Collecting and analysing cost data for complex public health trials: reflections on practice

Background

Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.

Objective

This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle-income countries.

Design

We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.

Results

When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute ‘start-up’ costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.

Conclusions

Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.

Cost-effectiveness of extended cessation treatment for older smokers

AIMS

We examined the cost-effectiveness of extended smoking cessation treatment in older smokers.

DESIGN

Participants who completed a 12-week smoking cessation program were factorial randomized to extended cognitive behavioral treatment and extended nicotine replacement therapy.

SETTING

A free-standing smoking cessation clinic.

PARTICIPANTS

A total of 402 smokers aged 50 years and older were recruited from the community.

MEASUREMENTS

The trial measured biochemically verified abstinence from cigarettes after 2 years and the quantity of smoking cessation services utilized. Trial findings were combined with literature on changes in smoking status and the age- and gender-adjusted effect of smoking on health-care cost, mortality and quality of life over the long term in a Markov model of cost-effectiveness over a lifetime horizon.

FINDINGS

The addition of extended cognitive behavioral therapy added $83 in smoking cessation services cost [P = 0.012, confidence interval (CI) = $22-212]. At the end of follow-up, cigarette abstinence rates were 50.0% with extended cognitive behavioral therapy and 37.2% without this therapy (P < 0.05, odds ratio 1.69, CI 1.18-2.54). The model-based incremental cost-effectiveness ratio was $6324 per quality-adjusted life year (QALY). Probabilistic sensitivity analysis found that the additional $947 in lifetime cost of the intervention had a 95% confidence interval of -$331 to 2081; the 0.15 additional QALYs had a confidence interval of 0.035-0.280, and that the intervention was cost-effective against a $50 000/QALY acceptance criterion in 99.6% of the replicates. Extended nicotine replacement therapy was not cost-effective.

CONCLUSIONS

Adding extended cognitive behavior therapy to standard cessation treatment was cost-effective. Further intensification of treatment may be warranted.

Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease

BACKGROUND

According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared.

METHODS

Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD.

RESULTS

CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, € 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR.

CONCLUSIONS

The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.

Cost-effectiveness of ticagrelor versus clopidogrel in patients with acute coronary syndromes in Canada

BACKGROUND

Ticagrelor demonstrated a significant reduction in major cardiac events in patients with acute coronary syndrome (ACS) compared with clopidogrel in the Platelet Inhibition and Patient Outcomes (PLATO) trial. The objective of this study was to assess the cost-effectiveness of ticagrelor compared with clopidogrel in ACS patients from the perspective of the Canadian publicly funded health care system.

METHODS

A two-part model was developed consisting of a 1-year decision tree and a lifetime Markov model. Within the decision tree, patients remained event-free, experienced a nonfatal myocardial infarction, a nonfatal stroke, or death due to vascular or nonvascular related causes based on data from the PLATO trial. The lifetime Markov model followed these patients and allowed for subsequent myocardial infarction, stroke, and death. Patient utility and resource use were derived from the PLATO trial. Transition probabilities and specific Canadian unit costs were derived from published sources. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

In the base case lifetime analysis, treatment with ticagrelor resulted in more years of life per person (0.097), more quality-adjusted life years per person (QALYs, 0.084), and an incremental cost per QALY gained of $9,745 (Canadian$), assuming a generic cost for clopidogrel. A probabilistic sensitivity analysis demonstrated the robustness of the base case analysis, with a 93% probability of being below $20,000 per QALY gained and a 99% probability of being below $30,000 per QALY gained.

CONCLUSION

Ticagrelor is a clinically superior and cost-effective option for the prevention of thrombotic events among ACS patients in Canada.

