***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The Valsartan Heart Failure Trial ( Val-HeFT ) compared valsartan versus placebo in 5010 patients taking prescribed background therapy for New York Heart Association class II to IV heart failure .  Valsartan reduced the risk of heart failure hospitalization and improved clinical signs and symptoms of heart failure . We sought to compare re source use , costs , and health outcomes among patients taking prescribed therapy for heart failure and r and omly assigned to receive valsartan or placebo .  METHODS Measures of re source use were based on data collected during the trial . Unit cost estimates were collected from individual countries and converted to 1999 US dollars . Total costs were estimated for hospitalizations , inpatient and outpatient physician services , ambulance transportation , deaths outside the hospital , and outpatient cardiovascular medications . RESULTS Mean follow-up was 23 months . Mean costs for heart failure hospitalizations were 423 dollars lower among patients receiving valsartan ( 95 % CI , -706 to -146 ) . Mean total costs were 9008 dollars for patients receiving valsartan and 8464 dollars for patients receiving placebo , a net incremental cost of 545 dollars ( 95 % CI , -149 to 1148 ) , including the cost of valsartan . There was an overall reduction in total costs of 929 dollars ( 95 % CI , -3243 to 1533 ) among patients not receiving an ACE inhibitor at baseline but a slight increase in costs of 334 dollars ( 95 % CI , -497 to 1199 ) among those receiving an ACE inhibitor without a beta-blocker and a 1246 dollars increase ( 95 % CI , 54 to 2230 ) in patients receiving both an ACE inhibitor and a beta-blocker at baseline . CONCLUSIONS Valsartan provided clinical benefits at a mean incremental cost of 285 dollars per year during the trial . In patients not taking ACE inhibitors , valsartan was economically attractive , increasing survival while reducing or marginally increasing overall costs Background —Both stenting and the glycoprotein IIb/IIIa inhibitor abciximab improve outcomes for patients undergoing primary angioplasty for acute myocardial infa rct ion ( AMI ) . However , the cost-effectiveness of these strategies is unknown . Methods and Results —We performed a prospect i ve cost-utility analysis among US participants in the CADILLAC trial . Patients with AMI ( n=1703 ) were r and omized to stenting versus balloon angioplasty ( PTCA ) and abciximab versus no abciximab according to a 2-by-2 factorial design . Total 1-year costs and lifetime incremental cost-effectiveness ratios , measured as cost per quality -adjusted year of life ( QALY ) gained , were calculated . Compared with PTCA , stenting increased procedural costs by $ 1148 and initial hospital costs by $ 1384 ( both P < 0.001 ) . By 1-year , stenting led to fewer repeat revascularization procedures and reduced follow-up medical care costs by $ 1215 , such that aggregate costs were similar for the PTCA and stent groups ( $ 18 690 versus $ 18 859 , P = 0.75 ) . The cost-effectiveness ratio for stenting versus PTCA was favorable at $ 11 237/QALY gained and remained < $ 20 000/QALY in sensitivity analyses . Compared with st and ard anticoagulation , abciximab increased initial procedural costs by $ 1122 ( P < 0.001 ) . By facilitating accelerated hospital discharge , abciximab reduced length of stay by ≈0.6 days , off setting most of the drug costs . These cost offsets were not maintained , however ; aggregate 1-year costs for the abciximab group were $ 1244 greater than for st and ard therapy ( $ 19 389 versus $ 18 145 , P = 0.02 ) . Abciximab was reasonably cost-effective ( cost-effectiveness ratio $ 21 305/QALY ) only if nonsignificant differences in 1-year mortality ( 3.7 % versus 4.3 % , P = 0.62 ) were incorporated in the analysis . Conclusions — Primary stenting is a highly cost-effective treatment for AMI . The cost-effectiveness of abciximab in this setting is uncertain and depends primarily on whether long-term survival is enhanced Objectives The study aims to increase knowledge about the performance of the EuroQol-visual analogue scales ( EQ-VAS ) in the UK NHS patient-reported outcome measures ( PROMs ) programme , which covers groin hernia , hip and knee replacement and varicose vein surgery , and make suggestions for improved collection , coding