Conceptualizing a model: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force--2

Cost-Effectiveness of Plasma Microbial Cell-Free DNA Sequencing When Added to Usual Care Diagnostic Testing for Immunocompromised Host Pneumonia

INTRODUCTION

Immunocompromised host pneumonia (ICHP) is an important cause of morbidity and mortality, yet usual care (UC) diagnostic tests often fail to identify an infectious etiology. A US-based, multicenter study (PICKUP) among ICHP patients with hematological malignancies, including hematological cell transplant recipients, showed that plasma microbial cell-free DNA (mcfDNA) sequencing provided significant additive diagnostic value.

AIM

The objective of this study was to perform a cost-effectiveness analysis (CEA) of adding mcfDNA sequencing to UC diagnostic testing for hospitalized ICHP patients.

METHODS

A semi-Markov model was utilized from the US third-party payer's perspective such that only direct costs were included, using a lifetime time horizon with discount rates of 3% for costs and benefits. Three comparators were considered: (1) All UC, which included non-invasive (NI) and invasive testing and early bronchoscopy; (2) All UC & mcfDNA; and (3) NI UC & mcfDNA & conditional UC Bronch (later bronchoscopy if the initial tests are negative). The model considered whether a probable causative infectious etiology was identified and if the patient received appropriate antimicrobial treatment through expert adjudication, and if the patient died in-hospital. The primary endpoints were total costs, life-years (LYs), equal value life-years (evLYs), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio per QALY. Extensive scenario and probabilistic sensitivity analyses (PSA) were conducted.

RESULTS

At a price of $2000 (2023 USD) for the plasma mcfDNA, All UC & mcfDNA was more costly ($165,247 vs $153,642) but more effective (13.39 vs 12.47 LYs gained; 10.20 vs 9.42 evLYs gained; 10.11 vs 9.42 QALYs gained) compared to All UC alone, giving a cost/QALY of $16,761. NI UC & mcfDNA & conditional UC Bronch was also more costly ($162,655 vs $153,642) and more effective (13.19 vs 12.47 LYs gained; 9.96 vs 9.42 evLYs gained; 9.96 vs 9.42 QALYs gained) compared to All UC alone, with a cost/QALY of $16,729. The PSA showed that above a willingness-to-pay threshold of $50,000/QALY, All UC & mcfDNA was the preferred scenario on cost-effectiveness grounds (as it provides the most QALYs gained). Further scenario analyses found that All UC & mcfDNA always improved patient outcomes but was not cost saving, even when the price of mcfDNA was set to $0.

CONCLUSIONS

Based on the evidence available at the time of this analysis, this CEA suggests that mcfDNA may be cost-effective when added to All UC, as well as in a scenario using conditional bronchoscopy when NI testing fails to identify a probable infectious etiology for ICHP. Adding mcfDNA testing to UC diagnostic testing should allow more patients to receive appropriate therapy earlier and improve patient outcomes.

Adverse drug events in cost-effectiveness models of pharmacological interventions for diabetes, diabetic retinopathy, and diabetic macular edema: a scoping review

OBJECTIVE

The objective of this review was to examine the role of adverse drug events (ADEs) caused by pharmacological interventions in cost-effectiveness models for diabetes mellitus, diabetic retinopathy, and diabetic macular edema.

INTRODUCTION

Guidelines for economic evaluation recognize the importance of including ADEs in the analysis, but in practice, consideration of ADEs in cost-effectiveness models seem to be vague. Inadequate inclusion of these harmful outcomes affects the reliability of the results, and the information provided by economic evaluation could be misleading. Reviewing whether and how ADEs are incorporated in cost-effectiveness models is necessary to understand the current practices of economic evaluation.

INCLUSION CRITERIA

Studies included were published between 2011-2022 in English, representing cost-effectiveness analyses using modeling framework for pharmacological interventions in the treatment of diabetes mellitus, diabetic retinopathy, or diabetic macular edema. Other types of analyses and other types of conditions were excluded.

METHODS

The databases searched included MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Web of Science Core Collection, and NHS Economic Evaluation Database. Gray literature was searched via the National Institute for Health and Care Excellence, European Network for Health Technology Assessment, the National Institute for Health and Care Research, and the International Network of Agencies for Health Technology Assessment. The search was conducted on January 1, 2023. Titles and abstracts were screened for inclusion by 2 independent reviewers. Full-text review was conducted by 3 independent reviewers. A data extraction form was used to extract and analyze the data. Results were presented in tabular format with a narrative summary, and discussed in the context of existing literature and guidelines.

