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Standaert B, Ethgen O. Discounting health gain: a different view. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2275350. [PMID: 37937314 PMCID: PMC10627044 DOI: 10.1080/20016689.2023.2275350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/22/2023] [Indexed: 11/09/2023]
Abstract
At least since the Age of Enlightenment, good health has been a tenet for society. Healthy societies could learn better, work harder, improve their wealth, and live longer. Today societies focus on life expectancy, as we value long and healthy lives. As illustrated by the provision of COVID-19 vaccines first for the elderly, societies value life-saving actions. Paradoxically, health economic assessments conventionally devalue long-lasting health through the practice of discounting health benefits along with costs. However, health, with its intrinsic and instrumental characteristics, is not synonymous with money cash, a tradeable asset that devalues with time. If improving healthy life expectancy is a societal ambition, it seems counter-intuitive to value future health less as a result of an artificial mathematical construct when evaluating economically new medical interventions. In this paper, we investigate the application of discounting health in healthcare and consider paradoxical findings, especially in relation to disease prevention with vaccination. We argue that there is no economically sustainable argument to discount health gains, except for the benefit of the payer with a goal of spending less on life-saving products. If that is the objective for discounting health, there are other means to achieve the same goal in a more transparent and simpler way. From the long-term perspective of healthcare development, not discounting health gains would encourage research that values long-term effects. This in turn has the potential to benefit the investor, the payer, and the patient/consumer, improving the situation from multiple perspectives.
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Affiliation(s)
- Baudouin Standaert
- Faculty of Medicine & Life sciences, University of Hasselt, Diepenbeek, Belgium
| | - Olivier Ethgen
- Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium
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Rubin JL, Lopez A, Booth J, Gunther P, Jena AB. Limitations of standard cost-effectiveness methods for health technology assessment of treatments for rare, chronic diseases: a case study of treatment for cystic fibrosis. J Med Econ 2022; 25:783-791. [PMID: 35549639 DOI: 10.1080/13696998.2022.2077550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Cost-effectiveness analysis (CEA) is useful to assess the value of health care interventions based on clinical effectiveness and costs. However, standard CEA methods make important assumptions that may significantly increase the incremental cost-effectiveness ratio (ICER) for lifelong treatments for rare, chronic diseases. We used the cost-effectiveness of elexacaftor/tezacaftor/ivacaftor and ivacaftor (ELX/TEZ/IVA) for the treatment of cystic fibrosis as a case study to explore how alternative assumptions for (1) discounting, (2) utility measures, (3) disease management costs, and (4) static drug pricing impact cost-effectiveness outcomes. MATERIALS AND METHODS Cost-effectiveness of ELX/TEZ/IVA was evaluated using base-case inputs and assumptions reflecting standard CEA methods and was then compared with cost-effectiveness estimates obtained with alternate assumptions: (1) applying a lower discount rate to health benefits (1.5%) than costs (3%); (2) including a treatment-specific utility increment; (3) excluding disease management costs incurred during the period of extended survival attributable to ELX/TEZ/IVA treatment; and (4) decreasing the price of ELX/TEZ/IVA following loss of exclusivity. RESULTS Modifying assumptions for these four factors together reduced the ICER by 75% from the base case, with the largest reduction (45%) occurring when the price trajectory was modified to allow for generic entry. Differential discounting, use of a treatment-specific utility increment, and exclusion of additional disease management costs each individually reduced the ICER by 36%, 14%, and 10%, respectively, from the base case. CONCLUSIONS This study illustrates the impact that modifications to standard CEA methods may have on measures of cost-effectiveness for rare, chronic diseases.
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Affiliation(s)
- Jaime L Rubin
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Andrea Lopez
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
| | - Jason Booth
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA
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Annemans L, Beutels P, Bloom DE, De Backer W, Ethgen O, Luyten J, Van Wilder P, Willem L, Simoens S. Economic Evaluation of Vaccines: Belgian Reflections on the Need for a Broader Perspective. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:105-111. [PMID: 33431141 DOI: 10.1016/j.jval.2020.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 05/21/2023]
Abstract
OBJECTIVES The standard framework of economic evaluation of health programs, which is increasingly used for policy funding decisions, is insufficiently equipped to reflect the full range of health and economic benefits conferred by vaccines and thus undervalues vaccination. METHODS In 2019, a group of Belgian health economic and clinical experts, supported by 2 senior international vaccination experts (1 American, 1 Belgian), convened 4 roundtable meetings to highlight which particular value elements of vaccination remain neglected in economic evaluations. RESULTS They concluded that the standard economic evaluation framework fails to reflect the full value of vaccination with respect to prevention of complications linked to some vaccine-preventable diseases, health gains for caregivers, herd effects, changes in exposure to and distribution of serotypes, the effect on antimicrobial resistance, productivity gains for caregivers and patients, and the distributive implications of vaccination programs. CONCLUSIONS Here, suggestions are made regarding how these shortcomings can be addressed in future economic evaluations of vaccines and how a more level playing field between vaccines and other health programs can be created.
