poisson regression for trends in rates and predicting factors. A Cox proportional hazards regression model for time to recurrence.  Results: Data associated with 1975 samples from 1437 patients was reviewed. This included 904 patients with 1,045 CDI episodes, 151 (8%) patients with 490 samples who initially had CDI but the subsequent episode did not meet the case definition and 382 (19%) patients with 440 samples who never met the CDI case definition. When RT were reviewed by CDI origin and case type, no difference was observed between healthcare associated (HA) and community associated (CA) groups for the commonest RTs. CDI testing was requested by clinicians in only 22.4% cases. The majority of CDI was HA (82.2%) with more females affected than males (OR 2.3 p Discussion and Conclusion: Despite rigorous CDI IPC programmes HA-CDI rates have not changed, even when more sensitive testing methods were introduced, whereas CA-CDI is at its highest in a decade. These findings underpin the importance of using prospective, multidisciplinary surveillance to inform local decision making. The convergence of ribotypes between HA and CA CDI as well as the onset of CDI symptoms in the community question the traditional view of CDI as a hospital issue. Further research to trace circulating RTs between healthcare facilities and the community is needed.</p

Cost Effectiveness of Fecal DNA Screening for Colorectal Cancer: A Systematic Review and Quality Appraisal of the Literature

Background Fecal DNA (fDNA) testing is a noninvasive potential alternative to current colorectal cancer screening tests. Objective We conducted a systematic review and quality assessment of studies of cost-effectiveness of fDNA as a colorectal cancer screening tool (compared with no screening and other screening modalities), and identified key variables that impinged on cost-effectiveness. Data sources We searched MEDLINE, Embase, and the Centre for Reviews and Dissemination for cost-effectiveness studies of fDNA-based screening, published in English by September 2011. Study selection Studies that undertook an economic evaluation of fDNA, using either a cost-effectiveness or cost-utility analysis, compared with other relevant screening modalities and/or no screening were included. Additional inclusion criteria related to the presentation of data pertaining to model variables including time horizon, costs, fDNA performance characteristics, screening uptake, and comparators. A total of 369 articles were initially identified for review. After removing duplicates and applying inclusion and exclusion criteria, seven articles were included in the final review. Study appraisal Data was abstracted on key descriptor variables including screening scenarios, time horizon, costs, test performance characteristics, screening uptake, comparators, and incremental cost-effectiveness ratios. Quality assessment was undertaken using a standard checklist for economic evaluations. Studies cited by cost-effectiveness articles as the source of data on fDNA test performance characteristics were also reviewed. Results Seven cost-effectiveness studies were included, from the USA (4), Canada (1), Israel (1), and Taiwan (1). Markov models (5), a partially observable Markov decision process model (1) and MISCAN and SimCRC (1) microsimulation models were used. All studies took a third-party payer perspective and one included, in addition, a societal perspective. Comparator screening tests, screening intervals, and specific fDNA tests varied between studies. fDNA sensitivity and specificity parameters were derived from 12 research studies and one meta-analysis. Outcomes assessed were life-years gained and quality-adjusted life-years gained. fDNA was cost-effective when compared with no screening in six studies. Compared with other screening modalities, fDNA was not considered cost-effective in any of the base-case analyses: in five studies it was dominated by all alternatives considered. Sensitivity analyses identified cost, compliance, and test parameters as key influential parameters. In general, poor presentation of “study design” and “data collection” details lowered the quality of included articles. Limitations Although the literature searches were designed for high sensitivity, the possibility cannot be excluded that some eligible studies may have been missed. Reports (such as Health Technology Assessments produced by government agencies) and other forms of grey literature were excluded because they are difficult to identify systematically and/or may not report methods and results in sufficient detail for assessment. Conclusion On the basis of the available (albeit limited) evidence, while fDNA is cost-effective when compared with no screening, it is currently dominated by most of the other available screening options. Cost and test performance appear to be the main influences on cost-effectiveness

Cost-effectiveness of computed tomography colonography in colorectal cancer screening: a systematic review

Objectives: The European Code Against Cancer recommends individuals aged ≥50 should participate in colorectal cancer screening. CT-colonography (CTC) is one of several screening tests available. We systematically reviewed evidence on, and identified key factors influencing, cost-effectiveness of CTC screening. Methods: PubMed, Medline, and the Cochrane library were searched for cost-effectiveness or cost-utility analyses of CTC-based screening, published in English, January 1999 to July 2010. Data was abstracted on setting, model type and horizon, screening scenario(s), comparator(s), participants, uptake, CTC performance and cost, effectiveness, ICERs, and whether extra-colonic findings and medical complications were considered. Results: Sixteen studies were identified from the United States (n = 11), Canada (n = 2), and France, Italy, and the United Kingdom (1 each). Markov state-transition (n = 14) or microsimulation (n = 2) models were used. Eleven considered direct medical costs only; five included indirect costs. Fourteen compared CTC with no screening; fourteen compared CTC with colonoscopy-based screening; fewer compared CTC with sigmoidoscopy (8) or fecal tests (4). Outcomes assessed were life-years gained/saved (13), QALYs (2), or both (1). Three considered extra-colonic findings; seven considered complications. CTC appeared cost-effective versus no screening and, in general, flexible sigmoidoscopy and fecal occult blood testing. Results were mixed comparing CTC to colonoscopy. Parameters most influencing cost-effectiveness included: CTC costs, screening uptake, threshold for polyp referral, and extra-colonic findings. Conclusion: Evidence on cost-effectiveness of CTC screening is heterogeneous, due largely to between-study differences in comparators and parameter values. Future studies should: compare CTC with currently favored tests, especially fecal immunochemical tests; consider extra-colonic findings; and conduct comprehensive sensitivity analyses