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Wang T, Bahrampour M, Byrnes J, Scuffham P, Kirk E, Downes M. Economic evaluation of reproductive carrier screening for recessive genetic conditions: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2021; 22:197-206. [PMID: 34643123 DOI: 10.1080/14737167.2022.1993063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Autosomal recessive (AR) and x-linked (XL) conditions are rare but collectively common which impact millions of people globally on morbidity, mortality and costs. Advanced medical technologies allow prospective parents to make informed reproductive decisions to avoid having affected children. Economic evaluations targeting on reproductive carrier screening (RCS) for AR and/or XL conditions have been conducted, but there has not been a systematic review in this area. AREAS COVERED A systematic search of economic evaluations for RCS was undertaken using the following databases - EMBASE, MEDLINE and SCOPUS. The search strategy was designed to capture full economic evaluations related to RCS since 1990. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) strategy. The included 23 studies adopted various types of methodologies to conduct economic evaluations. The majority of studies examined a single condition. The various clinical strategies and screened conditions caused the different cost-effectiveness conclusions in the published studies. EXPERT OPINION Establishing a validated and practical clinical strategy of RCS and investigating the cost-effectiveness of multiple conditions in one economic evaluation are critical for implementing RCS in the future. Further economic evaluations are essential to provide evidence-based practice for decision-makers.
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Affiliation(s)
- Tianjiao Wang
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Mina Bahrampour
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Edwin Kirk
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, Australia.,School of Women's and Children's Health, University of New South Wales, Randwick, Australia.,New South Wales Health Pathology Randwick Genomics Laboratory, Randwick, Australia
| | - Martin Downes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Goldhaber-Fiebert JD, Brandeau ML. Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Med Decis Making 2015; 35:818-46. [PMID: 25926281 DOI: 10.1177/0272989x15583845] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/01/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
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Affiliation(s)
- Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDGF)
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA (MLB)
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Angelis A, Tordrup D, Kanavos P. Socio-economic burden of rare diseases: A systematic review of cost of illness evidence. Health Policy 2014; 119:964-79. [PMID: 25661982 DOI: 10.1016/j.healthpol.2014.12.016] [Citation(s) in RCA: 167] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 11/25/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
Cost-of-illness studies, the systematic quantification of the economic burden of diseases on the individual and on society, help illustrate direct budgetary consequences of diseases in the health system and indirect costs associated with patient or carer productivity losses. In the context of the BURQOL-RD project ("Social Economic Burden and Health-Related Quality of Life in patients with Rare Diseases in Europe") we studied the evidence on direct and indirect costs for 10 rare diseases (Cystic Fibrosis [CF], Duchenne Muscular Dystrophy [DMD], Fragile X Syndrome [FXS], Haemophilia, Juvenile Idiopathic Arthritis [JIA], Mucopolysaccharidosis [MPS], Scleroderma [SCL], Prader-Willi Syndrome [PWS], Histiocytosis [HIS] and Epidermolysis Bullosa [EB]). A systematic literature review of cost of illness studies was conducted using a keyword strategy in combination with the names of the 10 selected rare diseases. Available disease prevalence in Europe was found to range between 1 and 2 per 100,000 population (PWS, a sub-type of Histiocytosis, and EB) up to 42 per 100,000 population (Scleroderma). Overall, cost evidence on rare diseases appears to be very scarce (a total of 77 studies were identified across all diseases), with CF (n=29) and Haemophilia (n=22) being relatively well studied, compared to the other conditions, where very limited cost of illness information was available. In terms of data availability, total lifetime cost figures were found only across four diseases, and total annual costs (including indirect costs) across five diseases. Overall, data availability was found to correlate with the existence of a pharmaceutical treatment and indirect costs tended to account for a significant proportion of total costs. Although methodological variations prevent any detailed comparison between conditions and based on the evidence available, most of the rare diseases examined are associated with significant economic burden, both direct and indirect.