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Affiliation(s)
- Lieven Annemans
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Olivier Ethgen
- Department of Public Health, Epidemiology and Health Economics, Faculty of Medicine, University of Liège, Liège, Belgium
| | - Jeroen Luyten
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | | | - Lander Willem
- Centre for Health Economics Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Kellerborg K, Brouwer W, van Baal P. Costs and benefits of interventions aimed at major infectious disease threats: lessons from the literature. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1329-1350. [PMID: 32789780 PMCID: PMC7425274 DOI: 10.1007/s10198-020-01218-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/03/2020] [Indexed: 06/11/2023]
Abstract
Pandemics and major outbreaks have the potential to cause large health losses and major economic costs. To prioritize between preventive and responsive interventions, it is important to understand the costs and health losses interventions may prevent. We review the literature, investigating the type of studies performed, the costs and benefits included, and the methods employed against perceived major outbreak threats. We searched PubMed and SCOPUS for studies concerning the outbreaks of SARS in 2003, H5N1 in 2003, H1N1 in 2009, Cholera in Haiti in 2010, MERS-CoV in 2013, H7N9 in 2013, and Ebola in West-Africa in 2014. We screened titles and abstracts of papers, and subsequently examined remaining full-text papers. Data were extracted according to a pre-constructed protocol. We included 34 studies of which the majority evaluated interventions related to the H1N1 outbreak in a high-income setting. Most interventions concerned pharmaceuticals. Included costs and benefits, as well as the methods applied, varied substantially between studies. Most studies used a short time horizon and did not include future costs and benefits. We found substantial variation in the included elements and methods used. Policymakers need to be aware of this and the bias toward high-income countries and pharmaceutical interventions, which hampers generalizability. More standardization of included elements, methodology, and reporting would improve economic evaluations and their usefulness for policy.
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Affiliation(s)
- Klas Kellerborg
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Werner Brouwer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Pieter van Baal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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John J, Koerber F, Schad M. Differential discounting in the economic evaluation of healthcare programs. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:29. [PMID: 31866768 PMCID: PMC6918700 DOI: 10.1186/s12962-019-0196-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/29/2019] [Indexed: 11/10/2022] Open
Abstract
Background The question of appropriate discount rates in health economic evaluations has been a point of continuous scientific debate. Today, it is widely accepted that, under certain conditions regarding the social objective of the healthcare decision maker and the fixity of the budget for healthcare, a lower discount rate for health gains than for costs is justified if the consumption value of health is increasing over time. To date, however, there is neither empirical evidence nor a strong theoretical a priori supporting this assumption. Given this lack of evidence, we offer an additional approach to check the appropriateness of differential discounting. Methods Our approach is based on a two-goods extension of Ramsey's optimal growth model which allows accounting for changing relative values of goods explicitly. Assuming a constant elasticity of substitution (CES) utility function, the growth rate of the consumption value of health depends on three variables: the growth rate of consumption, the growth rate of health, and the income elasticity of the willingness to pay for health. Based on a review of the empirical literature on the monetary value of health, we apply the approach to obtain an empirical value of the growth rate of the consumption value of health in Germany. Results The empirical literature suggests that the income elasticity of the willingness to pay for health is probably not larger but rather smaller than 1 and probably not smaller but rather larger than 0.2. Combining this finding with reasonable values of the annual growth rates in consumption (1.5-1.6%) and health (0.1%) suggests, for Germany, an annual growth rate of the consumption value of health between 0.3 and 1.5%. Conclusion In the light of a two-goods extension of Ramsey's optimal growth model, the available empirical evidence makes the case for a growing consumption value of health. Therefore, the current German practice of applying the same discount rate to costs and health gains introduces a systematic bias against healthcare technologies with upfront costs and long-term health effects. Differential discounting with a lower rate for health effects appears to be a more appropriate discounting model.
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Affiliation(s)
- Jürgen John
- 1Institute for Health Economics and Health Care Management, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | | | - Mareike Schad
- 3Independent Researcher, Grüner Weg 2, 88339 Bad Waldsee, Germany
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Abstract
Appropriate discounting rules in economic evaluations have received considerable attention in the literature and in national guidelines for economic evaluations. Rightfully so, as discounting can be quite influential on the outcomes of economic evaluations. The most prominent controversies regarding discounting involve the basis for and height of the discount rate, whether costs and effects should be discounted at the same rate, and whether discount rates should decline or stay constant over time. Moreover, the choice for discount rules depends on the decision context one adopts as the most relevant. In this article, we review these issues and debates, and describe and discuss the current discounting recommendations of the countries publishing their national guidelines. We finish the article by proposing a research agenda.
