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      A health economic evaluation of screening and treatment in patients with adolescent idiopathic scoliosis

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          Abstract

          Summary of background data

          Adolescent idiopathic scoliosis can progress and affect the health related quality of life of the patients. Research shows that screening is effective in early detection, which allows for bracing and reduced surgical rates, and may save costs, but is still controversial from a health economic perspective.

          Study design

          Model based cost minimisation analysis using hospital’s costs, administrative data, and market prices to estimate costs in screening, bracing and surgical treatment. Uncertainty was characterised by deterministic and probabilistic sensitivity analyses. Time horizon was 6 years from first screening at 11 years of age.

          Objective

          To compare estimated costs in screening and non-screening scenarios (reduced treatment rates of 90%, 80%, 70% of screening, and non-screening Norway 2012).

          Methods

          Data was based on screening and treatment costs in primary health care and in hospital care settings. Participants were 4000, 12-year old children screened in Norway, 115190 children screened in Hong Kong and 112 children treated for scoliosis in Norway in 2012. We assumed equivalent outcome of health related quality of life, and compared only relative costs in screening and non-screening settings. Incremental cost was defined as positive when a non-screening scenario was more expensive relative to screening.

          Results

          Screening per child was € 8.4 (95% CrI 6.6 to10.6), € 10350 (8690 to 12180) per patient braced, and € 45880 (39040 to 55400) per child operated. Incremental cost per child in non-screening scenario of 90% treatment rate was € 13.3 (1 to 27), increasing from € 1.3 (−8 to 11) to € 27.6 (14 to 44) as surgical rates relative to bracing increased from 40% to 80%. For the 80% treatment rate non-screening scenario, incremental cost was € 5.5 (−6 to 18) when screening all, and € 11.3 (2 to 22) when screening girls only. For the non-screening Norwegian scenario, incremental cost per child was € -0.1(−14 to 16). Bracing and surgery were the main cost drivers and contributed most to uncertainty.

          Conclusions

          With the assumptions applied in the present study, screening is cost saving when performed in girls only, and when it leads to reduced treatment rates. Cost of surgery was dominating in non-screening whilst cost of bracing was dominating in screening. The economic gain of screening increases when it leads to higher rates of bracing and reduced surgical rates.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13013-014-0021-8) contains supplementary material, which is available to authorized users.

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          Most cited references41

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          Decision Modelling for Health Economic Evaluation

          In financially constrained health systems across the world, increasing emphasis is being placed on the ability to demonstrate that health care interventions are not only effective, but also cost-effective. This book deals with decision modelling techniques that can be used to estimate the value for money of various interventions including medical devices, surgical procedures, diagnostic technologies, and pharmaceuticals. Particular emphasis is placed on the importance of the appropriate representation of uncertainty in the evaluative process and the implication this uncertainty has for decision making and the need for future research. This highly practical guide takes the reader through the key principles and approaches of modelling techniques. It begins with the basics of constructing different forms of the model, the population of the model with input parameter estimates, analysis of the results, and progression to the holistic view of models as a valuable tool for informing future research exercises. Case studies and exercises are supported with online templates and solutions. This book will help analysts understand the contribution of decision-analytic modelling to the evaluation of health care programmes. [Ed.]
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            Adolescent idiopathic scoliosis.

            Adolescent idiopathic scoliosis (AIS) affects 1-3% of children in the at-risk population of those aged 10-16 years. The aetiopathogensis of this disorder remains unknown, with misinformation about its natural history. Non-surgical treatments are aimed to reduce the number of operations by preventing curve progression. Although bracing and physiotherapy are common treatments in much of the world, their effectiveness has never been rigorously assessed. Technological advances have much improved the ability of surgeons to safely correct the deformity while maintaining sagittal and coronal balance. However, we do not have long-term results of these changing surgical treatments. Much has yet to be learned about the general health, quality of life, and self-image of both treated and untreated patients with AIS.
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              Effects of bracing in adolescents with idiopathic scoliosis.

              The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.).
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                Author and article information

                Contributors
                radobor@ous-hf.no
                paal.joranger@hioa.no
                hsteen@ous-hf.no
                stale.navrud@nmbu.no
                jbrox@ous-hf.no
                Journal
                Scoliosis
                Scoliosis
                Scoliosis
                BioMed Central (London )
                1748-7161
                6 December 2014
                6 December 2014
                2014
                : 9
                : 1
                : 21
                Affiliations
                [ ]Section for Spine Surgery, Department of Orthopedic Surgery, Oslo University Hospital-Rikshospitalet, Pb 4950, Nydalen, N-0424 Oslo, Norway
                [ ]Oslo and Akershus University College of Applied Sciences, P. O Box 4, St. Olavs plass, N-0130 Oslo, Norway
                [ ]School of Economics and Business, Norwegian University of Life Sciences, P. O. Box 5003, N-1432 Ås, Norway
                [ ]Biomechanic lab, Department of Orthopedic Surgery, Oslo University Hospital-Rikshospitalet, Pb 4950, Nydalen, N-0424 Oslo, Norway
                [ ]Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Pb 4950, Nydalen, N-0424 Oslo, Norway
                Article
                21
                10.1186/s13013-014-0021-8
                4298059
                24559234
                16443265-9a60-4871-b9e2-c2d04d597f63
                © Adobor et al.; licensee BioMed Central. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 19 August 2014
                : 18 November 2014
                Categories
                Research
                Custom metadata
                © The Author(s) 2014

                Orthopedics
                cost minimisation analysis,scoliosis screening,scoliosis treatment,health related quality of life

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