How to Appropriately Extrapolate Costs and Utilities in Cost-Effectiveness Analysis

Comparison of specialist ataxia centres with non-specialist services in terms of treatment, care, health services resource utilisation and costs in the UK using patient-reported data

OBJECTIVES

This study aims to assess the patient-reported benefits and the costs of coordinated care and multidisciplinary care at specialist ataxia centres (SACs) in the UK compared with care delivered in standard neurological clinics.

DESIGN

A patient survey was distributed between March and May 2019 to patients with ataxia or carers of patients with ataxia through the Charity Ataxia UK's mailing list, website, magazine and social media to gather information about the diagnosis, management of the ataxias in SAC and non-specialist settings, utilisation of various healthcare services and patients' satisfaction. We compared mean resource use for each contact type and health service costs per patient, stratifying patients by whether they were currently attending a SAC or never attended one.

SETTING

Secondary care including SACs and general neurology clinics.

PARTICIPANTS

We had 277 participants in the survey, aged 16 years old and over, diagnosed with ataxia and living in the UK.

PRIMARY OUTCOME MEASURES

Patient experience and perception of the two healthcare services settings, patient level of satisfaction, difference in healthcare services use and costs.

RESULTS

Patients gave positive feedback about the role of SAC in understanding their condition (96.8% of SAC group), in coordinating referrals to other healthcare specialists (86.6%), and in offering opportunities to take part in research studies (85.2%). Participants who attended a SAC reported a better management of their symptoms and a more personalised care received compared with participants who never attended a SAC (p<0.001). Costs were not significantly different in between those attending a SAC and those who did not. We identified some barriers for patients in accessing the SACs, and some gaps in the care provided, for which we made some recommendations.

CONCLUSIONS

This study provides useful information about ataxia patient care pathways in the UK. Overall, the results showed significantly higher patient satisfaction in SAC compared with non-SAC, at similar costs. The findings can be used to inform policy recommendations on how to improve treatment and care for people with these very rare and complex neurological diseases. Improving access to SAC for patients across the UK is one key policy recommendation of this study.

Impact of specialist ataxia centres on health service resource utilisation and costs across Europe: cross-sectional survey

BACKGROUND

Little is known about the costs of treating ataxia and whether treatment at a specialist ataxia centre affects the cost of care. The aim of this study was to investigate whether patients who attended specialist ataxia centres in three European countries reported differences in their health care use and costs compared with patients who did not attend a specialist ataxia centre. We compared mean resource use and health service costs per patient affected by ataxia in the United Kingdom, Italy and Germany over a 12-month period. Data were obtained from a survey distributed to people with ataxia in the three countries. We compared mean resource use for each contact type and costs, stratifying patients by whether they were currently attending a specialist ataxia centre or had never attended one.

RESULTS

Responses were received from 181 patients from the United Kingdom, 96 from Italy and 43 from Germany. Differences in the numbers of contacts for most types of health service use between the specialist ataxia centre and non-specialist ataxia centre groups were non-significant. In the United Kingdom the mean total cost per patient was €2209 for non-specialist ataxia centre patients and €1813 for specialist ataxia centre patients (P = 0.59). In Italy these figures were €2126 and €1971, respectively (P = 0.84). In Germany they were €2431 and €4087, respectively (P = 0.19). Inpatient stays made the largest contribution to total costs.

CONCLUSIONS

Within each country, resource use and costs were broadly similar for specialist ataxia centre and non-specialist ataxia centre groups. There were differences between countries in terms of health care contacts and costs.

Economic analysis of early intervention for autistic children: findings from four case studies in England, Ireland, Italy, and Spain

BACKGROUND

Many autistic children experience difficulties in their communication and language skills development, with consequences for social development into adulthood, often resulting in challenges over the life-course and high economic impacts for individuals, families, and society. The Preschool Autism Communication Trial (PACT) intervention is effective in terms of improved social communication and some secondary outcomes. A previously published within-trial economic analysis found that results at 13 months did not support its cost-effectiveness. We modeled cost-effectiveness over 6 years and across four European countries.