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Affiliation(s)
- Arthur E Attema
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Werner B F Brouwer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | - Karl Claxton
- Centre for Health Economics, University of York, York, UK
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Hettle R, Corbett M, Hinde S, Hodgson R, Jones-Diette J, Woolacott N, Palmer S. The assessment and appraisal of regenerative medicines and cell therapy products: an exploration of methods for review, economic evaluation and appraisal. Health Technol Assess 2018; 21:1-204. [PMID: 28244858 DOI: 10.3310/hta21070] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) commissioned a 'mock technology appraisal' to assess whether changes to its methods and processes are needed. This report presents the findings of independent research commissioned to inform this appraisal and the deliberations of a panel convened by NICE to evaluate the mock appraisal. METHODS Our research included reviews to identify issues, analysis methods and conceptual differences and the relevance of alternative decision frameworks, alongside the development of an exemplar case study of chimeric antigen receptor (CAR) T-cell therapy for treating acute lymphoblastic leukaemia. RESULTS An assessment of previous evaluations of regenerative medicines found that, although there were a number of evidential challenges, none was unique to regenerative medicines or was beyond the scope of existing methods used to conceptualise decision uncertainty. Regarding the clinical evidence for regenerative medicines, the issues were those associated with a limited evidence base but were not unique to regenerative medicines: small non-randomised studies, high variation in response and the intervention subject to continuing development. The relative treatment effects generated from single-arm trials are likely to be optimistic unless it is certain that the historical data have accurately estimated the efficacy of the control agent. Pivotal trials may use surrogate end points, which, on average, overestimate treatment effects. To reduce overall uncertainty, multivariate meta-analysis of all available data should be considered. Incorporating indirectly relevant but more reliable (more mature) data into the analysis can also be considered; such data may become available as a result of the evolving regulatory pathways being developed by the European Medicines Agency. For the exemplar case of CAR T-cell therapy, target product profiles (TPPs) were developed, which considered the 'curative' and 'bridging to stem-cell transplantation' treatment approaches separately. Within each TPP, three 'hypothetical' evidence sets (minimum, intermediate and mature) were generated to simulate the impact of alternative levels of precision and maturity in the clinical evidence. Subsequent assessments of cost-effectiveness were undertaken, employing the existing NICE reference case alongside additional analyses suggested within alternative frameworks. The additional exploratory analyses were undertaken to demonstrate how assessments of cost-effectiveness and uncertainty could be impacted by alternative managed entry agreements (MEAs), including price discounts, performance-related schemes and technology leasing. The panel deliberated on the range of TPPs, evidence sets and MEAs, commenting on the likely recommendations for each scenario. The panel discussed the challenges associated with the exemplar and regenerative medicines more broadly, focusing on the need for a robust quantification of the level of uncertainty in the cost-effective estimates and the potential value of MEAs in limiting the exposure of the NHS to high upfront costs and loss associated with a wrong decision. CONCLUSIONS It is to be expected that there will be a significant level of uncertainty in determining the clinical effectiveness of regenerative medicines and their long-term costs and benefits, but the existing methods available to estimate the implications of this uncertainty are sufficient. The use of risk sharing and MEAs between the NHS and manufacturers of regenerative medicines should be investigated further. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Robert Hettle
- Centre for Health Economics, University of York, York, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
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Hayman DTS, Marshall JC, French NP, Carpenter TE, Roberts MG, Kiedrzynski T. Cost-benefit analyses of supplementary measles immunisation in the highly immunized population of New Zealand. Vaccine 2017; 35:4913-4922. [PMID: 28802754 DOI: 10.1016/j.vaccine.2017.07.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/23/2017] [Accepted: 07/24/2017] [Indexed: 11/19/2022]
Abstract
As endemic measles is eliminated from countries through increased immunisation, the economic benefits of enhanced immunisation programs may come into question. New Zealand has suffered from outbreaks after measles introductions from abroad and we use it as a model system to understand the benefits of catch up immunisation in highly immunised populations. We provide cost-benefit analyses for measles supplementary immunisation in New Zealand. We model outbreaks based on estimates of the basic reproduction number in the vaccinated population (Rv, the number of secondary infections in a partially immunised population), based on the number of immunologically-naïve people at district and national levels, considering both pre- and post-catch up vaccination scenarios. Our analyses suggest that measles Rv often includes or exceeds one (0.18-3.92) despite high levels of population immunity. We calculate the cost of the first 187 confirmed and probable measles cases in 2014 to be over NZ$1 million (∼US$864,200) due to earnings lost, case management and hospitalization costs. The benefit-cost ratio analyses suggest additional vaccination beyond routine childhood immunisation is economically efficient. Supplemental vaccination-related costs are required to exceed approximately US$66 to US$1877 per person, depending on different scenarios, before supplemental vaccination is economically inefficient. Thus, our analysis suggests additional immunisation beyond childhood programs to target naïve individuals is economically beneficial even when childhood immunisation rates are high.