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Affiliation(s)
- Aris Angelis
- Medical Technology Research Group, LSE Health, London School of Economics and Political Science, Houghton Street, WC2A 2AE London, United Kingdom.
| | - David Tordrup
- Medical Technology Research Group, LSE Health, London School of Economics and Political Science, Houghton Street, WC2A 2AE London, United Kingdom
| | - Panos Kanavos
- Medical Technology Research Group, LSE Health, London School of Economics and Political Science, Houghton Street, WC2A 2AE London, United Kingdom
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Radhakrishnan M, van Gool K, Hall J, Delatycki M, Massie J. Economic evaluation of cystic fibrosis screening: A review of the literature. Health Policy 2008; 85:133-47. [PMID: 17728003 DOI: 10.1016/j.healthpol.2007.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 06/27/2007] [Accepted: 07/02/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To critically examine the economic evidence regarding cystic fibrosis (CF) carrier screening and to understand issues relating to the transferability of international findings to any national context for policy decisions. METHODS A systematic literature search identified 14 studies (out of 29 economic studies on CF) focusing on preconception or prenatal screening between 1990 and 2006. These studies were then assessed against international benchmarks on conducting and reporting of economic evaluations, costing methodology used and focusing on the transferability of the evidence to national contexts. RESULTS The primary outcome measures varied considerably between studies and there was considerable ambiguity and variation on how costs were estimated. The Incremental Cost Effectiveness Ratio (ICER) and net savings, for preconception and prenatal screening were inconsistent and varied significantly, even after adjusting for timing and exchange rates. Differences in screening participation rates, reproductive choices, test sensitivity, cost of test and lifetime cost of care make up a large part of the ICER variations. CONCLUSION The heterogeneity in study design, model inputs and reporting of economic evaluations of CF carrier screening makes comparability and transferability across countries and even within countries difficult. This reinforces the need to assess any technology within the relevant context, and to not simply generalize from reported studies. In turn, this adds to the complex task of making efficient resource allocation decisions in the area of CF carrier screening. Our evaluation adds weight to the calls for revisiting the way economic studies are conducted and reported.
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Krauth C, Jalilvand N, Welte T, Busse R. Cystic fibrosis: cost of illness and considerations for the economic evaluation of potential therapies. PHARMACOECONOMICS 2003; 21:1001-1024. [PMID: 13129414 DOI: 10.2165/00019053-200321140-00002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Cystic fibrosis (CF) is the most common life-shortening inherited disease of the Caucasian race, with a prevalence of around 1 in 2500 live births. Advances in the treatment and management of respiratory and pancreatic disorders have dramatically increased the life expectancy of patients with CF. This article presents an overview of cost-of-illness studies of CF, identifies deficits in the available health economic analyses of CF and discusses which specific factors are essential for the economic evaluation of potential therapies, based on a critical review of the health economic literature on two main therapeutic strategies. Cost-of-illness studies of CF have predominantly been restricted to direct costs. According to the literature, direct costs amount to between 6200- 16300 US dollars (1996 values) per patient per year. As most studies likely underestimated the actual costs (e.g. by disregarding provision of certain healthcare services), real healthcare costs tend to be at the upper end of the cost range. Healthcare costs depend on the patient's age (for adults, costs are approximately twice as high as for children), the grade of severity (the cost relationship of severe to mild CF is between 4.5 and 7.1) and other factors. Lifetime direct costs of CF are estimated at 200 000-300000 US dollars (at 1996 values and a discount rate of 5%). Home intravenous (IV) antibacterial therapy and recombinant human DNase (rhDNase; dornase alfa) treatment are the two main therapeutic strategies most often evaluated in health economic studies of CF. While home IV antibacterial therapy (compared with inpatient IV antibacterial therapy) is assumed to be cost saving, rhDNase treatment is a very cost-intensive therapy intended to efficiently achieve health improvements. Health economic analyses of future CF therapeutic technologies should present explicit data regarding healthcare services provision, resource consumption and unit costs. Indirect costs and patient costs should be considered more often than they have to date, particularly when they are significantly influenced by novel CF technologies. The perspective of health economic studies should be stated explicitly and always include the societal perspective. More economic studies should be based on a controlled, and preferably randomised, design. The observation period must be long enough to identify long-term effects of interventions. A greater number of effectiveness studies should be performed to determine costs and outcomes of therapies applied under everyday life conditions for patients with CF. Finally, international comparison studies should identify the influence of different healthcare systems on the costs and outcomes of interventions.