Evidence synthesis for decision making 6: embedding evidence synthesis in probabilistic cost-effectiveness analysis

When multiple parameters are estimated from the same synthesis model, it is likely that correlations will be induced between them. Network meta-analysis (mixed treatment comparisons) is one example where such correlations occur, along with meta-regression and syntheses involving multiple related outcomes. These correlations may affect the uncertainty in incremental net benefit when treatment options are compared in a probabilistic decision model, and it is therefore essential that methods are adopted that propagate the joint parameter uncertainty, including correlation structure, through the cost-effectiveness model. This tutorial paper sets out 4 generic approaches to evidence synthesis that are compatible with probabilistic cost-effectiveness analysis. The first is evidence synthesis by Bayesian posterior estimation and posterior sampling where other parameters of the cost-effectiveness model can be incorporated into the same software platform. Bayesian Markov chain Monte Carlo simulation methods with WinBUGS software are the most popular choice for this option. A second possibility is to conduct evidence synthesis by Bayesian posterior estimation and then export the posterior samples to another package where other parameters are generated and the cost-effectiveness model is evaluated. Frequentist methods of parameter estimation followed by forward Monte Carlo simulation from the maximum likelihood estimates and their variance-covariance matrix represent’a third approach. A fourth option is bootstrap resampling—a frequentist simulation approach to parameter uncertainty. This tutorial paper also provides guidance on how to identify situations in which no correlations exist and therefore simpler approaches can be adopted. Software suitable for transferring data between different packages, and software that provides a user-friendly interface for integrated software platforms, offering investigators a flexible way of examining alternative scenarios, are reviewed.

Evidence synthesis for decision making 5: the baseline natural history model

Most cost-effectiveness analyses consist of a baseline model that represents the absolute natural history under a standard treatment in a comparator set and a model for relative treatment effects. We review synthesis issues that arise on the construction of the baseline natural history model. We cover both the absolute response to treatment on the outcome measures on which comparative effectiveness is defined and the other elements of the natural history model, usually “downstream” of the shorter-term effects reported in trials. We recommend that the same framework be used to model the absolute effects of a “standard treatment” or placebo comparator as that used for synthesis of relative treatment effects and that the baseline model is constructed independently from the model for relative treatment effects, to ensure that the latter are not affected by assumptions made about the baseline. However, simultaneous modeling of baseline and treatment effects could have some advantages when evidence is very sparse or when other research or study designs give strong reasons for believing in a particular baseline model. The predictive distribution, rather than the fixed effect or random effects mean, should be used to represent the baseline to reflect the observed variation in baseline rates. Joint modeling of multiple baseline outcomes based on data from trials or combinations of trial and observational data is recommended where possible, as this is likely to make better use of available evidence, produce more robust results, and ensure that the model is internally coherent.

Evidence synthesis for decision making 7: a reviewer's checklist

This checklist is for the review of evidence syntheses for treatment efficacy used in decision making based on either efficacy or cost-effectiveness. It is intended to be used for pairwise meta-analysis, indirect comparisons, and network meta-analysis, without distinction. It does not generate a quality rating and is not prescriptive. Instead, it focuses on a series of questions aimed at revealing the assumptions that the authors of the synthesis are expecting readers to accept, the adequacy of the arguments authors advance in support of their position, and the need for further analyses or sensitivity analyses. The checklist is intended primarily for those who review evidence syntheses, including indirect comparisons and network meta-analyses, in the context of decision making but will also be of value to those submitting syntheses for review, whether to decision-making bodies or journals. The checklist has 4 main headings: A) definition of the decision problem, B) methods of analysis and presentation of results, C) issues specific to network synthesis, and D) embedding the synthesis in a probabilistic cost-effectiveness model. The headings and implicit advice follow directly from the other tutorials in this series. A simple table is provided that could serve as a pro forma checklist.

Strategies for efficient computation of the expected value of partial perfect information

Expected value of information methods evaluate the potential health benefits that can be obtained from conducting new research to reduce uncertainty in the parameters of a cost-effectiveness analysis model, hence reducing decision uncertainty. Expected value of partial perfect information (EVPPI) provides an upper limit to the health gains that can be obtained from conducting a new study on a subset of parameters in the cost-effectiveness analysis and can therefore be used as a sensitivity analysis to identify parameters that most contribute to decision uncertainty and to help guide decisions around which types of study are of most value to prioritize for funding. A common general approach is to use nested Monte Carlo simulation to obtain an estimate of EVPPI. This approach is computationally intensive, can lead to significant sampling bias if an inadequate number of inner samples are obtained, and incorrect results can be obtained if correlations between parameters are not dealt with appropriately. In this article, we set out a range of methods for estimating EVPPI that avoid the need for nested simulation: reparameterization of the net benefit function, Taylor series approximations, and restricted cubic spline estimation of conditional expectations. For each method, we set out the generalized functional form that net benefit must take for the method to be valid. By specifying this functional form, our methods are able to focus on components of the model in which approximation is required, avoiding the complexities involved in developing statistical approximations for the model as a whole. Our methods also allow for any correlations that might exist between model parameters. We illustrate the methods using an example of fluid resuscitation in African children with severe malaria.