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Affiliation(s)
- D T S Hayman
- (m)EpiLab, Infectious Diseases Research Centre, Massey University, Palmerston North 4442, New Zealand.
| | - J C Marshall
- (m)EpiLab, Infectious Diseases Research Centre, Massey University, Palmerston North 4442, New Zealand
| | - N P French
- (m)EpiLab, Infectious Diseases Research Centre, Massey University, Palmerston North 4442, New Zealand
| | - T E Carpenter
- EpiCentre, Infectious Diseases Research Centre, Massey University, Palmerston North 4442, New Zealand
| | - M G Roberts
- Infectious Diseases Research Centre, Institute of Natural & Mathematical Sciences, New Zealand Institute for Advanced Study, Massey University, Private Bag 102 904, North Shore Mail Centre, Auckland, New Zealand
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Assessment of the Broader Economic Consequences of HPV Prevention from a Government-Perspective: A Fiscal Analytic Approach. PLoS One 2016; 11:e0160707. [PMID: 27490258 PMCID: PMC4973918 DOI: 10.1371/journal.pone.0160707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/22/2016] [Indexed: 11/23/2022] Open
Abstract
Background Cervical cancer poses a substantial burden in terms of morbidity, mortality, and economic losses, especially in low/middle-income countries. HPV vaccination and/or cervical cancer screening among females may reduce the burden of HPV-related diseases, including cervical cancer. However, limited funds may impede the implementation of population-based programmes. Governmental investments in the prevention of infectious disease may have broader economic and fiscal benefits, which are not accounted in conventional economic analyses. This study estimates the broader economic and fiscal impacts of implementing HPV vaccination and/or cervical cancer screening in Indonesia from the perspective of the government. Methods A government-perspective quantitative analytic framework was applied to assess the Net Present Value (NPV) of investment on cervical cancer prevention strategies including HPV vaccination, cervical screening and its combination in Indonesia. All monetary values were presented in International Dollars (I$). Results Based on a cohort of 10,000,000 Indonesian 12-year-old females, it was estimated that HPV vaccination and/or cervical cancer screening result in a positive NPV for the Indonesian government. The combination of cervical screening and HPV vaccination generated a substantial reduction of cervical cancer incidence and HPV-related mortality of 87,862 and 19,359, respectively. It was estimated that HPV vaccination in combination with cervical screening is the most favorable option for cervical cancer prevention (NPV I$2.031.786.000), followed by HPV vaccination alone (NPV I$1.860.783.000) and cervical screening alone (NPV I$375.244.000). Conclusion In addition to clinical benefits, investing in HPV vaccination and cervical screening may yield considerable fiscal benefits for the Indonesian governments due to lifelong benefits resulting from reduction of cervical cancer-related morbidity and mortality.
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Ultsch B, Damm O, Beutels P, Bilcke J, Brüggenjürgen B, Gerber-Grote A, Greiner W, Hanquet G, Hutubessy R, Jit M, Knol M, von Kries R, Kuhlmann A, Levy-Bruhl D, Perleth M, Postma M, Salo H, Siebert U, Wasem J, Wichmann O. Methods for Health Economic Evaluation of Vaccines and Immunization Decision Frameworks: A Consensus Framework from a European Vaccine Economics Community. PHARMACOECONOMICS 2016; 34:227-44. [PMID: 26477039 PMCID: PMC4766233 DOI: 10.1007/s40273-015-0335-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Incremental cost-effectiveness and cost-utility analyses [health economic evaluations (HEEs)] of vaccines are routinely considered in decision making on immunization in various industrialized countries. While guidelines advocating more standardization of such HEEs (mainly for curative drugs) exist, several immunization-specific aspects (e.g. indirect effects or discounting approach) are still a subject of debate within the scientific community. OBJECTIVE The objective of this study was to develop a consensus framework for HEEs of vaccines to support the development of national guidelines in Europe. METHODS A systematic literature review was conducted to identify prevailing issues related to HEEs of vaccines. Furthermore, European experts in the field of health economics and immunization decision making were nominated and asked to select relevant aspects for discussion. Based on this, a workshop was held with these experts. Aspects on 'mathematical modelling', 'health economics' and 'decision making' were debated in group-work sessions (GWS) to formulate recommendations and/or--if applicable--to state 'pros' and 'contras'. RESULTS A total of 13 different aspects were identified for modelling and HEE: model selection, time horizon of models, natural disease history, measures of vaccine-induced protection, duration of vaccine-induced protection, indirect effects apart from herd protection, target population, model calibration and validation, handling uncertainty, discounting, health-related quality of life, cost components, and perspectives. For decision making, there were four aspects regarding the purpose and the integration of HEEs of vaccines in decision making as well as the variation of parameters within uncertainty analyses and the reporting of results from HEEs. For each aspect, background information and an expert consensus were formulated. CONCLUSIONS There was consensus that when HEEs are used to prioritize healthcare funding, this should be done in a consistent way across all interventions, including vaccines. However, proper evaluation of vaccines implies using tools that are not commonly used for therapeutic drugs. Due to the complexity of and uncertainties around vaccination, transparency in the documentation of HEEs and during subsequent decision making is essential.