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Affiliation(s)
- Christian Krauth
- Department of Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Hannover, Germany.
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Nielsen R, Gyrd-Hansen D. Prenatal screening for cystic fibrosis: an economic analysis. HEALTH ECONOMICS 2002; 11:285-299. [PMID: 12007162 DOI: 10.1002/hec.652] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Cystic fibrosis (CF) is the most common life-shortening genetically transmitted disease in Denmark with a birth prevalence of 1 in 4700, resulting in 12-15 new cases of cystic fibroses annually. The aim of this study is to disclose the societal resource implications of introducing a population wide prenatal screening programme for cystic fibrosis in Denmark. The present analysis is limited to the monetary consequences of introducing a screening programme, where costs of screening are compared to the potential benefits measured in cost savings involved if births of CF patients are avoided. Screening costs in a Danish setting were estimated at DKK 2 771 262 ( pound sterlings 231 438) per aborted affected fetus in the first screening round, stabilising at DKK 1 864 594 ( pound sterlings 155 383) per aborted affected fetus at subsequent screening rounds. Comparing this figure with the estimated benefits of avoiding a CF case (DKK 2.1-4.4 million; pound sterlings 175 000-366 667) suggests that introducing a screening programme for cystic fibrosis will be net cost saving irrespective of the perspective of the analysis, assumptions on replacement children and method of estimating long-term production gains/losses.
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Petrou S. Methodological limitations of economic evaluations of antenatal screening. HEALTH ECONOMICS 2001; 10:775-778. [PMID: 11747056 DOI: 10.1002/hec.636] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
A review of recent economic studies of antenatal screening reveals widespread violation of accepted economic evaluation methodology. In particular, the costs and benefits of antenatal screening are often misclassified and conflated, and the non-resource effects of averted costs are often excluded from the evaluation process. The result is a widespread violation of the explicit and systematic approaches taken by economic analysts more generally, and conclusions that may be described as misleading. This letter calls for economic analysts to be consistent in their application of economic evaluation methodology to antenatal screening programmes.
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Affiliation(s)
- S Petrou
- National Perinatal Epidemiology Unit, Institute of Health Sciences, University of Oxford, Oxford, UK.
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Toledano-Alhadef H, Basel-Vanagaite L, Magal N, Davidov B, Ehrlich S, Drasinover V, Taub E, Halpern GJ, Ginott N, Shohat M. Fragile-X carrier screening and the prevalence of premutation and full-mutation carriers in Israel. Am J Hum Genet 2001; 69:351-60. [PMID: 11443541 PMCID: PMC1235307 DOI: 10.1086/321974] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2001] [Accepted: 06/01/2001] [Indexed: 11/03/2022] Open
Abstract
Fragile-X syndrome is caused by an unstable CGG trinucleotide repeat in the FMR1 gene at Xq27. Intermediate alleles (51-200 repeats) can undergo expansion to the full mutation on transmission from mother to offspring. To evaluate the effectiveness of a fragile-X carrier-screening program, we tested 14,334 Israeli women of child-bearing age for fragile-X carrier status between 1992 and 2000. These women were either preconceptional or pregnant and had no family history of mental retardation. All those found to be carriers of premutation or full-mutation alleles were offered genetic counseling and also prenatal diagnosis, if applicable. We identified 207 carriers of an allele with >50 repeats, representing a prevalence of 1:69. There were 127 carriers with >54 repeats, representing a prevalence of 1:113. Three asymptomatic women carried the fully mutated allele. Among the premutation and full-mutation carriers, 177 prenatal diagnoses were performed. Expansion occurred in 30 fetuses, 5 of which had an expansion to the full mutation. On the basis of these results, the expected number of avoided patients born to women identified as carriers, the cost of the test in this study (U.S. $100), and the cost of lifetime care for a mentally retarded person (>$350,000), screening was calculated to be cost-effective. Because of the high prevalence of fragile-X premutation or full-mutation alleles, even in the general population, and because of the cost-effectiveness of the program, we recommend that screening to identify female carriers should be carried out on a wide scale.