Cost-effectiveness analysis of Mammostrat® compared with Oncotype DX® to inform the treatment of breast cancer

Purpose

To compare the cost-effectiveness of the tumor subtyping assays Mammostrat® and Oncotype DX® for assessing risk of recurrence in early-stage breast cancer and the potential benefit of adjuvant chemotherapy.

Methods

Cost-effectiveness analysis from a US third-party payer perspective. A 10 year Markov model was developed to estimate costs and effects of using each method of risk assessment. The percentages of patients assessed as high, moderate, or low risk were obtained from multicenter, prospective, randomized controlled trials. The analysis simulated the experience of women progressing through various model states representing clinical treatments and subsequent disease. Published recurrence data for Mammostrat® were adjusted appropriately to account for differences between definitions and samples of Oncotype DX® and Mammostrat® in the original clinical trials. Cost and utility data were obtained from previously published studies. Sensitivity analyses examined how base-case results might differ when input values and assumptions varied.

Results

Base-case costs for women assessed using Mammostrat® were $15,782, compared with $18,051 for women assessed with Oncotype DX®. Thus, cost savings of $2,268 resulted from using Mammostrat®. Both Mammostrat® and Oncotype DX® resulted in similar life years (9.880 and 9.882) and quality-adjusted life years (7.935 and 7.940), respectively. Sensitivity analyses demonstrated that the assumptions made about recurrence are the key drivers of model results.

Discussion

Cost savings associated with the use of Mammostrat® instead of Oncotype DX® are largely due to the difference in cost between the two tests. Since survival and quality-adjusted life years were similar using either assay, Mammostrat® has economic advantages for women with early-stage breast cancer.

Cost-effectiveness of roflumilast as an add-on treatment to long-acting bronchodilators in the treatment of COPD associated with chronic bronchitis in the United Kingdom

OBJECTIVE

To estimate the cost-effectiveness of adding a selective phosphodiesterase-4 inhibitor, roflumilast, to a long-acting bronchodilator therapy (LABA) for the treatment of patients with severe-to-very severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis with a history of frequent exacerbations from the UK payer perspective.

METHODS

A Markov model was developed to predict the lifetime cost and outcomes [exacerbations rates, life expectancy, and quality-adjusted life years (QALY)] in patients treated with roflumilast, which showed a reduction in the exacerbation rates and lung function improvement in a pooled analysis from two clinical trials, M2-124 and M2-125. Sensitivity analyses were conducted to explore the impact of uncertainties on the cost-effectiveness.

RESULTS

The addition of roflumilast to concomitant LABA reduced the number of exacerbations from 15.6 to 12.7 [2.9 (95 % CI 0.88-4.92) exacerbations avoided] and increased QALYs from 5.45 to 5.61 [0.16 (95 % CI 0.02-0.31) QALYs gained], at an incremental cost of £3,197 (95 % CI £2,135-£4,253). Cost in LABA alone and LABA + roflumilast were £16,161 and £19,358 respectively. The incremental cost-effectiveness ratios in the base case were £19,505 (95 % CI £364-£38,646) per quality-adjusted life-year gained and 18,219 (95 % CI £12,697-£49,135) per life-year gained. Sensitivity analyses suggest that among the main determinants of cost-effectiveness are the reduction of exacerbations and the case fatality rate due to hospital-treated exacerbations. Probabilistic sensitivity analysis suggests that the probability of roflumilast being cost-effective is 82 % at willingness-to-pay £30,000 per QALY.

CONCLUSIONS

The addition of roflumilast to LABA in the treatment of patients with severe-to-very severe COPD reduces the rate of exacerbations and can be cost-effective in the UK setting.