and analysis of data . Methods Four hundred scanned images of matched before- and -after EQ-VAS PROMs responses were selected at r and om . These were classified according to the different ways in which they were completed . Patient-level PROMs programme data linked to Hospital Episode Statistics for all patients from April 2009 to February 2011 were used to analyse the relationship between the EQ-VAS and the EQ-5D profile , index-weighted profile and condition-specific instruments . The linked PROMs and HES data comprise 331,951 anonymised patient records . Results A large majority ( 95 % ) of EQ-VAS responses were completed in an unambiguous way , but only a minority ( 45 % ) conformed strictly to the instructions given , posing challenges for data coding . The EQ-VAS data have a predictable and consistent relationship with the EQ-5D profile , although the correlations between the EQ-VAS and other measures of patient-reported health , both before and after surgery and in the change between them , are weak . Conclusions EQ-VAS data might be improved by providing better guidance on collection and coding . It is argued that the observed differences in results from EQ-VAS and other measures of health reflect the fact that it measures a broader underlying construct of health , arguably providing a means of summarising overall health that is closer to the patient ’s perspective This study aim ed to evaluate the cost-effectiveness of formoterol ( Oxis ) Turbuhaler 4.5 microg and salbutamol 200 microg as reliever medications in Sweden and Spain . The study used data on effectiveness ( exacerbations and symptom-free days ) and re source utilisation from an open , 6-month , parallel-group , multicentre r and omised trial with 18,124 asthma patients in 24 countries . Country-specific unit costs for Sweden and for Spain were used to transform re source utilisation data into costs . Total healthcare costs were not significantly different between formoterol and salbutamol dry powder inhalers in Sweden , whereas in Spain , the healthcare costs were 20 % higher for formoterol vs. salbutamol pressurised metered dose inhalers . Total healthcare costs increased with disease severity , defined according to the Global Initiative for Asthma guidelines . Compared with salbutamol , formoterol produced statistically significant improvements in effectiveness , less reliever and maintenance medication usage , reduced healthcare re source utilisation , with no increase or a limited increase in healthcare cost BACKGROUND The Inhaled Steroid as Regular Therapy in Early Asthma ( START ) study reported that early intervention with budesonide in mild persistent asthma reduces severe asthmatic events and improves symptom outcomes and lung function in adults and children . OBJECTIVE We sought to estimate the incremental cost-effectiveness of early intervention with budesonide , as observed within the START study . METHODS START was a r and omized , 3-year controlled trial of budesonide in early onset mild asthma among 7165 subjects ages 5 to 66 years . Three age groups ( 5 - 10 , 11 - 17 , and > or=18 years ) were studied separately and overall . Differences in the probability of emergency treatments , symptom-free days ( SFDs ) , and costs of health care were determined . Incremental cost-effectiveness ratios were estimated from the health care payer and societal perspectives . RESULTS Compared with usual therapy , patients receiving budesonide experienced an average of 14.1 ( SE , 1.3 ) more SFDs per year ( P < .001 ) , fewer hospital days ( 69 % , P < .001 ) , and fewer emergency department visits ( 67 % , P < .05 ) . From the health care payer perspective , the net cost of early use of budesonide was an additional US dollars 0.42 ( SE , dollars 0.04 ) per day , and the result ant cost-effectiveness ratio was US dollars 11.30 ( 95 % CI , US dollars 8.60-US dollars 14.90 ) per SFD gained . From the societal perspective , the cost offsets of lower absence from school or work reduced the net cost of early budesonide to US dollars 0.14 ( SE , US dollars 0.07 ) per day and decreased the cost-effectiveness ratio to US dollars 3.70 ( 95 % CI , US dollars 0.10-US dollars 8.00 ) . Early intervention was more effective and cost saving in the youngest age group . CONCLUSION Long-term treatment with budesonide appears to be cost-effective