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Affiliation(s)
- Hagit Toledano-Alhadef
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Lina Basel-Vanagaite
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Nurit Magal
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Bella Davidov
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Sophie Ehrlich
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Valerie Drasinover
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Ellen Taub
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Gabrielle J. Halpern
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Nathan Ginott
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Mordechai Shohat
- Department of Pediatrics, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel; Department of Medical Genetics, Beilinson Campus, and Felsenstein Medical Research Center, Rabin Medical Center, Petah Tikva, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Rawashdeh M, Manal H. Cystic fibrosis in Arabs: a prototype from Jordan. ANNALS OF TROPICAL PAEDIATRICS 2000; 20:283-6. [PMID: 11219165 DOI: 10.1080/02724936.2000.11748148] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cystic fibrosis is believed to be rare in Arabs. We report 202 cases (114 boys and 88 girls) diagnosed in Jordan over a period of 9 years. The mean age at diagnosis was 2.9 years. Classical presentation with growth failure, malabsorption and respiratory symptoms occurred in 75.4% of cases. Eighteen (10.8%) presented with hepatomegaly, 12 (7.2%) with meconium ileus and 11 (6.6%) had Pseudo-Bartter syndrome. Thirty-eight (23%) children died, most below the age of 1 year which may reflect a more severe disease in our population. Consanguineous marriage was present in 69% of cases. Genetic screening of 84 children and 66 parents revealed 24 different CFTR mutations with a DF508 mutation accounting for only 7.4%. Among the mutations detected, six were alleles identified for the first time. The fact that boys outnumber girls might reflect more deaths in girls due to the observed gender gap in CF mortality. It is possible that the low incidence of the DF508 mutation is due to a confounding effect and the high mortality in those carrying this mutation. The large number of different mutations reflects the ethnic diversity of the Jordanian population and the complex history of the country.
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Affiliation(s)
- M Rawashdeh
- Department of Paediatrics, Faculty of Medicine, University of Science & Technology, PO Box 3030, Irbid, Jordan.
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Haddow JE, Bradley LA, Palomaki GE, Doherty RA, Bernhardt BA, Brock DJ, Cheuvront B, Cunningham GC, Donnenfeld AE, Erickson JL, Erlich HA, Ferrie RM, FitzSimmons SC, Greene MF, Grody WW, Haddow PK, Harris H, Holmes LB, Howell RR, Katz M, Klinger KW, Kloza EM, LeFevre ML, Little S, Loeben G, McGovern M, Pyeritz RE, Rowley PT, Saiki RK, Short MP, Tabone J, Wald NJ, Wilker NL, Witt DR. Issues in implementing prenatal screening for cystic fibrosis: results of a working conference. Genet Med 1999; 1:129-35. [PMID: 11258347 DOI: 10.1097/00125817-199905000-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To summarize a conference convened to examine how cystic fibrosis screening might appropriately be introduced into routine prenatal practice. METHODS Participants included experts from various relevant disciplines. Systematic reviews and data from individual trials were presented; issues were identified and discussed. RESULTS Judged by published criteria, prenatal cystic fibrosis screening is suitable for introduction. Screening can be performed cost-effectively by identifying racial/ethnic groups at sufficient risk and then using either of two models for delivering laboratory services. Validated educational materials exist. Ethical issues are not unique. CONCLUSIONS Once adequate facilities for patient and provider education, testing, counseling, quality control, and monitoring are in place, individual programs can begin prenatal screening for cystic fibrosis.
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Affiliation(s)
- J E Haddow
- Foundation for Blood Research, Scarborough, Maine 04070-0190, USA.
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van den Boom G, van Schayck CP, van Möllen MP, Tirimanna PR, den Otter JJ, van Grunsven PM, Buitendijk MJ, van Herwaarden CL, van Weel C. Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program. Am J Respir Crit Care Med 1998; 158:1730-8. [PMID: 9847260 DOI: 10.1164/ajrccm.158.6.9709003] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.