Cost-effectiveness of Triple Therapy with Telaprevir for Chronic Hepatitis C Virus Patients in Germany

Background: About 400,000-500,000 people are infected with hepatitis C in Germany. Long-term consequences are the development of liver cirrhosis and hepatocellular carcinoma. The introduction of first generation protease inhibitors has significantly improved the treatment of hepatitis C genotype 1 patients. The aim of the study was to assess the cost-effectiveness of triple therapy with telaprevir in Germany. Methods: We used a Markov model on disease progression and natural history to assess the cost-effectiveness of triple therapy with telaprevir compared to standard treatment with pegylated interferon and ribavirin. Model structure and inputs were discussed with clinical experts. Deterministic and probabilistic sensitivity analyses were performed to verify the robustness of results. Results: The base-case analyses shows that triple therapy results in higher costs (untreated patients: €48,446 vs. €30,691; previously treated patients: €63,228 vs. €48,603) and better outcomes (untreated patients: 16.85 qualily of life years [QALYs] vs. 15.97 QALYs; previously treated patients: 14.16 QALYs vs. 12.89 QALYs). The incremental cost-effectiveness ratio (ICER) was €20,131 per QALY and €30,567 per life year gained (LYG) for previously untreated patients. ICER in treatment experienced patients was €7,664 per QALY for relapse patients, €12,506 per QALY for partial responders and €28,429 per QALY for null responders. Results were robust in sensitivity analyses. Conclusion: Although triple therapy with telaprevir leads to additional costs, there is a high probability of being cost-effective for different thresholds. This health economic analysis makes an important contribution to current debates on cost savings and efficient resource allocation in the German healthcare sector.

Optimizing the cost-effectiveness of treatment for chronic kidney disease-mineral and bone disorder

Chronic kidney disease-mineral and bone disorder (CKD-MBD) is an important risk factor in patients with CKD, and some medications for treating CKD-MBD have been recently marketed. Because assessment of health-care cost-effectiveness is growing in importance with increases in health expenditures, several cost-effectiveness analyses for new medications such as sevelamer, lanthanum carbonate, cinacalcet hydrochloride, and paricalcitol have been conducted. The results of these analyses have stimulated discussion on the efficient use of these medications and, in some cases, have affected treatment recommendation. However, most of these studies had methodological problems, one of them being that the effectiveness of medications was estimated based on changes of surrogate parameters, such as vascular calcification or serum biochemistry values. Furthermore, even if cost-effectiveness analyses were based on a given clinical trial, the results might differ from country to country. To provide greater health benefits under limited health expenditures based on the results of cost-effectiveness analyses, it is necessary to confirm the effectiveness of medications through well-designed clinical trials having mortality as the primary end point. In addition, cost-effectiveness analyses need to be performed separately for each country.

Cost-effectiveness analysis of Recovery Management Checkups (RMC) for adults with chronic substance use disorders: evidence from a 4-year randomized trial

AIMS

This study performs the first cost-effectiveness analysis (CEA) of Recovery Management Checkups (RMC) for adults with chronic substance use disorders.

DESIGN

Cost-effectiveness analysis of a randomized clinical trial of RMC. Participants were assigned randomly to a control condition of outcome monitoring (OM-only) or the experimental condition OM-plus-RMC, with quarterly follow-up for 4 years.

SETTING

Participants were recruited from the largest central intake unit for substance abuse treatment in Chicago, Illinois, USA.

PARTICIPANTS

A total of 446 participants who were 38 years old on average, 54% male, and predominantly African American (85%).

MEASUREMENTS

Data on the quarterly cost per participant come from a previous study of OM and RMC intervention costs. Effectiveness is measured as the number of days of abstinence and number of substance use-related problems.

FINDINGS

Over the 4-year trial, OM-plus-RMC cost on average $2184 more than OM-only (P < 0.01). Participants in OM-plus-RMC averaged 1026 days abstinent and had 89 substance use-related problems. OM-only averaged 932 days abstinent and reported 126 substance use-related problems. Mean differences for both effectiveness measures were statistically significant (P < 0.01). The incremental cost-effectiveness ratio for OM-plus-RMC was $23.38 per day abstinent and $59.51 per reduced substance-related problem. When additional costs to society were factored into the analysis, OM-plus-RMC was less costly and more effective than OM-only.

CONCLUSIONS

Recovery Management Checkups are a cost-effective and potentially cost-saving strategy for promoting abstinence and reducing substance use-related problems among chronic substance users.