METHODS

Using simulation modeling, we built on economic analyses in the original trial, exploring longer-term cost-effectiveness at 6 years (in England). We adapted our model to undertake an economic analysis of PACT in Ireland, Italy, and Spain. Data on resource use were taken from the original trial and a more recent Irish observational study.

RESULTS

PACT is cost-saving over time from a societal perspective, even though we confirmed that, at 13 months post-delivery, PACT is more expensive than usual treatment (across all countries) when given to preschool autistic children. After 6 years, we found that PACT has lower costs than usual treatment in terms of unpaid care provided by parents (in all countries). Also, if we consider only out-of-pocket expenses from an Irish study, PACT costs less than usual treatment.

DISCUSSION

PACT may be recommended as a cost-saving early intervention for families with an autistic child.

Protocol for the TRANSLATE prospective, multicentre, randomised clinical trial of prostate biopsy technique

OBJECTIVES

Primary objectives: to determine whether local anaesthetic transperineal prostate (LATP) biopsy improves the detection of clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology (ISUP) Grade Group ≥2 disease (i.e., any Gleason pattern 4 disease), compared to transrectal ultrasound-guided (TRUS) prostate biopsy, in biopsy-naïve men undergoing biopsy based on suspicion of csPCa.

SECONDARY OBJECTIVES

to compare (i) infection rates, (ii) health-related quality of life, (iii) patient-reported procedure tolerability, (iv) patient-reported biopsy-related complications (including bleeding, bruising, pain, loss of erectile function), (v) number of subsequent prostate biopsy procedures required, (vi) cost-effectiveness, (vii) other histological parameters, and (viii) burden and rate of detection of clinically insignificant PCa (ISUP Grade Group 1 disease) in men undergoing these two types of prostate biopsy.

PATIENTS AND METHODS

The TRANSLATE trial is a UK-wide, multicentre, randomised clinical trial that meets the criteria for level-one evidence in diagnostic test evaluation. TRANSLATE is investigating whether LATP biopsy leads to a higher rate of detection of csPCa compared to TRUS prostate biopsy. Both biopsies are being performed with an average of 12 systematic cores in six sectors (depending on prostate size), plus three to five target cores per multiparametric/bi-parametric magnetic resonance imaging lesion. LATP biopsy is performed using an ultrasound probe-mounted needle-guidance device (either the 'Precision-Point' or BK UA1232 system). TRUS biopsy is performed according to each hospital's standard practice. The study is 90% powered to detect a 10% difference (LATP biopsy hypothesised at 55% detection rate for csPCa vs 45% for TRUS biopsy). A total of 1042 biopsy-naïve men referred with suspected PCa need to be recruited.

CONCLUSIONS

This trial will provide robust prospective data to determine the diagnostic ability of LATP biopsy vs TRUS biopsy in the primary diagnostic setting.

Estimating Quality of Life Decrements in Oncology Using Time to Death

OBJECTIVES

The estimation of lifetime quality-adjusted life-years (QALYs) requires the extrapolation of both length and quality of life (QoL). The extrapolation of QoL has received little attention in the literature. Here we explore the predictive value of "time to death" (TTD) for extrapolating QoL in oncology.

METHODS

We used QoL and survival data from the Patient Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship registry, which is linked to The Netherlands Cancer Registry. QoL was assessed with EQ-5D and SF-6D. We tested the relationship between TTD and QoL using linear, 2-part, and beta regression models. Incremental QALYs were compared using the TTD approach and an annual age-related disutility approach using artificial survival data with varying mortality rates.

RESULTS

A total of 6 samples with &gt;100 patients each were used for the analysis. A declining pattern in QoL was observed when patients were closer to death, confirming the predictive value of TTD for QoL. The declining pattern in QoL was most pronounced when QoL was measured with SF-6D. Proximity to death had a larger impact on QoL than age. Incremental QALYs were higher using the TTD approach than annual age-related disutility, ranging from +0.139 to +0.00003 depending on mortality rates.