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Affiliation(s)
- G van den Boom
- Departments of Pulmonology and of General Practice and Social Medicine, University of Nijmegen, Nijmegen, The Netherlands.
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Rowley PT, Loader S, Kaplan RM. Prenatal screening for cystic fibrosis carriers: an economic evaluation. Am J Hum Genet 1998; 63:1160-74. [PMID: 9758600 PMCID: PMC1377475 DOI: 10.1086/302042] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The cloning of the CFTR gene has made it technically possible to avert the unwanted birth of a child with cystic fibrosis (CF). Several large trials offering prenatal CF carrier screening suggest that such screening is practical and that identified carriers generally use the information obtained. Therefore, a critical question is whether the cost of such screening is justified. Decision analysis was performed that used information about choices that pregnant women were observed to make at each stage in the Rochester prenatal carrier-screening trial. The cost of screening per CF birth voluntarily averted was estimated to be $1,320,000-$1,400,000. However, the lifetime medical cost of the care of a CF child in today's dollars was estimated to be slightly>$1,000,000. Therefore, despite both the high cost of carrier testing and the relative infrequency of CF conceptions in the general population, the averted medical-care cost resulting from choices freely made are estimated to offset approximately 74%-78% of the costs of a screening program. At present, if it is assumed that a pregnancy terminated because of CF is replaced, the marginal cost for prenatal CF carrier screening is estimated to be $8,290 per quality-adjusted life-year. This value compares favorably with that of many accepted medical services. The cost of prenatal CF carrier screening could fall to equal the averted costs of CF patient care if the cost of carrier testing were to fall to $100.
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Affiliation(s)
- P T Rowley
- Department of Medicine, Division of Genetics, Unviersity of Rochester School of Medicine, NY, USA.
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Kiiskinen U, Vartiainen E, Puska P, Aromaa A. Long-term cost and life-expectancy consequences of hypertension. J Hypertens 1998; 16:1103-12. [PMID: 9794712 DOI: 10.1097/00004872-199816080-00004] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate hypertension's long-term cost and impact on life expectancy. DESIGN A 19-year individual follow-up study. Subjects were categorized according to their baseline (1972) diastolic blood pressure (DBP) level into three groups: normotensive (DBP < 95 mmHg), mildly hypertensive (DBP 95-104 mmHg), and severely hypertensive (DBP > 104 mmHg). By using their social security identification numbers, we linked the subjects to a set of national registers covering hospital admissions, use of major drugs, absence due to sickness, disability pensions, and deaths. SUBJECTS A random population sample of 10 284 men and women aged 25-59 years from the provinces of Kuopio and North Karelia in eastern Finland. MAIN OUTCOME MEASURES The numbers of years of life and years of work lost, the cost of drugs and hospitalization, and the value of productivity lost due to disability and premature mortality. RESULTS The difference in life expectancy between normotensive and severely hypertensive men was 2.7 years, of which 2.0 years was due to cardiovascular disease (CVD). Among women the corresponding differences were 2.0 and 1.5 years. Severely hypertensive men lost 2.6 years of work more than did normotensive men, of which 1.7 years was due to CVD. Among women the differences were 2.2 and 1.3 years. The mean undiscounted total costs (USA dollars at 1992 prices) were $132 500 among normotensive, $146 500 among mildly hypertensive, and $219 300 among severely hypertensive men, of which CVD accounted for 28, 39, and 43%, respectively. More than 90% of the total costs were indirect productivity losses. Among women the total costs were lower for all DBP categories, as were the shares of CVD-related costs. The proportional increase in costs on going from the lowest to the highest DBP category was, however, somewhat larger among women. CONCLUSIONS On the population level, severe hypertension leads to considerable losses in terms of years of life lost, years of work lost, and costs. However, the overall impact of mild hypertension is much more limited.
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Affiliation(s)
- U Kiiskinen
- Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki, Finland.