Validation of models that estimate the cost-effectiveness of improving patient adherence

This note suggests a test for internal validation of models that estimate the costs and effects of improving patient adherence. We apply the validation test to two published cost-effectiveness models on adherence improvement.

An integrated approach to evaluating alternative risk prediction strategies: a case study comparing alternative approaches for preventing invasive fungal disease

OBJECTIVES

This article proposes an integrated approach to the development, validation, and evaluation of new risk prediction models illustrated with the Fungal Infection Risk Evaluation study, which developed risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive fungal disease (IFD).

METHODS

Our decision-analytical model compared alternative strategies for preventing IFD at up to three clinical decision time points (critical care admission, after 24 hours, and end of day 3), followed with antifungal prophylaxis for those judged "high" risk versus "no formal risk assessment." We developed prognostic models to predict the risk of IFD before critical care unit discharge, with data from 35,455 admissions to 70 UK adult, critical care units, and validated the models externally. The decision model was populated with positive predictive values and negative predictive values from the best-fitting risk models. We projected lifetime cost-effectiveness and expected value of partial perfect information for groups of parameters.

RESULTS

The risk prediction models performed well in internal and external validation. Risk assessment and prophylaxis at the end of day 3 was the most cost-effective strategy at the 2% and 1% risk threshold. Risk assessment at each time point was the most cost-effective strategy at a 0.5% risk threshold. Expected values of partial perfect information were high for positive predictive values or negative predictive values (£11 million-£13 million) and quality-adjusted life-years (£11 million).

CONCLUSIONS

It is cost-effective to formally assess the risk of IFD for non-neutropenic, critically ill adult patients. This integrated approach to developing and evaluating risk models is useful for informing clinical practice and future research investment.

Mifamurtide for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection: a cost-effectiveness analysis

OBJECTIVES

Mifamurtide is an immune macrophage stimulant that when added to standard chemotherapy has demonstrated survival benefit for newly diagnosed osteosarcoma. The objectives of this study were to investigate the cost-effectiveness of adding mifamurtide to standard three- or four-agent chemotherapy for high-grade, resectable, nonmetastatic osteosarcoma following surgical resection and the issues of obtaining robust cost-effectiveness estimates for ultra-orphan drugs, given the shortage of data.

METHODS

An economic evaluation was conducted from the perspective of the UK's National Health Service as part of the manufacturer's submission to the National Institute for Health and Care Excellence. The disease process was simplified to a transition through a series of health states, modeled by using a Markov approach. Data to inform the model were derived from patient-level data of Study INT-0133, published literature, and expert opinion. The final efficacy measure was life-years gained (LYG), and utilities were used to obtain quality-adjusted life-years (QALYs).

RESULTS

For a 60-year time frame and a discount rate of 3.5% for outcomes, patients receiving mifamurtide benefited from an average additional 1.57 years of life and 1.34 QALYs, compared with patients receiving chemotherapy alone, giving an incremental cost-effectiveness ratio (ICER) of £58,737 per LYG and £68,734 per QALY. Because treatment effects were both substantial in restoring health and sustained over a very long period, the National Institute for Health and Care Excellence changed its guidance to allow a discount of 1.5% for outcomes to be applied in these special circumstances. By using this discount factor, it was found that patients receiving mifamurtide had an average additional 2.58 years of life and 2.20 QALYs compared with patients receiving chemotherapy alone, resulting in an ICER of £35,765 per LYG and £41,933 per QALY.

CONCLUSION

Mifamurtide's ICER is cost-effective compared with that of other orphan and ultra-orphan drugs, for which prices and corresponding cost-effectiveness estimates are high.

The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia

CONTEXT

Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported.

OBJECTIVES

To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia.

METHODS

NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months.

RESULTS

Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355).

CONCLUSION

Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.

Cost-effectiveness of modified-release prednisone in the treatment of moderate to severe rheumatoid arthritis with morning stiffness based on directly elicited public preference values

Background

Assessing the cost-effectiveness of treatments in rheumatoid arthritis (RA) is of growing importance due to the chronic nature of the disease, rising treatment costs, and budget-constrained health care systems. This analysis assesses the cost-effectiveness of modified-release (MR) prednisone compared with immediate-release (IR) prednisone for the treatment of morning stiffness due to RA.