CONCLUSIONS

TTD is a predictor variable for QoL. Using TTD allows cost-effectiveness models that lack QoL data to extrapolate morbidity using overall survival estimates. The TTD approach generates more incremental QALYs than an annual age-related disutility, most notably for longer survival periods.

A Review of Methodological Considerations for Economic Evaluations of Gene Therapies and Their Application in Literature

OBJECTIVES

To identify methodological considerations discussed in literature addressing economic evaluations (EEs) of gene therapies (GTs). Additionally, we assessed if these considerations are applied in published GT EEs to increase understanding and explore impact.

METHODS

First a peer-reviewed literature review was performed to identify research addressing methodological considerations of GT EEs until August 2019. Identified considerations were grouped in themes using thematic content analysis. A second literature search was conducted in which we identified published evaluations. The EE quality of reporting was assessed using Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

The first literature search yielded 13 articles discussing methodological considerations. The second search provided 12 EEs. Considerations identified were payment models, definition of perspectives, addressing uncertainty, data extrapolation, discount rates, novel value elements, and use of indirect and surrogate endpoints. All EEs scored satisfactory to good according to Consolidated Health Economic Evaluation Reporting Standards. Regarding methodological application, we found 1 methodological element (payment models) was applied in 2 base cases. Scenarios explored alternative perspectives, survival assumptions, and extrapolation methods in 10 EEs.

CONCLUSIONS

Although EE quality of reporting was considered good, their informativeness for health technology assessment and decision makers seemed limited owing to many uncertainties. We suggest accepted EE methods can broadly be applied to GTs, but few elements may need adjustment. Further research and multi-stakeholder consensus is needed to determine appropriateness and application of individual methodological considerations. For now, we recommend including scenario analyses to explore impact of methodological choices and (clinical) uncertainties. This study contributes to better understanding of perceived appropriate evaluation of GTs and informs best modeling practices.

Cost-Effectiveness of Operative Versus Nonoperative Management of Patients With Intra-articular Calcaneal Fractures

OBJECTIVE

To assess the costs, health gains, and cost-effectiveness of operative versus nonoperative treatment of calcaneal fractures over a 5-year time horizon from both US societal and payer perspectives.

METHODS

The societal perspective analysis included both direct medical costs and costs for missed work, whereas the health care payer perspective analysis included only direct medical costs associated with treatment and complications. A decision tree simulation model was developed to estimate the direct medical and indirect costs (2018 US$) and quality-adjusted life-years (QALYs) for treatment of patients sustaining intra-articular calcaneal fractures fixed with an extensile lateral approach. Direct medical costs were obtained from a large US health care system in Utah, Intermountain Healthcare, and indirect costs from the literature. Utility and probability parameters were also derived from the literature. Parameter uncertainty was explored using both one-way and probabilistic sensitivity analysis.

RESULTS

From a US societal perspective, operative treatment costs less ($35,110 vs. $39,870) and yielded more QALYs (3.89 vs. 3.51) over 5 years compared with nonoperative treatment. At a willingness-to-pay threshold of $50,000 per QALY, operative fixation had an 89% probability of being cost-effective. From a health care payer perspective, operative management remained cost-effective as the incremental cost-effectiveness ratio is below the willingness-to-pay threshold of $50,000/QALY.

CONCLUSION

From both US societal and health care payer perspectives, operative treatment of displaced intra-articular calcaneal fractures utilizing an extensile lateral approach is cost-effective at commonly accepted willingness-to-pay thresholds compared with nonoperative treatment over a 5-year time horizon. Patient variability may impact cost-effectiveness and should be explored in future research.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lifetime Costs of Surviving Cancer-A Queensland Study (COS-Q): Protocol of a Large Healthcare Data Linkage Study