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Affiliation(s)
- Bernhard Ultsch
- Department for Infectious Disease Epidemiology, Immunisation Unit, Robert Koch Institute (RKI), Seestr. 10, 13353, Berlin, Germany.
| | | | | | | | | | | | | | | | | | - Mark Jit
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Public Health England (PHE), London, UK
| | - Mirjam Knol
- Centre for Infectious Disease Control (RIVM), Bilthoven, The Netherlands
| | | | | | | | | | | | - Heini Salo
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Uwe Siebert
- University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria
- ONCOTYROL, Center for Personalized Cancer Medicine, Innsbruck, Austria
| | | | - Ole Wichmann
- Department for Infectious Disease Epidemiology, Immunisation Unit, Robert Koch Institute (RKI), Seestr. 10, 13353, Berlin, Germany
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O'Mahony JF, Newall AT, van Rosmalen J. Dealing with Time in Health Economic Evaluation: Methodological Issues and Recommendations for Practice. PHARMACOECONOMICS 2015; 33:1255-68. [PMID: 26105525 PMCID: PMC4661216 DOI: 10.1007/s40273-015-0309-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Time is an important aspect of health economic evaluation, as the timing and duration of clinical events, healthcare interventions and their consequences all affect estimated costs and effects. These issues should be reflected in the design of health economic models. This article considers three important aspects of time in modelling: (1) which cohorts to simulate and how far into the future to extend the analysis; (2) the simulation of time, including the difference between discrete-time and continuous-time models, cycle lengths, and converting rates and probabilities; and (3) discounting future costs and effects to their present values. We provide a methodological overview of these issues and make recommendations to help inform both the conduct of cost-effectiveness analyses and the interpretation of their results. For choosing which cohorts to simulate and how many, we suggest analysts carefully assess potential reasons for variation in cost effectiveness between cohorts and the feasibility of subgroup-specific recommendations. For the simulation of time, we recommend using short cycles or continuous-time models to avoid biases and the need for half-cycle corrections, and provide advice on the correct conversion of transition probabilities in state transition models. Finally, for discounting, analysts should not only follow current guidance and report how discounting was conducted, especially in the case of differential discounting, but also seek to develop an understanding of its rationale. Our overall recommendations are that analysts explicitly state and justify their modelling choices regarding time and consider how alternative choices may impact on results.
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Affiliation(s)
- James F O'Mahony
- Department of Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Anthony T Newall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Haeussler K, Marcellusi A, Mennini FS, Favato G, Picardo M, Garganese G, Bononi M, Costa S, Scambia G, Zweifel P, Capone A, Baio G. Cost-Effectiveness Analysis of Universal Human Papillomavirus Vaccination Using a Dynamic Bayesian Methodology: The BEST II Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:956-68. [PMID: 26686779 DOI: 10.1016/j.jval.2015.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/05/2015] [Accepted: 08/08/2015] [Indexed: 05/23/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) plays a role in the development of benign and malign neoplasms in both sexes. The Italian recommendations for HPV vaccines consider only females. The BEST II study (Bayesian modelling to assess the Effectiveness of a vaccination Strategy to prevent HPV-related diseases) evaluates 1) the cost-effectiveness of immunization strategies targeting universal vaccination compared with cervical cancer screening and female-only vaccination and 2) the economic impact of immunization on various HPV-induced diseases. OBJECTIVE The objective of this study was to evaluate whether female-only vaccination or universal vaccination is the most cost-effective intervention against HPV. METHODS We present a dynamic Bayesian Markov model to investigate transmission dynamics in cohorts of females and males in a follow-up period of 55 years. We assumed that quadrivalent vaccination (against HPV 16, 18, 6, and 11) is available for 12-year-old individuals. The model accounts for the progression of subjects across HPV-induced health states (cervical, vaginal, vulvar, anal, penile, and head/neck cancer as well as anogenital warts). The sexual mixing is modeled on the basis of age-, sex-, and sexual behavioral-specific matrices to obtain the dynamic force of infection. RESULTS In comparison to cervical cancer screening, universal vaccination results in an incremental cost-effectiveness ratio of €1,500. When universal immunization is compared with female-only vaccination, it is cost-effective with an incremental cost-effectiveness ratio of €11,600. Probabilistic sensitivity analysis shows a relatively large amount of parameter uncertainty, which interestingly has, however, no substantial impact on the decision-making process. The intervention being assessed seems to be associated with an attractive cost-effectiveness profile. CONCLUSIONS Universal HPV vaccination is found to be a cost-effective choice when compared with either cervical cancer screening or female-only vaccination within the Italian context.