Methods

A health state transition model was used to categorize RA patients into four health states, defined by duration of morning stiffness. The model applied a 1-year time horizon and adopted a UK National Health Service (NHS) perspective. Health benefits were measured in quality-adjusted life years (QALYs) and the final output was the incremental cost-effectiveness ratio (ICER). Efficacy data were derived from the CAPRA-1 (Circadian Administration of Prednisone in Rheumatoid Arthritis) study, drug costs from the British National Formulary (BNF), and utility data from a direct elicitation time-trade-off (TTO) study in the general population. Sensitivity analyses were conducted.

Results

Mean treatment costs per patient were higher for MR-prednisone (£649.70) than for IR-prednisone (£46.54) for the duration of the model. However, the model generated an incremental QALY of 0.044 in favor of MR-prednisone which resulted in an ICER of £13,577. Deterministic sensitivity analyses did not lead to significant changes in the ICER. Probabilistic sensitivity analysis reported that MR-prednisone had an 84% probability of being cost-effective at a willingness-to-pay threshold of £30,000 per QALY. The model only considers drug costs and there was a lack of comparative long-term data for IR-prednisone. Furthermore, utility benefits were not captured in the clinical setting.

Conclusion

This analysis demonstrates that, based on the CAPRA-1 trial and directly elicited public preference values, MR-prednisone is a cost-effective treatment option when compared with IR-prednisone for RA patients with morning stiffness over one year, according to commonly applied UK thresholds (£20,000–£30,000 per QALY). Further research into the costs of morning stiffness in RA is required.

Automatic assessment of socioeconomic impact on cardiac rehabilitation

Disability-Adjusted Life Years (DALYs) and Quality-Adjusted Life Years (QALYs), which capture life expectancy and quality of the remaining life-years, are applied in a new method to measure socioeconomic impacts related to health. A 7-step methodology estimating the impact of health interventions based on DALYs, QALYs and functioning changes is presented. It relates the latter (1) to the EQ-5D-5L questionnaire (2) to automatically calculate the health status before and after the intervention (3). This change of status is represented as a change in quality of life when calculating QALYs gained due to the intervention (4). In order to make an economic assessment, QALYs gained are converted to DALYs averted (5). Then, by inferring the cost/DALY from the cost associated to the disability in terms of DALYs lost (6) and taking into account the cost of the action, cost savings due to the intervention are calculated (7) as an objective measure of socioeconomic impact. The methodology is implemented in Java. Cases within the framework of cardiac rehabilitation processes are analyzed and the calculations are based on 200 patients who underwent different cardiac-rehabilitation processes. Results show that these interventions result, on average, in a gain in QALYs of 0.6 and a cost savings of 8,000 €.

A lesson in business: cost-effectiveness analysis of a novel financial incentive intervention for increasing physical activity in the workplace

BACKGROUND

Recently both the UK and US governments have advocated the use of financial incentives to encourage healthier lifestyle choices but evidence for the cost-effectiveness of such interventions is lacking. Our aim was to perform a cost-effectiveness analysis (CEA) of a quasi-experimental trial, exploring the use of financial incentives to increase employee physical activity levels, from a healthcare and employer's perspective.

METHODS

Employees used a 'loyalty card' to objectively monitor their physical activity at work over 12 weeks. The Incentive Group (n=199) collected points and received rewards for minutes of physical activity completed. The No Incentive Group (n=207) self-monitored their physical activity only. Quality of life (QOL) and absenteeism were assessed at baseline and 6 months follow-up. QOL scores were also converted into productivity estimates using a validated algorithm. The additional costs of the Incentive Group were divided by the additional quality adjusted life years (QALYs) or productivity gained to calculate incremental cost effectiveness ratios (ICERs). Cost-effectiveness acceptability curves (CEACs) and population expected value of perfect information (EVPI) was used to characterize and value the uncertainty in our estimates.

RESULTS

The Incentive Group performed more physical activity over 12 weeks and by 6 months had achieved greater gains in QOL and productivity, although these mean differences were not statistically significant. The ICERs were £2,900/QALY and £2,700 per percentage increase in overall employee productivity. Whilst the confidence intervals surrounding these ICERs were wide, CEACs showed a high chance of the intervention being cost-effective at low willingness-to-pay (WTP) thresholds.

