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Illenberger N, Mitra N, Spieker AJ. A regression framework for a probabilistic measure of cost-effectiveness. HEALTH ECONOMICS 2022; 31:1438-1451. [PMID: 35460149 DOI: 10.1002/hec.4517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/07/2022] [Accepted: 03/31/2022] [Indexed: 06/14/2023]
Abstract
To make informed health policy decisions regarding a treatment, we must consider both its cost and its clinical effectiveness. In past work, we introduced the net benefit separation (NBS) as a novel measure of cost-effectiveness. The NBS is a probabilistic measure that characterizes the extent to which a treated patient will be more likely to experience benefit as compared to an untreated patient. Due to variation in treatment response across patients, uncovering factors that influence cost-effectiveness can assist policy makers in population-level decisions regarding resource allocation. In this paper, we introduce a regression framework for NBS in order to estimate covariate-specific NBS and find determinants of variation in NBS. Our approach is able to accommodate informative cost censoring through inverse probability weighting techniques, and addresses confounding through a semiparametric standardization procedure. Through simulations, we show that NBS regression performs well in a variety of common scenarios. We apply our proposed regression procedure to a realistic simulated data set as an illustration of how our approach could be used to investigate the association between cancer stage, comorbidities and cost-effectiveness when comparing adjuvant radiation therapy and chemotherapy in post-hysterectomy endometrial cancer patients.
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Affiliation(s)
- Nicholas Illenberger
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Spieker AJ, Illenberger N, Roy JA, Mitra N. Net benefit separation and the determination curve: A probabilistic framework for cost-effectiveness estimation. Stat Methods Med Res 2021; 30:1306-1319. [PMID: 33826460 PMCID: PMC8211369 DOI: 10.1177/0962280221995972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Considerations regarding clinical effectiveness and cost are essential in comparing the overall value of two treatments. There has been growing interest in methodology to integrate cost and effectiveness measures in order to inform policy and promote adequate resource allocation. The net monetary benefit aggregates information on differences in mean cost and clinical outcomes; the cost-effectiveness acceptability curve was developed to characterize the extent to which the strength of evidence regarding net monetary benefit changes with fluctuations in the willingness-to-pay threshold. Methods to derive insights from characteristics of the cost/clinical outcomes besides mean differences remain undeveloped but may also be informative. We propose a novel probabilistic measure of cost-effectiveness based on the stochastic ordering of the individual net benefit distribution under each treatment. Our approach is able to accommodate features frequently encountered in observational data including confounding and censoring, and complements the net monetary benefit in the insights it provides. We conduct a range of simulations to evaluate finite-sample performance and illustrate our proposed approach using simulated data based on a study of endometrial cancer patients.
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Affiliation(s)
- Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nicholas Illenberger
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason A Roy
- Department of Biostatistics and Epidemiology, Rutgers University, New Brunswick, NJ, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Spieker AJ, Ko EM, Roy JA, Mitra N. Nested g-computation: A causal approach to analysis of censored medical costs in the presence of time-varying treatment. J R Stat Soc Ser C Appl Stat 2020; 69:1189-1208. [PMID: 34108743 DOI: 10.1111/rssc.12441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rising medical costs are an emerging challenge in policy decisions and resource allocation planning. When cumulative medical cost is the outcome, right-censoring induces informative missingness due to heterogeneity in cost accumulation rates across subjects. Inverse-weighting approaches have been developed to address the challenge of informative cost trajectories in mean cost estimation, though these approaches generally ignore post-baseline treatment changes. In post-hysterectomy endometrial cancer patients, data from a linked database of Medicare records and the Surveillance, Epidemiology, and End Results program of the National Cancer Institute reveal substantial within-subject variation in treatment over time. In such a setting, the utility of existing intent-to-treat approaches is generally limited. Estimates of population mean cost under a hypothetical time-varying treatment regime can better assist with resource allocation when planning for a treatment policy change; such estimates must inherently take time-dependent treatment and confounding into account. In this paper, we develop a nested g-computation approach to cost analysis to address this challenge, while accounting for censoring. We develop a procedure to evaluate sensitivity to departures from baseline treatment ignorability. We further conduct a variety of simulations and apply our nested g-computation procedure to two-year costs from endometrial cancer patients.