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Affiliation(s)
- Katrin Haeussler
- Department of Statistical Science, University College London, London, UK.
| | - Andrea Marcellusi
- Economic Evaluation and HTA, Faculty of Economics, University of Rome "Tor Vergata," Rome, Italy; Department of Demography, University of Rome "La Sapienza," Rome, Italy
| | - Francesco Saverio Mennini
- Economic Evaluation and HTA, Faculty of Economics, University of Rome "Tor Vergata," Rome, Italy; Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Giampiero Favato
- Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Mauro Picardo
- Laboratory of Cutaneous Pathophysiology, San Gallicano Dermatological Institute (IRCCS), Rome, Italy
| | - Giorgia Garganese
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Bononi
- Department of Surgery Pietro Valdoni, University of Rome "La Sapienza," Rome, Italy
| | - Silvano Costa
- Department of Gynecology and Obstetrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Peter Zweifel
- Socioeconomic Institute, University of Zurich, Zurich, Switzerland
| | - Alessandro Capone
- Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, UK
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13
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Discounting in the evaluation of the cost-effectiveness of a vaccination programme: A critical review. Vaccine 2015; 33:3788-94. [DOI: 10.1016/j.vaccine.2015.06.084] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 06/21/2015] [Accepted: 06/22/2015] [Indexed: 12/24/2022]
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14
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Kim MJ, Ki MS, Kim K, Shim HJ, Hwang JE, Bae WK, Chung IJ, Lee DH, Lee JK, Yoon TM, Lim SC, Chung WK, Jeong JU, Lim HS, Choi YD, Cho SH. Different protein expression associated with chemotherapy response in oropharyngeal cancer according to HPV status. BMC Cancer 2014; 14:824. [PMID: 25380690 PMCID: PMC4232654 DOI: 10.1186/1471-2407-14-824] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 10/24/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGOUND Oropharyngeal cancer (OPC) associated with human papilloma virus (HPV OPC) shows better treatment outcomes than non-HPV OPC. We investigated the expression of p53, β-tubulin, bcl-2 and ERCC 1, which are well-known biomarkers to predict the chemotherapy response, according to HPV status in OPC patients. METHODS Patients who treated with at least 2 cycles of induction chemotherapy followed by concurrent chemoradiotherapy for locally advanced oropharyngeal cancer were reviewed. HPV PCR and immunohistochemical stain was done in paraffin embedded tumor tissue and evaluated the relation with the chemotherapy response and survival outcomes according to HPV status. RESULTS Seventy-four patients were enrolled for this study and all patients received induction chemotherapy with docetaxel, 5-FU and cisplatin. After induction chemotherapy, complete response (CR) was shown in 22 patients (30%) and partial response (PR) in 46 patients (62%). HPV + was detected in 21 patients (28%), while 35 patients (47%) showed p16+ expression by IHC analysis. p16 positive patients showed better overall response, PFS and OS than p16 negative patients. p53 and class III beta-tubulin expression were significantly higher in HPV- and p16- than HPV + and p16+ patients. Conversely, bcl-2 expression was greater in HPV + or p16+ than HPV- or p16- patients. ERCC1 expression did not differ significantly according to HPV status. In multivariate analyses, early T stage (p = 0.036) and good PS (PS 0) (p = 0.029) showed a better 3Y-PFS rate, and low p53 expression (p = 0.012) and complete response after induction chemotherapy (p = 0.026) were highly associated with 3Y-OS rate. Low expression of p53 and p16 positive patients showed significantly prolonged OS than others (p = 0.010). CONCLUSION P53, class III beta-tubulin and bcl-2 were differently expressed in OPC according to HPV status and present study suggested the underlying mechanism of better response to chemotherapy in case of HPV OPC than non-HPV OPC. Among these biomarkers, p53 is the strongest prognostic marker in OPC and p53 in addition to p16 support the rationale to study of de-escalation strategy for OPC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sang-Hee Cho
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, 322 Seoyangro, Hwasun, Jeollanamdo 519-763, Republic of Korea.
