[Economic evaluation of the introduction of 4CMenB (Bexsero®) in the national vaccine schedule in Spain]

INTRODUCTION

Bexsero® (4CMenB), meningococcal B vaccine, was licensed in Europe in 2013. In Spain, despite MenB being the most frequent cause of invasive meningococcal disease (IMD), Bexsero® is recommended and financed for patients at increased risk of IMD but is not financed by the NHS in the routine vaccination schedule.

OBJECTIVE

to evaluate the cost-utility, epidemiological impact, and total costs of the introduction of 4CMenB into the vaccination schedule to help inform vaccine policy in Spain.

METHOD

We adapted a cost-utility analysis, a probabilistic decision-tree, to Spain. A cohort of new-born infants in 2015 was modelled with two dosages, using two different strategies: routine vaccination schedule with 4CMenB and non-vaccination. Costs were measured from a payer perspective and benefits were calculated in quality-adjusted life years (QALYs). A Monte Carlo analysis and 32 scenarios were performed to assess the robustness and the uncertainty of our results.

RESULTS

With the 3+1 dosage, routine vaccination prevented 54% of cases and deaths and an incremental cost-utility ratio (ICUR) of 351.389 €/QALY (95% confidence interval [95%CI]: 265,193-538,428) was estimated. The 2+1 dosage prevented 50% of cases and deaths, with an ICUR of 278.556 €/QALY (95%CI: 210,285-430,122).

CONCLUSIONS

Given the current incidence of invasive meningococcal disease in Spain and the information available from 4CMenB, our model shows that routine vaccination is not cost-effective at the current price. Only with a vaccine price of 1.45 € for the 3+1 schedule or 3.37 € for the 2+1 schedule could it be recommended based on efficiency criteria.

Comprehensive biomarker analyses identifies HER2, EGFR, MET RNA expression and thymidylate synthase 5'UTR SNP as predictors of benefit from S-1 adjuvant chemotherapy in Japanese patients with stage II/III gastric cancer

Purpose: A comprehensive molecular analysis was conducted to identify prognostic and predictive markers for adjuvant S-1 chemotherapy in stage II/III Japanese gastric cancer (GC) patients and to evaluate their potential suitability for alternative cytotoxic or targeted drugs.

Experimental Design: We investigated genetic polymorphisms of enzymes potentially involved in 5-fluoruracil (5-FU) metabolism as well as platinum resistance, previously identified genomic subtypes potentially predicting 5-FU benefit, and mRNA expression levels of receptor tyrosine kinases and KRAS as potential treatment targets in a single institution cohort of 252 stage II/III GC patients treated with or without S-1 after D2 gastrectomy.

Results: 88% and 62% GC had a potentially 5-FU sensitive phenotype by SNP analyses of TS 3'UTR, and TS 5'UTR, respectively. 24%, 46%, 40%, 5%, and 44% GC had a potentially platinum sensitive phenotype by SNP analyses of GSTP1, ERCC1 rs11615, ERCC1 rs3212986, ERCC2, and XRCC1, respectively. High HER2, EGFR, FGFR2, or MET mRNA expression was observed in 49%, 66%, 72%, and 54% GC, respectively. High HER2 expression was the only significant prognosticator (HR=3.912, 95%CI: 1.706-8.973, p=0.0005). High HER2 (p=0.031), low EGFR (p=0.124), high MET (p=0.165) RNA expression, and TS 5'UTR subtype 2R/2R, 2R/3C, or 3C (p=0.058) were significant independent predictors for S-1 resistance.

Conclusions: The present study suggests that platinum-based or RTK targeted agents could be alternative treatment options for a substantial subgroup of Japanese GC patients currently treated with S-1. HER2, EGFR, MET, and TS 5'UTR SNP appear to be promising predictive markers for S-1 resistance warranting validation in an independent GC series.

P2679Normal high sensitive troponin I and suspected myocardial infarction, is the rapid rule out algorythm for all?

Introduction

Since the introduction of High sensitive troponin assays, many studies showed that patients presenting to the ED with cardiac chest pain and HsTnI under 5 ng/dl have very good prognosis and extremely low risk for major cardiovascular events at follow up. These studies led to a few rapid rule out algorythms for MI according to undetectable HsTnI in first hours following admission.