CONCLUSIONS

The Physical Activity Loyalty card (PAL) scheme is potentially cost-effective from both a healthcare and employer's perspective but further research is warranted to reduce uncertainty in our results. It is based on a sustainable "business model" which should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviors and settings. This comes at a time when both UK and US governments are encouraging business involvement in tackling public health challenges.

Portfolios of biomedical HIV interventions in South Africa: a cost-effectiveness analysis

BACKGROUND

Recent clinical trials of male circumcision, oral pre-exposure prophylaxis (PrEP), and a vaginal microbicide gel have shown partial effectiveness at reducing HIV transmission, stimulating interest in implementing portfolios of biomedical prevention programs.

OBJECTIVE

To evaluate the effectiveness and cost-effectiveness of combination biomedical HIV prevention and treatment scale-up in South Africa, given uncertainty in program effectiveness.

DESIGN

Dynamic HIV transmission and disease progression model with Monte Carlo simulation and cost-effectiveness analysis.

PARTICIPANTS

Men and women aged 15 to 49 years in South Africa.

INTERVENTIONS

HIV screening and counseling, antiretroviral therapy (ART), male circumcision, PrEP, microbicide, and select combinations.

MAIN MEASURES

HIV incidence, prevalence, discounted costs, discounted quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

KEY RESULTS

Providing half of all uninfected persons with PrEP averts 28 % of future HIV infections for $9,000/QALY gained, but the affordability of such a program is questionable. Given limited resources, annual HIV screening and ART utilization by 75 % of eligible infected persons could avert one-third of new HIV infections, for approximately $1,000/QALY gained. Male circumcision is more cost-effective, but disproportionately benefits men. A comprehensive portfolio of expanded screening, ART, male circumcision, microbicides, and PrEP could avert 62 % of new HIV infections, reducing HIV prevalence from a projected 14 % to 10 % after 10 years. This strategy doubles treatment initiation and adds 31 million QALYs to the population. Despite uncertainty in program effectiveness, a comprehensive portfolio costs less than $10,000/QALY gained in 33 % of simulation iterations and less than $30,000/QALY gained in 90 % of iterations, assuming an annual microbicide cost of $100.

CONCLUSIONS

A portfolio of modestly-effective biomedical HIV prevention programs, including male circumcision, vaginal microbicides, and oral PrEP, could substantially reduce HIV incidence and prevalence in South Africa and be likely cost-effective. Given limited resources, PrEP is the least cost-effective intervention of those considered.

Issues in the incorporation of economic perspectives and evidence into Cochrane reviews

BACKGROUND

Methods for systematic reviews of the effects of health interventions have focused mainly on addressing the question of 'What works?' or 'Is this intervention effective in achieving one or more specific outcomes?' Addressing the question 'Is it worth it given the resources available?' has received less attention. This latter question can be addressed by applying an economic lens to the systematic review process.This paper reflects on the value and desire for the consideration by end users for coverage of an economic perspective in a Cochrane review and outlines two potential approaches and future directions.

METHODS

Two frameworks to guide review authors who are seeking to include an economic perspective are outlined. The first involves conducting a full systematic review of economic evaluations that is integrated into a review of intervention effects. The second involves developing a brief economic commentary. The two approaches share a set of common stages but allow the tailoring of the economic component of the Cochrane review to the skills and resources available to the review team.

RESULTS

The number of studies using the methods outlined in the paper is limited, and further examples are needed both to explore the value of these approaches and to further develop them. The rate of progress will hinge on the organisational leadership, capacity and resources available to the CCEMG, author teams and other Cochrane entities. Particular methodological challenges to overcome relate to understanding the key economic trade-offs and casual relationships for a given decision problem and informing the development of evaluations designed to support local decision-makers.

CONCLUSIONS

Methods for incorporating economic perspectives and evidence into Cochrane intervention reviews are established. Their role is not to provide a precise estimate of 'cost-effectiveness' but rather to help end-users of Cochrane reviews to determine the implications of the economic components of reviews for their own specific decisions.

Do health economic evaluations using observational data provide reliable assessment of treatment effects?