Australia-wide, there are currently more than one million cancer survivors. There are over 32 million world-wide. A trend of increasing cancer incidence, medical innovations and extended survival places growing pressure on healthcare systems to manage the ongoing and late effects of cancer treatment. There are no published studies of the long-term health service use and cost of cancer survivorship on a population basis in Australia. All residents of the state of Queensland, Australia, diagnosed with a first primary malignancy from 1997–2015 formed the cohort of interest. State and national healthcare databases are linked with cancer registry records to capture all health service utilization and healthcare costs for 20 years (or death, if this occurs first), starting from the date of cancer diagnosis, including hospital admissions, emergency presentations, healthcare costing data, Medicare services and pharmaceuticals. Data analyses include regression and economic modeling. We capture the whole journey of health service contact and estimate long-term costs of all cancer patients diagnosed and treated in Queensland by linking routinely collected state and national healthcare data. Our results may improve the understanding of lifetime health effects faced by cancer survivors and estimate related healthcare costs. Research outcomes may inform policy and facilitate future planning for the allocation of healthcare resources according to the burden of disease.

Cost-benefit relationship of keeping dantrolene stocks from the point of view of healthcare institutions

Introduction: Malignant hyperthermia (MH) is an acute syndrome triggered by certain anesthetic medications. Dantrolene is the only specific treatment for MH crises. Without treatment, lethality may be as high as 80%. In Colombia, it is not mandatory to keep dantrolene supplies in stock. Objective: To establish the cost-benefit ratio, from the perspective of healthcare institutions, of keeping dantrolene supplies in stock in the operating theater. Methods: Using a decision tree, a Monte Carlo simulation was run with 10,000 scenarios to determine the median annual cost of keeping full or partial stocks (36 or 12 vials x 20 mg, respectively) of dantrolene. For the option of not keeping supplies in stock, the cost threshold was calculated where the expected value of both alternatives of the decision tree is equalized. Indifference curves were constructed for complete and partial supplies. Results: The median annual cost was estimated at 6.6 million Colombian pesos (COP) for full dantrolene supplies, and at COP 2.2 million for partial supplies. The median economic consequence threshold for 1 death due to the unavailability of dantrolene was estimated at COP 18.5 million for full supplies, and at COP 57.0 million for partial supplies. Conclusion: If, as a result of the unavailability of dantrolene, the economic consequences of a death due to MH exceed the threshold of COP 57.0 or COP 18.5 million, the purchase of full or partial stocks, respectively, is justified.

The Burden, Future Trends, And Economic Impact Of Lung Cancer In Saudi Arabia

Background

Incidence of cancer in Saudi Arabia has increased for the last two decades, ratcheting up to global levels. Yet, there is a dearth of research on the burden of lung cancer. This study examined the association between new cases of lung cancer and factors such as gender, age, and year of diagnosis; and forecast new cases and extrapolated future economic burden to 2030.

Methods

This a national-level cohort study that utilized the Saudi Cancer Registry data from 1999 to 2013. Multivariate regression was used; new lung cancer cases forecast and economic burden extrapolated to 20130. Sensitivity analysis was conducted to assess the impact of a range of epidemiologic and economic factors on the economic burden.

Results

Of the 166,497 new cancer cases (1999–2013), 3.8% was lung cancer. Males and Saudis had over threefold higher cases compared with females and non-Saudis, respectively. While the age group ≥65 years had 1.14 times or 14% increase in new cases, under-30 years had 97.2% fewer cases compared with age group 45–59. Compared with 1999, the period 2011–2013 had a 106% average increase. The years 2002–2010 registered an average 50% rise in new cases compared to 1999. New cases would rise to 1058 in 2030, an upsurge of 87% from 2013. The future economic burden was estimated at $2.49 billion in 2015 value, of which $520 million was attributable to care management and $1.97 billion in lost productivity. The economic burden for the period 2015–2030 will be $50.16 billion. The present value of this burden in 2015 values will be $34.60 billion, of which 21% will be attributable to care management. Estimates were robust to uncertainty, but the aged-standardized rate and 5-year survival rate would account for much of the variability compared with the economic factors.

Conclusion

Findings reveal an upsurge of lung cancer burden in incidence and potential economic burden, which may inform cancer control measures.