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Zarnke KB, Levine MA, O'Brien BJ. Cost-benefit analyses in the health-care literature: don't judge a study by its label. J Clin Epidemiol 1997; 50:813-22. [PMID: 9253393 DOI: 10.1016/s0895-4356(97)00064-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess whether health-care related economic evaluations labeled as "cost benefit analyses" (CBA) meet a contemporary definition of CBA methodology and to assess the prevalence of methods used for assigning monetary units to health outcomes. DATA SOURCES Medline, Current Contents, and HSTAR databases and reference lists of review articles, 1991-1995. STUDY SELECTION Economic analyses labeled as CBAs were included. Agreement on study selection was assessed. STUDY EVALUATION: CBA studies were classified according to standard definitions of economic analytical techniques. For those valuing health outcomes in monetary units (bona fide CBAs), the method of valuation was classified. RESULTS 53% of 95 studies were reclassified as cost comparisons because health outcomes were not appraised. Among the 32% considered bona fide CBAs, the human capital approach was employed to value health states in monetary units in 70%. Contingent valuation methods were employed infrequently (13%). CONCLUSIONS Studies labeled as CBAs in the health-care literature often offer only partial program evaluation. Decisions based only on resource costs are unlikely to improve efficiency in resource allocation. Among bona fide CBAs, the human capital approach was most commonly used to valuing health, despite its limitations. The results of health-care related CBAs should be interpreted with extreme caution.
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Affiliation(s)
- K B Zarnke
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, Ontario, Canada
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Abstract
This paper presents an alternative method of valuing the benefits of antenatal screening programmes based on individual preferences. The methods of benefit measurement used to date, namely averted costs, QALYs, and willingness to pay, are critically reviewed. The alternative method assumes that screening can be regarded as an investment in improved information, and that the benefits of screening can be measured by the value placed upon this information. The information is valued by presenting individuals with standard gamble questions framed in terms of a prenatal diagnostic choice. The approach is developed in the context of antenatal screening for Down's syndrome and for cystic fibrosis carrier status. Some empirical testing of the approach is reported for the latter.
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Affiliation(s)
- P Shackley
- Health Economics Research Unit, University Medical Buildings, Aberdeen, Scotland, UK
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Abstract
OBJECTIVES It is now possible to test individuals to assess their cystic fibrosis gene carrier status and a range of strategies for screening the population have been piloted. The objective of this research was to develop a planning framework which health care planners and purchasers can use to assess the overall quantifiable outcomes and direct costs resulting from a year of alternative screening strategies and the ways costs and outcomes evolve over time. Beyond broader ethical and clinical considerations the information provided by such a framework is needed to support decisions surrounding the development of screening programmes. DESIGN Operational Research modelling techniques were used to develop the planning framework. To help illustrate the framework it was then used to assess the quantifiable outcomes and direct costs of three of the main alternative screening strategies: from antenatal clinics, '2-step' screening where females are tested first followed by a screening invitation to the partners of female carriers, and 'couple' screening where both partners must agree to be tested at the outset; and from primary practice clinics 'active' contact of attenders. Quantifiable outcomes are defined as the number of individuals informed of their carrier status and the number of carriers, carrier couples, and affected fetuses detected. Direct costs are those associated with the recruitment and testing of individuals and the subsequent counselling of any gene carriers or carrier couples identified. Results are based on services for a resident population of 250,000 at two time points, year one and a year at 'steady state'. RESULTS The resultant framework estimates the number of individuals tested using data on the size of the target population, the proportion of that population alerted to the screening service, and the proportion who agree to be tested when approached. Given service users, prevalence data are used to assess service outcomes. Given the number of individuals approached and the subsequent demands for services, service costs can be estimated. Preliminary results indicate that in the short-term health care purchasers and planners who favour screening are likely to opt for antenatal strategies. Although the high coverage of the primary practice strategy leads to high outcomes in year one, relative to the antenatal strategies, it also leads to very high costs. At 'steady state', cost and outcome differences between the strategies are less marked. CONCLUSION This paper provides a framework which can be used to provide information to support decision-making surrounding the development of screening services. The methodology fills an important void in the literature and complements research elsewhere by health economists and by geneticists and their research colleagues. Preliminary findings based upon use of the approach demonstrate the need for continued research to further refine and improve the methodology.