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15
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Parouty MBY, Le HH, Krooshof D, Postma MJ. Differential time preferences for money and quality of life. PHARMACOECONOMICS 2014; 32:411-419. [PMID: 24464352 DOI: 10.1007/s40273-013-0124-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND This study provides an empirical investigation into differential time preferences between money and quality of life. Thus far, time preference investigations in health have mostly involved life-years gained and lives saved. However, the quality-adjusted life-year, which is recommended by several bodies, is a multiplicative measure of life duration and quality of life. To our knowledge, our study is the first to follow this approach specifically for quality of life. METHODS A questionnaire was developed to elicit time preferences for quality of life and for money, and it was distributed to a representative sample of the Dutch population. We also investigated the impact of population characteristics, such as current health state, optimistic/pessimistic future views or gender, on time preferences. RESULTS We found that discount rates for both money and quality of life decrease with increasing time of delay, with rates of the former being consistently at least two times higher than those of the latter. Similar trends in time preferences were observed across the subgroups, with the exception of the relatively high education subgroup. CONCLUSION In agreement with the results of other studies, our empirically derived discount rates are higher than the rates featured in national guidelines for health care economic assessment. Our empirical study adds to the evidence for differential discounting, both with regards to money and health, as well as in time.
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Affiliation(s)
- M B Y Parouty
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, the Netherlands
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16
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Rozenbaum MH, De Cao E, Westra TA, Postma MJ. Dynamic models for health economic assessments of pertussis vaccines: what goes around comes around…. Expert Rev Vaccines 2014; 11:1415-28. [DOI: 10.1586/erv.12.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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Parouty MBY, Krooshof DGM, Westra TA, Pechlivanoglou P, Postma MJ. Reviewing and piloting methods for decreasing discount rates; someone, somewhere in time. Expert Rev Pharmacoecon Outcomes Res 2014; 13:523-47. [DOI: 10.1586/14737167.2013.815404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Postma MJ, Westra TA, Quilici S, Largeron N. Economic evaluation of vaccines: specificities and future challenges illustrated by recent European examples. Expert Rev Vaccines 2013; 12:555-65. [PMID: 23659302 DOI: 10.1586/erv.13.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This study reviews the current challenges in the economic evaluation of vaccines with a focus on European countries. In particular, the type of clinical evidence generally available, the impact of discounting for time preference and the use of modeling to derive valid cost-effectiveness assessments are considered. First, the characteristics of evidence for vaccines are discussed, as well as potential difficulties faced when using evidence-based medicine applied to curative drugs to interpret vaccine evidence. Then, discounting is considered and specific examples illustrating issues with different types of discounting are described, taking HPV as the example. Finally, the need for sometimes complex dynamic models for vaccines is explored, and specific types of models are reviewed, keeping into consideration the adage "complex when needed, straightforward if allowed."
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Affiliation(s)
- Maarten J Postma
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.
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19
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Brisson M, Laprise JF, Drolet M, Van de Velde N, Franco EL, Kliewer EV, Ogilvie G, Deeks SL, Boily MC. Comparative cost-effectiveness of the quadrivalent and bivalent human papillomavirus vaccines: a transmission-dynamic modeling study. Vaccine 2013; 31:3863-71. [PMID: 23830974 DOI: 10.1016/j.vaccine.2013.06.064] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 06/05/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The quadrivalent and bivalent human papillomavirus (HPV) vaccines are now licensed in several countries. We compared the cost-effectiveness of the HPV vaccines to provide evidence for policy decisions. METHODS We developed HPV-ADVISE, a multi-type individual-based transmission-dynamic model of HPV infection and disease (anogenital warts, and cervical, anogenital and oropharyngeal cancers). We calibrated the model to sexual behavior and epidemiologic data from Canada, and estimated quality-adjusted life-years (QALYs) lost and costs ($CAN 2010) from the literature. Vaccine-type efficacy was based on a systematic literature review. The analysis was performed from the healthcare provider perspective, and costs and benefits were discounted at 3%. Predictions are presented using the median [10th;90th percentiles] of simulations. RESULTS Under base-case assumptions (vaccinating 10-year-old girls, 80% coverage, $95/dose), using the quadrivalent and bivalent vaccines is estimated to cost $15,528 [12,056;19,140] and $20,182 [15,531;25,240] per QALY-gained, respectively. At equal price, the quadrivalent vaccine is more cost-effective than bivalent under all scenarios investigated, except when assuming longer duration of protection for the bivalent and minimal anogenital warts burden. Under base-case assumptions, the maximum additional cost per dose for the quadrivalent vaccine to remain more cost-effective than the bivalent is $32 [17;46] (using a $40,000/QALY-gained threshold). Results were most sensitive to discounting, time-horizon, differences in durations of protection and anogenital warts burden. CONCLUSIONS Vaccinating pre-adolescent girls against HPV is predicted to be highly cost-effective. If equally priced, the quadrivalent is the most economically desirable vaccine. However, ultimately, the most cost-effective HPV vaccine will be determined by their relative price.