Purpose

The aim of the study was to examine whether a maximal HsTnI under 5 ng/dl, in a hemodynamicaly stable patient, is sufficient to discharge a patient without further testing.

Methods

Retrospective analysis of patients admitted to the emergency depatment due to suspected myocardial infarction between February 2016 and December 2018. All patients had a HsTnI under 5 ng/dl and were either discharged home or admitted for further observation and testing. The collection of data was performed by the MDCLONE software from the electronic medical records in our medical center.

Results

Between February 2016 and December 2018, 10,936 patients were admitted to the emergency department due to chest pain or suspected MI. In 7925 (72%) the maximal HsTnI value was under 5 ng/dl. Group 1 included 6699 (85%) patients who did not undergo any further test and group 2 included 1226 (15%) who were admitted for further testing. Further testing included Coronary CT in 999 (81%) and Stress myocardial perfusion imaging (MPI) in 227 (19%). 11 patients underwent both tests. Out of the 999 patients examined with coronary CT, 114 (11%) needed further evaluation with coronary angiogiography and 41 required angioplasty and stening. 18 (7%) patients that were evaluated using stress MPI needed angio and 7 (3%) required stenting.

Comparing the group 1 and 2, patients who went through further testing were more likely to be older, with higher prevalence of diabetes, hypertenstion, smoking history and after CABG in the past. Group 1 had 0.07%, 0.16% and 0.33% all cause mortality in 30, 90 and 360 days respectivly. Group 2 had no mortality in 30 and 90 days, and 0.25% all cause mortality in 360 days. No statistical significance was reached in all time points.

There was no difference in re-admissions in the first 90 days after discharge between the groups.

Conclusions

Based on our data, patients admitted to the emergency department due to suspected myocardial infarction and known cardiovascular risk factors but with HsTnI under the 5 ng/dl, the use of rapid rule out algorithms may be questionable.

Acknowledgement/Funding

None

Beyond the cost-effectiveness acceptability curve: The appropriateness of rank probabilities for presenting the results of economic evaluation in multiple technology appraisal

The cost-effectiveness acceptability curve (CEAC) shows the probability that an option ranks first for net benefit. Where more than two options are under consideration, the CEAC offers only a partial picture of the decision uncertainty. This paper discusses the appropriateness of showing the full set of rank probabilities for reporting the results of economic evaluation in multiple technology appraisal (MTA). A case study is used to illustrate the calculation of rank probabilities and associated metrics, based on Monte Carlo simulations from a decision model. Rank probabilities are often used to show uncertainty in the results of network meta-analysis, but until now have not been used for economic evaluation. They may be useful decision-making tools to complement the CEAC in specific MTA contexts.

Cost-effectiveness of lenalidomide maintenance in patients with multiple myeloma who have undergone autologous transplant of hematopoietic progenitor cells

The objective of this article is to analyze the ratio of cost-effectiveness and budgetary impact of lenalidomide treatment in patients with multiple myeloma who have undergone autologous transplant in Spain. The analyses were based on clinical trials CALGB 100104 and IFM 2005-02, from the perspective of the National Health System. The alternatives compared were the treatment with lenalidomide against maintenance without treatment (MwT). Efficiency measures used were years of life gained (YGs) and quality-adjusted life years (QALYs). According to the CALGB 100104 trial data, the average health costs of patients who were treated with lenalidomide for 120 months was €836,534.31 and without treatment was €528,963.63. The effectiveness of the lenalidomide group was 7.59YGs (5.72 QALY) against 6.58 of MwT (4.61 QALY). The incremental cost-utility ratio (ICUR) was €277,456.72/QALY and the incremental cost-effectiveness ratio was €303,191.05/YGs. From the analysis, the IFM2005-02 trial obtained 5.13 QALY in the lenalidomide group against the 4.98 QALY in the MwT group, with an ICUR of €1,502,780.55/QALY. In terms of budgetary impact, a range between 799 and 1452 patients susceptible to receive treatment with lenalidomide was assumed in Spain. In conclusion, the results show a high ICUR and budgetary impact, which adds uncertainty about the maximum prudent duration of the treatment.