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Affiliation(s)
- R Beech
- Department of Public Health Medicine, UMDS, St Thomas's Campus, London, UK
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Wildhagen MF, Verheij JB, Verzijl JG, Hilderink HB, Kooij L, Tijmstra T, ten Kate LP, Gerritsen J, Bakker W, Habbema JD, Habbema F. Cost of care of patients with cystic fibrosis in The Netherlands in 1990-1. Thorax 1996; 51:298-301. [PMID: 8779135 PMCID: PMC1090643 DOI: 10.1136/thx.51.3.298] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Research on the cost of care of patients with cystic fibrosis is scarce. The aim of this study was to estimate the costs using age-specific medical consumption from real patient data. METHODS The age-specific medical consumption of patients with cystic fibrosis in The Netherlands in 1991 was estimated from a survey of medical records and a patient questionnaire. A distinction was made between costs of hospital care, hospital and non-hospital medication, and home care. Costs per year were obtained by multiplying the yearly amount of care and the costs per unit. RESULTS On average the annual cost of a patient with cystic fibrosis in 1991 was 10,908 pounds (hospital care 42%, medication 37%, home care 20%). The cost of care of cystic fibrosis in The Netherlands, with approximately 1000 patients, is estimated at 10.9 million pounds per year, which is 0.07% of the total health care budget. The cost of care of a patient up to the age of 35 is estimated at 614,587 pounds. When year-to-year survival is taken into account and future costs are discounted to the year of birth with a yearly discount rate of 5%, the cost of care of a patient with cystic fibrosis is estimated at 164,365 pounds for 1991. This estimate will be used in a prospective evaluation of screening for cystic fibrosis carriers. CONCLUSIONS The cost of care of patients with cystic fibrosis estimated by age-specific medical consumption of real patients is higher than that estimated by non-age-specific medical consumption and/or expert opinions.
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Affiliation(s)
- M F Wildhagen
- Department of Public Health, Erasmus University, Rotterdam, The Netherlands
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Cuckle HS, Richardson GA, Sheldon TA, Quirke P. Cost effectiveness of antenatal screening for cystic fibrosis. BMJ (CLINICAL RESEARCH ED.) 1995; 311:1460-3; discussion 1463-4. [PMID: 8520332 PMCID: PMC2543729 DOI: 10.1136/bmj.311.7018.1460] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To estimate the cost effectiveness of different antenatal screening programmes for cystic fibrosis. SETTING Antenatal clinics and general practices in the United Kingdom. DESIGN Four components of the screening process were identified: information giving, DNA testing, genetic counselling, and prenatal diagnosis. The component costs were derived from the literature and from a pilot screening study in Yorkshire. The cost of a given screening programme was then obtained by summing the components according to the specific screening strategy adopted (sequential and couple), the proportion of carriers detected by the DNA test, and the uptake of screening. Baseline assumptions were made about the proportion with missing information on carrier status from previous pregnancies (20%), the proportion changing partners between pregnancies (20%), and the uptake of prenatal diagnosis (100%). Sensitivity analysis was performed by varying these assumptions. MAIN OUTCOME MEASURE Cost per affected pregnancy detected. RESULTS Under the baseline assumptions sequential screening costs between pounds 40,000 and pounds 90,000 per affected pregnancy detected, depending on the carrier detection rate and uptake. Couple screening was more expensive, ranging from pounds 46,000 to pounds 104,000. From the sensitivity analysis a 10% change in the assumed proportion with missing information from a previous pregnancy alters the cost by pounds 4000; a 10% change in the proportion with new partners has a similar effect but only for couple screening; and cost will change directly in proportion to the uptake of prenatal diagnosis. CONCLUSIONS While economic analysis cannot determine screening policy, the paper provides the NHS with the information on cost effectiveness needed to inform decisions on the introduction of a screening service for cystic fibrosis.
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Affiliation(s)
- H S Cuckle
- Centre for Reproduction, Growth and Development, Research School of Medicine, University of Leeds, UK
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Silcock J, Torgerson D. Evaluation of costs. Lancet 1994; 344:755-6. [PMID: 7915801 DOI: 10.1016/s0140-6736(94)92246-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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