Health technology assessment : HTA
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Health Technol Assess · Jul 2009
Review Meta AnalysisSystematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care.
To assess the accuracy in diagnosing heart failure of clinical features and potential primary care investigations, and to perform a decision analysis to test the impact of plausible diagnostic strategies on costs and diagnostic yield in the UK health-care setting. ⋯ The analysis suggests the need for important changes to the NICE recommendations. First, BNP (or NT-proBNP) should be recommended over ECG and, second, some patients should be referred straight for echocardiography without undergoing any preliminary investigation. Future work should include evaluation of the clinical rule described above in clinical practice.
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Health Technol Assess · Jul 2009
Review Comparative StudyEarly high-dose lipid-lowering therapy to avoid cardiac events: a systematic review and economic evaluation.
To evaluate the cost-effectiveness of high-dose statins (atorvastatin 80 mg/day, rosuvastatin 40 mg/day and simvastatin 80 mg/day) versus simvastatin 40 mg/day in individuals with acute coronary syndrome (ACS). ⋯ Simvastatin 80 mg/day cannot be recommended because of the high incidence rates of adverse events. If the cost of atorvastatin decreases in line with that observed for simvastatin when the patent ends in 2011, atorvastatin 80 mg/day will be the most cost-effective treatment for all thresholds; if the cost reduces to 25% of the current value, atorvastatin 80 mg/day will be the most cost-effective treatment for thresholds between 5000 pounds and 30,000 pounds per QALY. Large long-term RCTs reporting effects in terms of clinical events are required to determine the optimum statin use for subgroups.
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Health Technol Assess · Jun 2009
ReviewSensitivity analysis in economic evaluation: an audit of NICE current practice and a review of its use and value in decision-making.
To determine how we define good practice in sensitivity analysis in general and probabilistic sensitivity analysis (PSA) in particular, and to what extent it has been adhered to in the independent economic evaluations undertaken for the National Institute for Health and Clinical Excellence (NICE) over recent years; to establish what policy impact sensitivity analysis has in the context of NICE, and policy-makers' views on sensitivity analysis and uncertainty, and what use is made of sensitivity analysis in policy decision-making. ⋯ The review and the policy impact assessment focused exclusively on documentary evidence, excluding other sources that might have revealed further insights on this issue. In seeking to address parameter uncertainty, both deterministic and probabilistic sensitivity analyses should be used. It is evident that some cost-effectiveness work, especially around the sensitivity analysis components, represents a challenge in making it accessible to those making decisions. This speaks to the training agenda for those sitting on such decision-making bodies, and to the importance of clear presentation of analyses by the academic community.
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Health Technol Assess · Jun 2009
Trastuzumab for the treatment of primary breast cancer in HER2-positive women: a single technology appraisal.
This paper presents a summary of the evidence review group (ERG) report into the the clinical and cost-effectiveness of trastuzumab for the treatment of primary breast cancer in human epidermal growth factor 2 (HER2)-positive women based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's scope restricts the intervention to intravenous trastuzumab given for 1 year after surgery and after the completion of standard adjuvant chemotherapy, and the comparator to standard therapy without trastuzumab. The clinical rationale for the duration of treatment in the scope is open to question and leads to the exclsuion of one potentially relevant trial. ⋯ The addition of potential long-term cardiac events could push the ICER above 30,000 pounds, although there is no long-term evidence to date surrounding this issue. In addition, the small study excluded from the manufacturer's submission raises the possibility of an equally effective but shorter regimen, incurring lower cost and toxicity and with greater patient convenience. The guidance issued by NICE in June 2006 as a result of the STA states that trastuzumab, given at 3-week intervals for 1 year or until disease recurrence, is recommended as a treatment option for women with early-stage HER2-positive breast cancer following surgery, chemotherapy and radiotherapy.
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Health Technol Assess · Jun 2009
ReviewThe effect of different treatment durations of clopidogrel in patients with non-ST-segment elevation acute coronary syndromes: a systematic review and value of information analysis.
To update the previous systematic review of the use of clopidogrel in combination with aspirin for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), investigating the optimal duration of treatment and effects of withdrawal from treatment. ⋯ The review was limited by the lack of available data. There is considerable variation in the costs of uncertainty surrounding the different scenarios and populations considered. The validity of these may also be less reliable in the higher-risk groups owing to changes in clinical practice. An adequately powered, well-conducted RCT that directly compares different durations of clopidogrel treatment in patients with NSTE-ACS would ideally be required to provide more robust evidence in relation to the impact of clopidogrel withdrawal.