Fast and accurate tumor segmentation of histology images using persistent homology and deep convolutional features

Tumor segmentation in whole-slide images of histology slides is an important step towards computer-assisted diagnosis. In this work, we propose a tumor segmentation framework based on the novel concept of persistent homology profiles (PHPs). For a given image patch, the homology profiles are derived by efficient computation of persistent homology, which is an algebraic tool from homology theory. We propose an efficient way of computing topological persistence of an image, alternative to simplicial homology. The PHPs are devised to distinguish tumor regions from their normal counterparts by modeling the atypical characteristics of tumor nuclei. We propose two variants of our method for tumor segmentation: one that targets speed without compromising accuracy and the other that targets higher accuracy. The fast version is based on a selection of exemplar image patches from a convolution neural network (CNN) and patch classification by quantifying the divergence between the PHPs of exemplars and the input image patch. Detailed comparative evaluation shows that the proposed algorithm is significantly faster than competing algorithms while achieving comparable results. The accurate version combines the PHPs and high-level CNN features and employs a multi-stage ensemble strategy for image patch labeling. Experimental results demonstrate that the combination of PHPs and CNN features outperform competing algorithms. This study is performed on two independently collected colorectal datasets containing adenoma, adenocarcinoma, signet, and healthy cases. Collectively, the accurate tumor segmentation produces the highest average patch-level F1-score, as compared with competing algorithms, on malignant and healthy cases from both the datasets. Overall the proposed framework highlights the utility of persistent homology for histopathology image analysis.

The price of innovation - the role of drug pricing in financing pharmaceutical innovation. A conceptual framework

The debate on drug prices has reached new heights with the controversy around the role of prices in promoting innovation. Critics claim that prices of innovative drugs are excessive and argue that lowering prices will not harm the flourishing innovation. On the opposite end, the pharmaceutical industry insists that restrictive pricing policies will have a detrimental impact on their ability to generate innovation. Amid these two divergent positions, this manuscript presents a conceptual framework to better understand the role played by drug prices to influence the ability of pharmaceutical firms to raise money in capital markets and hence finance pharmaceutical innovation. We argue that deviations from established value-based pricing principles, by either firms or payers, will distort access by firms to capital and lead to an undesirable level of innovation in the long term. We hope that this framework helps policy-makers anticipate the impact of their proposals, and ultimately guide policies towards setting optimal drug prices as a means to maximise social welfare.

Primary prevention of cardiovascular disease: an umbrella review

BACKGROUND

The aim of this study is to determine the effectiveness of non-pharmacological interventions for prevention of cardiovascular disease (CVD) events and mortality in healthy adults or those at high risk of CVD.

METHODS

An umbrella review about primary prevention of non-pharmacological interventions was undertaken in key databases as PubMed Health, Effective Health Care Program AHRQ, McMaster University and the Cochrane Plus until July 2017. The primary outcomes were the relative risk of fatal and non-fatal CVD events, and mortality. Secondary outcomes were adverse events.

RESULTS

Twenty-four reviews were included of which thirteen reported outcomes of interest. Four of these found a pooled statistically significant risk reduction: dietary supplements of vitamin D, increased consumption of omega 3 fatty acids, Qigong, and counselling or education to modify more than one cardiovascular risk factor. Seven studies reported adverse events but minor or insignificant with respect to the control group.

CONCLUSIONS

Four non-pharmacological interventions have been shown to provide a statistically significant reduction in risk of CVD events or overall mortality, with minor adverse events if any. Further research should aim for higher methodological quality and longer follow-up of interventions to establish if these interventions, alone or in combination, translate into definite long-term health benefits.

Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma

OBJECTIVE

Given rising scrutiny of healthcare expenditures, understanding intervention costs is increasingly important. This study aimed to compare and characterize costs for vestibular schwannoma (VS) management with microsurgery and radiosurgery to inform practice decisions and appraise cost reduction strategies.

METHODS

In conjunction with medical records, internal hospital financial data were used to evaluate costs. Total cost was divided into index costs (costs from arrival through discharge for initial intervention) and follow-up costs (through 36 months) for 317 patients with unilateral VSs undergoing initial management between June 2011 and December 2015. A retrospective matched cohort based on tumor size with 176 patients (88 undergoing each intervention) was created to objectively compare costs between microsurgery and radiosurgery. The full sample of 203 patients treated with resection and 114 patients who underwent radiosurgery was used to evaluate a broad range of outcomes and identify cost contributors within each intervention group.

