Economic evaluation in long-term clinical trials

Twelve-month cost-effectiveness of telephone-delivered collaborative care for treating depression following CABG surgery: a randomized controlled trial

OBJECTIVE

To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians' usual care (UC).

METHODS

We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone 2 weeks following hospitalization (nine-item Patient Health Questionnaire ≥10) and were randomized to either an 8-month centralized, nurse-provided and telephone-delivered CC intervention for depression or to their physicians' UC.

RESULTS

At 12 months following randomization, CC patients had $2068 lower but statistically similar estimated median costs compared to UC (P=.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost-effectiveness ratio of CC was -$9889 (-$11,940 to -$7838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC "dominating" UC (more QALYs at lower cost).

CONCLUSIONS

Centralized, nurse-provided and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

Comparing the cost-effectiveness of two brain metastasis treatment modalities from a payer's perspective: stereotactic radiosurgery versus surgical resection

OBJECTIVES

This study aims to identify the cost-effectiveness of two brain metastatic treatment modalities, stereotactic radiosurgery (SRS) versus surgical resection (SR), from the perspective of Germany's Statutory Health Insurance (SHI) System.

METHODS

Retrospectively reviewing 373 patients with brain metastases (BMs) who underwent SR (n=113) and SRS (n=260). Propensity score matching was used to adjust for selection bias (n=98 each); means of survival time and survival curves were defined by the Kaplan-Meier estimator; and medical costs of follow-up treatment were calculated by the Direct (Lin) method. The bootstrap resampling technique was used to assess the impact of uncertainty.

RESULTS

Survival time means of SR and SRS were 13.0, 18.4 months, respectively (P=0.000). Medians of free brain tumor time were 10.4 months for SR and 13.8 months for SRS (P=0.003). Number of repeated SRS treatments significantly influenced the survival time of SRS (R(2)=0.249; P=0.006). SRS had a lower average cost per patient (€9964 - SD: 1047; Skewness: 7273) than SR (€11647 - SD: 1594; Skewness: 0.465), leading to an incremental cost effectiveness ratio of €-3740 per life year saved (LYS), meaning that using SRS costs €1683 less than SR per targeted patient, but increases LYS by 0.45 years.

CONCLUSION

SRS is more cost-effective than SR in the treatment of brain metastasis (BM) from the SHI perspective. When the clinical conditions allow it, early intervention with SRS in new BM cases and frequent SRS repetition in new BM recurrent cases should be advised.

Assigning resources to health care use for health services research: options and consequences

AIMS

Our goals are 3-fold: (1) to review the leading options for assigning resource coefficients to health services utilization; (2) to discuss the relative advantages of each option; and (3) to provide examples where the research question had marked implications for the choice of which resource measure to employ.

METHODS

Three approaches have been used to establish relative resource weights in health services research: (a) direct estimation of production costs through microcosting or step down allocation methods; (b) macrocosting/regression analysis; and (c) standardized resource assignment. We describe each of these methods and provide examples of how the study question drove the choice of resource-use measure.

FINDINGS

All empirical resource-intensity weighting systems contain distortions that limit their universal application. Hence, users must select the weighting system that matches the needs of their specific analysis. All systems require significant data resources and data processing. However, inattention to the distortions contained in a complex resource weighting system may undermine the validity and generalizability of an economic evaluation.

CONCLUSIONS

Direct estimation of production costs are useful for empirical analyses, but they contain distortions that undermine optimal resource allocation decisions. Researchers must ensure that the data being used meets both the study design and the question being addressed. They also should ensure that the choice of resource measure is the best fit for the analysis. IMPLICATIONS FOR RESEARCH AND POLICY: Researchers should consider which of the available measures is the most appropriate for the question being addressed rather than take "cost " or utilization as a variable over which they have no control.

The costs of colonoscopy in a Canadian hospital using a microcosting approach

BACKGROUND

Colonoscopy has become accepted as one of the most effective methods of screening patients for colorectal cancer, and is used to remove the majority of colonic adenomas.

OBJECTIVE

Because of the paucity of such estimates in the literature and the significant number of candidates for this procedure, the present study was performed to estimate the direct hospital costs of both diagnostic and therapeutic (polypectomy) colonoscopy.

METHODS

A microcosting methodology was used to itemize the costs of colonoscopy. Variable and fixed costs were divided into labour, supplies, equipment and overhead costs. A third-party payer perspective was adopted. All costs are expressed in 2007 Canadian dollars.

RESULTS

The cost of a diagnostic colonoscopy was $157 and the cost of a therapeutic colonoscopy was $199. Overhead costs represented approximately 30% of these amounts. When physician fees were added, these costs rose to $352 and $467, respectively.

CONCLUSION

Because the overhead costs represent a large proportion of the total costs, allocation methods for these costs should be improved to allow for a more precise determination of the total costs of a colonoscopy. These estimates are useful when analyzing the cost-effectiveness of a strategy that uses colonoscopy when screening for colorectal cancer.

Cost-effectiveness of bypass surgery versus stenting in patients with multivessel coronary artery disease

PURPOSE

To compare the cost-effectiveness of surgical and angioplasty-based coronary artery revascularization techniques, in particular, angioplasty with primary stenting.

METHODS

We used data from the Study of Economics and Quality of Life, a substudy of the Bypass Angioplasty Revascularization Investigation (BARI), to measure the outcomes and costs of angioplasty and bypass surgery in patients with multivessel coronary artery disease who had not undergone prior coronary artery revascularization. Using a Markov decision model, we updated the outcomes and costs to reflect technology changes since the time of enrollment in BARI, and projected the lifetime costs and quality-adjusted life-years (QALYs) for the two procedures from the time of initial treatment through death. We accounted for the effects of improved procedural safety and efficiency, and prolonged therapeutic effects of both surgery and stenting. This study was conducted from a societal perspective.

RESULTS

Surgical revascularization was less costly and resulted in better outcomes than catheter-based intervention including stenting. It remained the preferred strategy after adjusting the stent outcomes to eliminate the costs and events associated with target lesion restenosis. Among angioplasty-based strategies, primary stent use cost an additional 189,000 US dollars per QALY gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results.

CONCLUSION

Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost.