Objectives: To compare the safety, effectiveness and cost‐effectiveness of drug‐eluting coronary stents used in Australia with bare‐metal stents and determine whether the benefits are greater for high‐risk subgroups. Data sources: MEDLINE, Pre‐Medline, EMBASE, Current Contents, CINAHL and the Cochrane Library database were searched to identify eligible randomised controlled trials and systematic reviews published in English between January 1966 and June 2004. Study selection: Seven randomised controlled trials that assessed polymer‐based paclitaxel‐ or sirolimus‐eluting stents versus bare‐metal stents in patients with coronary atherosclerosis and reported on stent thrombosis, mortality, myocardial infarction, coronary artery bypass grafting or target lesion revascularisation. Data extraction: Two independent reviewers appraised eligible studies and extracted data. Relative risks (RRs) were calculated for each outcome and pooled using the Mantel–Haenszel method. Data synthesis: Rates of stent thrombosis, mortality, myocardial infarction and bypass grafts did not differ by stent type. Drug‐eluting stents (DESs) resulted in a 71%–80% lower risk of revascularisation at 12 months (RR 0.29 [95% CI, 0.20–0.43] for paclitaxel‐eluting stents [n = 1593 patients]; RR 0.20 [95% CI, 0.13–0.29] for sirolimus‐eluting stents [n = 1296 patients]). Similar benefits were seen in several high‐risk subgroups of patients: those with diabetes, lesion length > 20 mm and target‐vessel diameter ≤ 2.5 mm. The benefits of DESs in these high‐risk groups over lower‐risk groups were inconclusive because of low numbers. The cost per revascularisation avoided by using DESs was A$3750–$6100, with an estimated cost per quality‐adjusted‐life‐year (QALY) gained of A$46 829–$76 467. In sensitivity analyses, estimates varied from DESs being cost‐saving to costing an additional $314 385 per QALY gained. Conclusions: DESs are effective in reducing revascularisation. Estimates of cost‐effectiveness are very sensitive to changes in estimates of their true effects in clinical practice, market price and the number of stents used per patient. Decisions to limit DESs to only patients at the highest risk of restenosis may improve their cost‐effectiveness but will need to be reassessed when evidence is available to compare absolute benefits between patient groups.

Background Interpregnancy interval (IPI) <6 months is a potentially modifiable risk factor for adverse perinatal health outcomes. Objective This systematic review evaluated the international literature on the risk of perinatal death associated with IPI. Search strategy Two independent reviewers screened titles and abstracts identified in MEDLINE, EMBASE and Scopus from inception to 4 April 2019 (Prospero Registration #CRD42018092792). Selection criteria Studies were included if they provided a description of IPI measurement and perinatal death, including stillbirth and neonatal death. Data collection and analysis A narrative review was performed for all included studies. Random effects meta-analysis was used to compare unadjusted odds of perinatal death associated with IPI <6 months and IPI ≥6 months. Analyses were performed by outcome of the preceding pregnancy and study location. Main results Of the 624 unique articles identified, 26 met the inclusion criteria. The pooled unadjusted odds ratio of perinatal death for IPI <6 months was 1.34 (95% CI 1.17-1.53) following a previous live birth, 0.85 (95% CI 0.73-0.99) following a previous miscarriage and 1.07 (95% CI 0.84-1.36) following a previous stillbirth compared with IPI ≥6 months. However, few high-income country studies reported an association after adjustment. Fewer studies evaluated the impact of long IPI on perinatal death and what evidence was available showed mixed results. Conclusions Results suggest a possible association between short IPI and risk of perinatal death following a live birth, particularly in low-to middle-income countries.

Gamma Knife may be cost competitive only if demand for SRS services is high enough to fully use equipment working time. However, given low patient demand and competing radiotherapy needs, Gamma Knife appears more costly and further evidence of survival or quality of life advantages may be required to justify reimbursement.

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