RESULTS

Within the matched cohort, average index costs were significantly higher for microsurgery (100% by definition, because costs are presented as a percentage of the average index cost for the matched microsurgery group; 95% CI 93-107) compared to radiosurgery (38%, 95% CI 38-39). Microsurgery had higher average follow-up costs (1.6% per month, 95% CI 0.8%-2.4%) compared to radiosurgery (0.5% per month, 95% CI 0.4%-0.7%), largely due to costs incurred in the initial months after resection. A major contributor to total cost and cost variability for both resection and radiosurgery was the need for additional interventions in the follow-up period, which were necessary due to complications or persistent functional deficits. Although tumor size was not associated with increased total costs for radiosurgery, linear regression analysis demonstrated that, for patients who underwent microsurgery, each centimeter increase in tumor maximum diameter resulted in an estimated increase in total cost of 50.2% of the average index cost of microsurgery (95% CI 34.6%-65.7%) (p < 0.001, R2 = 0.17). There were no cost differences associated with the proportion of inpatient days in the ICU or with specific surgical approach for patients who underwent resection.

CONCLUSIONS

This study is the largest assessment to date based on internal cost data comparing VS management with microsurgery and radiosurgery. Both index and follow-up costs are significantly higher when tumors were managed with resection compared to radiosurgery. Larger tumors were associated with increased resection costs, highlighting the incremental costs associated with observation as the initial management.

Cost-effectiveness of a primary care-based exercise intervention in perimenopausal women. The FLAMENCO Project

OBJECTIVE

Adequate physical activity levels and a healthy lifestyle may prevent all kinds of non-communicable diseases, promote well-being and reduce health-care costs among perimenopausal women. This study assessed an exercise programme for perimenopausal women.

METHOD

A total of 150 women (aged 45-64 years) not engaged in regular physical activity were randomly assigned to either a 16 week exercise intervention or to the control group. The study was conducted from the perspective of the National Health System. Health outcomes were quality-adjusted life years (QALYs), measured by the EuroQol-5D-5L questionnaire. The total direct costs of the programme were the costs of visits to primary care, specialty care, emergency, medicines, instructor cost and infrastructure cost. The results were expressed as the incremental cost-effectiveness ratio. Sensitivity analysis was undertaken to test the robustness of the analysis.

RESULTS

Mean QALYs over 16 weeks were.228 in the control group and.230 in the intervention group (mean difference: .002; 95% confidence interval [95%CI]: -0.005 to 0.009). Improvements from baseline were greater in the intervention group in all dimensions of the EuroQol-5D-5L but not statistically significant. The total costs at the end of the intervention were 160.38 € in the control group and 167.80 € in the intervention group (mean difference: 7.42 €; 95%CI: -47 to 62). The exercise programme had an incremental cost-effectiveness ratio of 4,686 €/QALY.

CONCLUSIONS

The programme could be considered cost-effective, although the overall difference in health benefits and costs was very modest. Longer term follow-up is needed.

Novel digital signatures of tissue phenotypes for predicting distant metastasis in colorectal cancer

Distant metastasis is the major cause of death in colorectal cancer (CRC). Patients at high risk of developing distant metastasis could benefit from appropriate adjuvant and follow-up treatments if stratified accurately at an early stage of the disease. Studies have increasingly recognized the role of diverse cellular components within the tumor microenvironment in the development and progression of CRC tumors. In this paper, we show that automated analysis of digitized images from locally advanced colorectal cancer tissue slides can provide estimate of risk of distant metastasis on the basis of novel tissue phenotypic signatures of the tumor microenvironment. Specifically, we determine what cell types are found in the vicinity of other cell types, and in what numbers, rather than concentrating exclusively on the cancerous cells. We then extract novel tissue phenotypic signatures using statistical measurements about tissue composition. Such signatures can underpin clinical decisions about the advisability of various types of adjuvant therapy.

[What does the decision to opt for private health insurance reveal about public provision?]

OBJECTIVE

This study examines individuals' choice of private health insurance in Spain. Private health insurance choices reveal the attributes of health care most highly valued by the population, and the perceived responsiveness of the public system in delivering those preferences.

METHOD

The paper exploits the 2004, 2009 and 2014 waves of the national Health Barometer survey, examining the health insurance choice separately for the general population and a small but influential sector of elite public-sector employees who can opt out from the public health system (civil servants).