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Affiliation(s)
- Marc Brisson
- SP-POS, Centre de recherche du CHU de Québec, Québec, Canada.
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20
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Rozenbaum MH, Postma MJ. Response on “RE: Cost-effectiveness of pertussis booster vaccination in the Netherlands”. Vaccine 2013; 31:2024. [DOI: 10.1016/j.vaccine.2012.11.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 11/28/2012] [Indexed: 11/27/2022]
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21
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Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E. Consolidated Health Economic Evaluation Reporting Standards (CHEERS)--explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:231-50. [PMID: 23538175 DOI: 10.1016/j.jval.2013.02.002] [Citation(s) in RCA: 1506] [Impact Index Per Article: 136.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Economic evaluations of health interventions pose a particular challenge for reporting because substantial information must be conveyed to allow scrutiny of study findings. Despite a growth in published reports, existing reporting guidelines are not widely adopted. There is also a need to consolidate and update existing guidelines and promote their use in a user-friendly manner. A checklist is one way to help authors, editors, and peer reviewers use guidelines to improve reporting. OBJECTIVE The task force's overall goal was to provide recommendations to optimize the reporting of health economic evaluations. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update previous health economic evaluation guidelines into one current, useful reporting guidance. The CHEERS Elaboration and Explanation Report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force facilitates the use of the CHEERS statement by providing examples and explanations for each recommendation. The primary audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication. METHODS The need for new reporting guidance was identified by a survey of medical editors. Previously published checklists or guidance documents related to reporting economic evaluations were identified from a systematic review and subsequent survey of task force members. A list of possible items from these efforts was created. A two-round, modified Delphi Panel with representatives from academia, clinical practice, industry, and government, as well as the editorial community, was used to identify a minimum set of items important for reporting from the larger list. RESULTS Out of 44 candidate items, 24 items and accompanying recommendations were developed, with some specific recommendations for single study-based and model-based economic evaluations. The final recommendations are subdivided into six main categories: 1) title and abstract, 2) introduction, 3) methods, 4) results, 5) discussion, and 6) other. The recommendations are contained in the CHEERS statement, a user-friendly 24-item checklist. The task force report provides explanation and elaboration, as well as an example for each recommendation. The ISPOR CHEERS statement is available online via Value in Health or the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices - CHEERS Task Force webpage (http://www.ispor.org/TaskForces/EconomicPubGuidelines.asp). CONCLUSIONS We hope that the ISPOR CHEERS statement and the accompanying task force report guidance will lead to more consistent and transparent reporting, and ultimately, better health decisions. To facilitate wider dissemination and uptake of this guidance, we are copublishing the CHEERS statement across 10 health economics and medical journals. We encourage other journals and groups to consider endorsing the CHEERS statement. The author team plans to review the checklist for an update in 5 years.
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Affiliation(s)
- Don Husereau
- Institute of Health Economics, Edmonton, Canada.
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22
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Abstract
Performing a total health economic analysis of a vaccine newly introduced into the market today is a challenge when using the conventional cost-effectiveness analysis we normally apply on pharmaceutical products. There are many reasons for that, such as: the uncertainty in the total benefit (direct and indirect) to be measured in a population when using a cohort model; (1) appropriate rules about discounting the long-term impact of vaccines are absent jeopardizing therefore their value at the initial investment; (2) the presence of opposite contexts when introducing the vaccine in developed vs. the developing world with high benefits, low initial health care investment for the latter vs. marginal benefit and high cost for the former; with a corresponding paradox for the vaccine becoming very cost-effective in low income countries but rather medium in middle low to high middle income countries; (3) and the type of trial assessment for the newer vaccines is now often performed with immunogenicity reaction instead of clinical endpoints which still leaves questions on their real impact and their head-to-head comparison. (4.)
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Affiliation(s)
- Maarten J Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2); Department of Pharmacy; University of Groningen; Groningen, The Netherlands
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23
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Pharmacoeconomics of Pharmacogenetics within the Context of General Health Technology Assessments. Pharmacogenomics 2013. [DOI: 10.1016/b978-0-12-391918-2.00012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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