Process Improvement in Patient Pathways: A Case Study Applying Accelerated Longitudinal Design With Decomposition Method

EXECUTIVE SUMMARY

Evaluations of improvements in long chronic-patient pathways must include both short- and long-term effects on patients; that is, effects on the full patient pathway. Otherwise, costs might be cut without considering the long-term effects and, consequently, the overall cost of the pathway could increase. Unfortunately, current methods of evaluation present several issues: (1) they do not provide valid insights regarding the effects of a given improvement effort until several years later, (2) they provide imprecise and biased results, and (3) the aggregated results are not useful for identifying and disseminating the best practices that lead to an improvement. In this article, the accelerated longitudinal design with decomposition of total costs (ALDD) method is applied to evaluate the effects of improvement efforts on inpatient utilization for long cardiac pathways at a Danish hospital. The results show that the ALDD method can deliver valid results much faster than traditional methods and can uncover hidden improvements in the local work processes of clinical teams. Application of the ALDD method at a hospital in Denmark identified a significant reduction (15.4%) in the mean total bed utilization per cardiac pathway and revealed that this reduction was caused by improvements in the work processes.

Cancer Incidence Trends From 1999 to 2015 And Contributions Of Various Cancer Types To The Overall Burden: Projections To 2030 And Extrapolation Of Economic Burden In Saudi Arabia

Background

Cancer incidence in Saudi Arabia has increased for the last two decades, ratcheting up to global levels. The study aimed to analyze cancer trends and the contributions of various cancer types, forecast incidence, and estimate the economic burden in 2030.

Methods

A national-level cohort study utilizing the Data of Cancer Registry of patients who were diagnosed in 1999–2015. New cases in 2016–2030 were forecast and predicted based on 1999–2015 data. We used growth assumption and regression analysis to predict the trends of cancer cases. We assessed the contributions of cancer types to incidence trends. We carried forecasting of new cases and extrapolation of the potential economic burden. We conducted a sensitivity analysis of the cost of cancer with respect to changes in economic and epidemiologic factors.

Results

The findings suggest that the number of known cancer cases increased by 136% from 1999 to 2015 and is projected to rise by 63% in 2030. The forecast indicates female cases will account for higher number of cases and greater proportion increase. The future cost of all cancer types would be estimated at $7.91 billion in 2015 value, of which $3.76 billion will be attributable to care management and $4.15 billion in lost productivity. With the assumption of growth of the aged-standardized incidence rate, the costs of care management and lost productivity are projected to be $5.85 and $6.47 billion, respectively in 2030, an increase of 56% in each component. The future undiscounted total estimated economic burden for the period 2015–2030 would be $159.44 billion, of which 47.5% will be attributable to care management. Estimates were robust to uncertainty, but the 5-year prevalence of cancer survivorship would account for the greatest variability.

Conclusion

Our model showed an upsurge of cancer burden in terms of incidence and the potential economic burden, which may inform cancer control measures.

Longitudinal assessment of utilities in patients with migraine: an analysis of erenumab randomized controlled trials

Background

Cost-effectiveness analyses in patients with migraine require estimates of patients’ utility values and how these relate to monthly migraine days (MMDs). This analysis examined four different modelling approaches to assess utility values as a function of MMDs.

Methods

Disease-specific patient-reported outcomes from three erenumab clinical studies (two in episodic migraine [NCT02456740 and NCT02483585] and one in chronic migraine [NCT02066415]) were mapped to the 5-dimension EuroQol questionnaire (EQ-5D) as a function of the Migraine-Specific Quality of Life Questionnaire (MSQ) and the Headache Impact Test (HIT-6™) using published algorithms. The mapped utility values were used to estimate generic, preference-based utility values suitable for use in economic models. Four models were assessed to explain utility values as a function of MMDs: a linear mixed effects model with restricted maximum likelihood (REML), a fractional response model with logit link, a fractional response model with probit link and a beta regression model.

Results

All models tested showed very similar fittings. Root mean squared errors were similar in the four models assessed (0.115, 0.114, 0.114 and 0.114, for the linear mixed effect model with REML, fractional response model with logit link, fractional response model with probit link and beta regression model respectively), when mapped from MSQ. Mean absolute errors for the four models tested were also similar when mapped from MSQ (0.085, 0.086, 0.085 and 0.085) and HIT-6 and (0.087, 0.088, 0.088 and 0.089) for the linear mixed effect model with REML, fractional response model with logit link, fractional response model with probit link and beta regression model, respectively.