RESULTS

Public healthcare is a highly regarded provider in terms of technology and doctor training, even by those who chose private health insurance, but falls short in terms of amenities such as comfort and speed of attendance. These findings confirm well-known strengths and criticisms of the public system. However, the study also finds that citizens are concerned about the performance of the public sector in key domains of health system responsiveness, such as personal contact and information and these concerns also influence their decision to opt for private provision. Finally, civil servants, even the minority who opted for public provision, tend to have a lower opinion of the public health service than non-civil servants, especially in terms of personal contact, information, primary care and specialist care.

CONCLUSIONS

These perceptions and concerns of the public about the performance of the public health service will be of interest for policy makers and should be investigated further.

Cost-Effectiveness of Current and Emerging Treatments of Varicose Veins

OBJECTIVES

To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years.

METHODS

A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken.

RESULTS

CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures.

CONCLUSIONS

At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.

Cost-effectiveness of treatments for superficial venous reflux in patients with chronic venous ulceration

Background

Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost‐effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration.

Methods

A Markov decision analytical model was developed. The main outcome measures were quality‐adjusted life‐years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound‐guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta‐analysis of RCTs.

Results

Surgery gained 0·112 (95 per cent c.i. −0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €−1330 (−3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions.

Discussion

This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS.

Decision uncertainty and value of further research: a case-study in fenestrated endovascular aneurysm repair for complex abdominal aortic aneurysms

Background

Fenestrated endovascular aneurysm repair (fEVAR) is a new approach for complex abdominal aortic aneurysms, limited to a few specialist centers, with limited evidence base. We developed a cost-effectiveness decision model of fEVAR compared to open surgical repair (OSR) to investigate the likely direction of costs and benefits and inform further research projects on this technology.

Methods

A systematic review with meta-analysis and a four-state Markov model were used to estimate the cost-effectiveness of fEVAR versus OSR. We used a recent coverage with evidence development framework to characterize the main sources of uncertainty and inform decisions about the type of further research that would be most worthwhile and feasible.

Results

Seven observational comparative studies were identified, of which four presented odds ratios adjusted for confounders. The odds ratios for operative mortality varied widely between studies. Assuming a central estimate of the odds ratio of 0.54 (95% CI 0.05–6.24), the decision model estimated that the incremental cost per quality adjusted life year (QALY) was £74,580/QALY with a probability of 9 and 16% of being cost-effective at standard cost-effectiveness thresholds of £20,000/QALY and £30,000/QALY, respectively. The Expected Value of Perfect Information over 10 years at a threshold of £20,000/QALY was £11.2 million. Operative mortality contributed to most of the uncertainty in the decision model.

Conclusions

In the case of “maturing technologies”, decision modelling indicates the likely direction of costs and benefits and guides the development of further research projects. In our analysis of fEVAR versus OSR, decision uncertainty, particularly around operative mortality, might be effectively resolved by a short-term RCT, or possibly a well-conducted comparative observational study. Decision makers may consider that a conditional coverage decision is warranted with assessments required to make this type of recommendation depending on local priorities and circumstances.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0098-7) contains supplementary material, which is available to authorized users.

Glandular Morphometrics for Objective Grading of Colorectal Adenocarcinoma Histology Images

Determining the grade of colon cancer from tissue slides is a routine part of the pathological analysis. In the case of colorectal adenocarcinoma (CRA), grading is partly determined by morphology and degree of formation of glandular structures. Achieving consistency between pathologists is difficult due to the subjective nature of grading assessment. An objective grading using computer algorithms will be more consistent, and will be able to analyse images in more detail. In this paper, we measure the shape of glands with a novel metric that we call the Best Alignment Metric (BAM). We show a strong correlation between a novel measure of glandular shape and grade of the tumour. We used shape specific parameters to perform a two-class classification of images into normal or cancerous tissue and a three-class classification into normal, low grade cancer, and high grade cancer. The task of detecting gland boundaries, which is a prerequisite of shape-based analysis, was carried out using a deep convolutional neural network designed for segmentation of glandular structures. A support vector machine (SVM) classifier was trained using shape features derived from BAM. Through cross-validation, we achieved an accuracy of 97% for the two-class and 91% for three-class classification.