in patients with mild persistent asthma of recent onset OBJECTIVE To evaluate the cost-effectiveness of enoxaparin versus unfractionated heparin in conjunction with fibrinolysis in ST elevation myocardial infa rct ion patients within Canada . DESIGN Based on the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infa rct ion Treatment - Thrombolysis in Myocardial Infa rct ion ( ExTRACT-TIMI ) 25 trial , a model was created to analyze the cost-effectiveness of enoxaparin compared with unfractionated heparin in conjunction with fibrinolysis among ST elevation myocardial infa rct ion patients within Canada . Clinical outcomes were derived from published results of the main trial . Re source use costs were first assessed based on United States Diagnosis-Related Group values for hospitalizations and Current Procedural Terminology codes for outpatient visits and tests . Both were then converted using Canadian local costs . Survival and life expectancy were estimated from Framingham survival data . The incremental cost-effectiveness ratio was expressed as cost per life year gained . RESULTS Through 30 days after r and om assignment , the primary composite end point favoured the enoxaparin group over the unfractionated heparin group ( death or recurrent myocardial infa rct ion rate 9.9 % versus 12.0 % , P<0.001 ) , and was associated with a modest increased cost of $ 169.50 ( $ 8,757.00 versus $ 8,587.50 , respectively ) . Life years gained as a result of treatment with enoxaparin was increased by 0.11 years ( P<0.05 ) . Enoxaparin was found to be cost-effective , as indicated by an incremental cost-effectiveness ratio of $ 4,930 with a 99 % probability of costing less than $ 20,000 . CONCLUSIONS Although associated with modest increased direct medication costs , enoxaparin following fibrinolysis improved the clinical efficacy in STEMI patients and increased the life years gained Objective To determine the cost utility of treating schizophrenic patients with olanzapine  compared with other antipsychotics in a naturalistic outpatient setting . Methods The pan-European SOHO study is a 3-year , prospect i ve , outpatient , observational study of outcomes associated with antipsychotic treatment , focusing on olanzapine , in ten European countries . For the cost-utility analysis , healthcare re source use ( inpatient care , day care , outpatient psychiatric consultations and antipsychotic and concomitant medication use ) and EQ-5D data were collected at baseline and at 3 , 6 and 12 months . The perspective was that of the health service payer . UK healthcare unit costs ( year 2004 values ) were applied to the re source use data for the ten countries . UK population tariffs were applied to the EQ-5D data to determine utility values . An Epoch analysis was used to analyze the longitudinal data . Multivariate regression analyses that adjusted for baseline covariates were used to estimate the incremental cost and utility gains for patients treated with olanzapine compared with each of the other antipsychotics ( risperidone , quetiapine , amisulpride , clozapine and oral or depot typical antipsychotics ) . Results A total of 10 972 patients were enrolled at baseline , of which 9107 completed the 12-month study period . Treatment with olanzapine was more effective in terms of QALYs gained than all of the other antipsychotic treatments . Treatment with olanzapine dominated quetiapine and amisulpride . The incremental cost  for olanzapine compared with risperidone was £ 226 per patient over 12 months and the incremental cost per QALY gained was £ 5156 , with bootstrap analyses showing 100 % of the replications falling below a £ 30 000 per QALY gained threshold . Compared with treatment with clozapine , olanzapine was found to be marginally more effective , at an additional cost of £ 13 per patient over 12 months and to have an incremental cost per QALY gained of £ 775 . Bootstrap analyses showed that 81 % of replications fell below a £ 30 000 per QALY gained threshold . Comparing olanzapine with oral and depot typical antipsychotics , the incremental cost was £ 849 and £ 1106 per patient over 12 months and the incremental cost 
    Output:
    
The most common challenge appeared to be related to addressing differences between countries , which potentially hinders the generalisability and transferability of results .