Conclusions

This analysis describes the assessment of longitudinal approaches in modelling utility values and the four models proposed fitted the observed data well. Mapped utility values for patients treated with erenumab were generally higher than those for individuals treated with placebo with equivalent number of MMDs. Linking patient utility values to MMDs allows utility estimates for different levels of MMD to be predicted, for use in economic evaluations of preventive therapies.

Trial registration

ClinicalTrials.gov numbers of the trials used in this study: STRIVE, NCT02456740 (registered May 14, 2015), ARISE, NCT02483585 (registered June 12, 2015) and NCT02066415 (registered Feb 17, 2014).

Costs of screening for prostate cancer: Evidence from the Finnish Randomised Study of Screening for Prostate Cancer after 20-year follow-up using register data

OBJECTIVES

Few empirical analyses of the impact of organised prostate cancer (PCa) screening on healthcare costs exist, despite cost-related information often being considered as a prerequisite to informed screening decisions. Therefore, we estimate the differences in register-based costs of publicly funded healthcare in the two arms of the Finnish Randomised Study of Screening for Prostate Cancer (FinRSPC) after 20 years.

METHODS

We obtained individual-level register data on prescription medications, as well as inpatient and outpatient care, to estimate healthcare costs for 80,149 men during the first 20 years of the FinRSPC. We compared healthcare costs for the men in each trial arm and performed statistical analysis.

RESULTS

For all men diagnosed with PCa during the 20-year observation period, mean PCa-related costs appeared to be around 10% lower in the screening arm (SA). Mean all-cause healthcare costs for these men were also lower in the SA, but differences were smaller than for PCa-related costs alone, and no longer statistically significant. For men dying from PCa, although the difference was not statistically significant, mean all-cause healthcare costs were around 10% higher. When analysis included all observations, cumulative costs were slightly higher in the CA; however, after excluding extreme values, cumulative costs were slightly higher in the SA.

CONCLUSIONS

No major cost impacts due to screening were apparent, but the FinRSPC's 20-year follow-up period is too short to provide definitive evidence at this stage. Longer term follow-up will be required to be better informed about the costs of, or savings from, introducing mass PCa screening.

Adjuvant breast radiotherapy: How to trade-off cost and effectiveness?

INTRODUCTION

A series of health economic evaluations (HEE) has analysed the efficiency of new fractionation schedules and techniques for adjuvant breast radiotherapy. This overview assembles the available evidence and evaluates to what extent HEE-results can be compared.

METHODS

Based on a systematic literature review of HEEs from 1/1/2000 to 30/10/2016, all cost comparison (CC) and cost-effectiveness analyses (CEA) comparing different adjuvant breast radiotherapy approaches were analysed. Costs were extracted and converted to Euro 2016 and costs per QALY were summarized in cost-effectiveness planes.

RESULTS

Twenty-four publications are withheld, comparing different fractionation schedules and/or irradiation techniques or evaluating the value of adding radiotherapy. Normofractionation and intensity-modulated, interstitial or intraluminal techniques are important cost-drivers. Highest reimbursements are observed in the US, but may overestimate the real cost. Hypofractionation is cost-effective compared to normofractionation, the results of partial breast irradiation are less unequivocal. Intra-operative and external beam approaches seem the most cost-effective for favourable risk groups, but whole breast irradiation is superior in terms of health effect and omission of radiotherapy in terms of costs.

CONCLUSION

Hypofractionation may be considered the most relevant comparator for new strategies in adjuvant breast radiotherapy, with omission of radiotherapy as an interesting alternative in the very favourable subcategories, especially for partial breast techniques. Although comparison of CC and CEA is hampered by the variability in clinical and economic settings, HEE-based evidence can guide decision-making to tailor-made strategies, allocating the optimal treatment in terms of effectiveness as well as efficiency to the right indication.