Economic evaluation in modern health care systems is seen as a transparent scientific framework that can be used to advance progress towards improvements in population health at the best possible value. Despite the perceived superiority that trial-based studies have in terms of internal validity, economic evaluations often employ observational data. In this review, the interface between econometrics and economic evaluation is explored, with emphasis placed on highlighting methodological issues relating to the evaluation of cost-effectiveness within a bivariate framework. Studies that satisfied the eligibility criteria exemplified the use of matching, regression analysis, propensity scores, instrumental variables, as well as difference-in-differences approaches. All studies were reviewed and critically appraised using a structured template. The findings suggest that although state-of-the-art econometric methods have the potential to provide evidence on the causal effects of clinical and policy interventions, their application in economic evaluation is subject to a number of limitations. These range from no credible assessment of key assumptions and scarce evidence regarding the relative performance of different methods, to lack of reporting of important study elements, such as a summary outcome measure and its associated sampling uncertainty. Further research is required to better understand the ways in which observational data should be analysed in the context of the economic evaluation framework.

Program-specific cost-effectiveness analysis: breast cancer screening policies for a safety-net program

BACKGROUND

Every Woman Counts (EWC), a California breast cancer screening program, faced challenging budget cutbacks and policy choices.

METHODS

A microsimulation model evaluated costs, outcomes, and cost-effectiveness of EWC program mammography policy options on coverage for digital mammography (which has a higher cost than film mammography but recent legislation allowed reimbursement at the lower film rate); screening eligibility age; and screening frequency. Model inputs were based on analyses of program claims data linked to California Cancer Registry data, Surveillance, Epidemiology, and End Results data, and the Medi-Cal literature. Outcomes included number of procedures, cancers, cancer deaths, costs, and incremental cost per life-year.

RESULTS

Projected model outcomes matched program data closely. With restrictions on the number of clients screened, strategies starting screening at age 40 years were dominated (not cost-effective). This finding was highly robust in sensitivity analyses. Compared with no screening, biennial film mammography for women aged 50 to 64 years was projected to reduce 15-year breast cancer mortality by nearly 7.8% at $18,999 per additional life-year, annual film mammography was $106,428 per additional life-year, and digital mammography $180,333 per additional life-year. This more effective, more expensive strategy was projected to reduce breast cancer mortality by 8.6%. Under equal mammography reimbursement, biennial digital mammography beginning at age 50 years was projected to decrease 15-year breast cancer mortality by 8.6% at an incremental cost per additional life-year of $17,050.

CONCLUSIONS

For the EWC program, biennial screening mammography starting at age 50 years was the most cost-effective strategy. The impact of digital mammography on life expectancy was small. Program-specific cost-effectiveness analysis can be completed in a policy-relevant time frame to assist policymakers faced with difficult program choices.

Cost-effectiveness of procalcitonin-guided antibiotic use in community acquired pneumonia

BACKGROUND

Although prior randomized trials have demonstrated that procalcitonin-guided antibiotic therapy effectively reduces antibiotic use in patients with community-acquired pneumonia (CAP), uncertainties remain regarding use of procalcitonin protocols in practice.

OBJECTIVE

To estimate the cost-effectiveness of procalcitonin protocols in CAP.

DESIGN

Decision analysis using published observational and clinical trial data, with variation of all parameter values in sensitivity analyses.

PATIENTS

Hypothetical patient cohorts who were hospitalized for CAP.

INTERVENTIONS

Procalcitonin protocols vs. usual care.

MAIN MEASURES

Costs and cost per quality adjusted life year gained.

KEY RESULTS

When no differences in clinical outcomes were assumed, consistent with clinical trials and observational data, procalcitonin protocols cost $10-$54 more per patient than usual care in CAP patients. Under these assumptions, results were most sensitive to variations in: antibiotic cost, the likelihood that antibiotic therapy was initiated less frequently or over shorter durations, and the likelihood that physicians were nonadherent to procalcitonin protocols. Probabilistic sensitivity analyses, incorporating procalcitonin protocol-related changes in quality of life, found that protocol use was unlikely to be economically reasonable if physician protocol nonadherence was high, as observational study data suggest. However, procalcitonin protocols were favored if they decreased hospital length of stay.

CONCLUSIONS

Procalcitonin protocol use in hospitalized CAP patients, although promising, lacks physician nonadherence and resource use data in routine care settings, which are needed to evaluate its potential role in patient care.