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Affiliation(s)
- Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37203
| | - Emily M Ko
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104.,Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Jason A Roy
- Department of Biostatistics and Epidemiology, Rutgers University, Piscataway, NJ 08854
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA 19104.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104
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Jit M, Ng DHL, Luangasanatip N, Sandmann F, Atkins KE, Robotham JV, Pouwels KB. Quantifying the economic cost of antibiotic resistance and the impact of related interventions: rapid methodological review, conceptual framework and recommendations for future studies. BMC Med 2020; 18:38. [PMID: 32138748 PMCID: PMC7059710 DOI: 10.1186/s12916-020-1507-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/31/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Antibiotic resistance (ABR) poses a major threat to health and economic wellbeing worldwide. Reducing ABR will require government interventions to incentivise antibiotic development, prudent antibiotic use, infection control and deployment of partial substitutes such as rapid diagnostics and vaccines. The scale of such interventions needs to be calibrated to accurate and comprehensive estimates of the economic cost of ABR. METHODS A conceptual framework for estimating costs attributable to ABR was developed based on previous literature highlighting methodological shortcomings in the field and additional deductive epidemiological and economic reasoning. The framework was supplemented by a rapid methodological review. RESULTS The review identified 110 articles quantifying ABR costs. Most were based in high-income countries only (91/110), set in hospitals (95/110), used a healthcare provider or payer perspective (97/110), and used matched cohort approaches to compare costs of patients with antibiotic-resistant infections and antibiotic-susceptible infections (or no infection) (87/110). Better use of methods to correct biases and confounding when making this comparison is needed. Findings also need to be extended beyond their limitations in (1) time (projecting present costs into the future), (2) perspective (from the healthcare sector to entire societies and economies), (3) scope (from individuals to communities and ecosystems), and (4) space (from single sites to countries and the world). Analyses of the impact of interventions need to be extended to examine the impact of the intervention on ABR, rather than considering ABR as an exogeneous factor. CONCLUSIONS Quantifying the economic cost of resistance will require greater rigour and innovation in the use of existing methods to design studies that accurately collect relevant outcomes and further research into new techniques for capturing broader economic outcomes.
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Affiliation(s)
- Mark Jit
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Immunisation, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Modelling and Economics Unit, National Infections Service, Public Health England, London, UK.
- School of Public Health, University of Hong Kong, Hong Kong, SAR, China.
| | - Dorothy Hui Lin Ng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Nantasit Luangasanatip
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Immunisation, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frank Sandmann
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Immunisation, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Modelling and Economics Unit, National Infections Service, Public Health England, London, UK
| | - Katherine E Atkins
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Immunisation, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for Global Health Research, The Usher Institute for Population Health Science and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infections Service, Public Health England, London, UK
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Koen B Pouwels
- Modelling and Economics Unit, National Infections Service, Public Health England, London, UK
- The National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Choi KB, Suh KN, Muldoon KA, Roth VR, Forster AJ. Hospital-acquired Clostridium difficile infection: an institutional costing analysis. J Hosp Infect 2019; 102:141-147. [PMID: 30690051 DOI: 10.1016/j.jhin.2019.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/21/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Healthcare-acquired Clostridium difficile infection (HA-CDI) is a common infection and a financial burden on the healthcare system. AIM To estimate the hospital-based financial costs of HA-CDI by comparing time-fixed statistical models that attribute cost to the entire hospital stay to time-varying statistical models that adjust for the time between admission, diagnosis of HA-CDI, and discharge and that only attribute HA-CDI costs post diagnosis. METHODS A retrospective cohort study was conducted (April 2008 to March 2011) using clinical and administrative costing data of inpatients (≥15 years) who were admitted to The Ottawa Hospital with stays >72 h. Two time-fixed analyses, ordinary least square regression and generalized linear regression, were contrasted with two time-dependent approaches using Kaplan-Meier survival curve. FINDINGS A total of 49,888 admissions were included and 366 (0.73%) patients developed HA-CDI. Estimated total costs (Canadian dollars) from time-fixed models were as high as $74,928 per patient compared to $28,089 using a time-varying model, and these were 1.47-fold higher compared to a patient without HA-CDI (incremental cost $8,997 per patient). The overall annual institutional cost at The Ottawa Hospital associated with HA-CDI was as high as $10.07 million using time-fixed models and $1.62 million using time-varying models. CONCLUSION When calculating costs associated with HA-CDI, accounting for the time between admission, diagnosis, and discharge can substantially reduce the estimated institutional costs associated with HA-CDI.
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Affiliation(s)
- K B Choi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - K N Suh
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K A Muldoon
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - V R Roth
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - A J Forster
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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