RESULTS

A total of 242 reports were extracted and analyzed in this scoping review. For the included analyses, type 2 diabetes was the most common disease (86%) followed by type 1 diabetes (10%), diabetic macular edema (9%), and diabetic retinopathy (0.4%). The majority of the included analyses used a health care payer perspective (88%) and had a time horizon of 30 years or more (75%). The most common model type was a simulation model (57%), followed by a Markov simulation model (18%). Of the included cost-effectiveness analyses, 26% included ADEs in the modeling, and 13% of the analyses excluded them. Most of the analyses (61%) partly considered ADEs; that is, only 1 or 2 ADEs were included. No difference in overall inclusion of ADEs between the different conditions existed, but the models for diabetic retinopathy and diabetic macular edema more often omitted the ADE-related impact on quality of life compared with the models for diabetes mellitus. Most analyses included ADEs in the models as probabilities (55%) or as a submodel (40%), and the most common source for ADE incidences were clinical trials (65%).

CONCLUSIONS

The inclusion of ADEs in cost-effectiveness models is suboptimal. The ADE-related costs were better captured than the ADE-related impact on quality of life, which was most pronounced in the models for diabetic retinopathy and diabetic macular edema. Future research should investigate the potential impact of ADEs on the results, and identify the criteria and policies for practical inclusion of ADEs in economic evaluation.

Cost-Effectiveness of Lovotibeglogene Autotemcel (Lovo-Cel) Gene Therapy for Patients with Sickle Cell Disease and Recurrent Vaso-Occlusive Events in the United States

BACKGROUND AND OBJECTIVE

Gene therapies for sickle cell disease (SCD) may offer meaningful benefits for patients and society. This study evaluated the cost-effectiveness of lovotibeglogene autotemcel (lovo-cel), a one-time gene therapy administered via autologous hematopoietic stem cell transplantation, compared with common care for patients in the United States (US) with SCD aged ≥ 12 years with ≥ 4 vaso-occlusive events (VOEs) in the past 24 months.

METHODS

We developed a patient-level simulation model accounting for lovo-cel and SCD-related events, complications, and mortality over a lifetime time horizon. The pivotal phase 1/2 HGB-206 clinical trial (NCT02140554) served as the basis for lovo-cel efficacy and safety. Cost, quality-of-life, and other clinical data were sourced from HGB-206 data and the literature. Analyses were conducted from US societal and third-party payer perspectives. Uncertainty was assessed through probabilistic sensitivity analysis and extensive scenario analyses.

RESULTS

Patients treated with lovo-cel were predicted to survive 23.84 years longer on average (standard deviation [SD], 12.80) versus common care (life expectancy, 62.24 versus 38.40 years), with associated discounted patient quality-adjusted life-year (QALY) gains of 10.20 (SD, 4.10) and direct costs avoided of $1,329,201 (SD, $1,346,446) per patient. Predicted societal benefits included discounted caregiver QALY losses avoided of 1.19 (SD, 1.38) and indirect costs avoided of $540,416 (SD, $262,353) per patient. Including lovo-cel costs ($3,282,009 [SD, $29,690] per patient) resulted in incremental cost-effectiveness ratios of $191,519 and $124,051 per QALY gained from third-party payer and societal perspectives, respectively. In scenario analyses, the predicted cost-effectiveness of lovo-cel also was sensitive to baseline age and VOE frequency and to the proportion of patients achieving and maintaining complete resolution of VOEs.

CONCLUSIONS

Our analysis of lovo-cel gene therapy compared with common care for patients in the US with SCD with recurrent VOEs estimated meaningful improvements in survival, quality of life, and other clinical outcomes accompanied by increased overall costs for the health care system and for broader society. The predicted economic value of lovo-cel gene therapy was influenced by uncertainty in long-term clinical effects and by positive spillover effects on patient productivity and caregiver burden.

Value of Information for Clinical Trial Design: The Importance of Considering All Relevant Comparators

Value of Information (VOI) analyses calculate the economic value that could be generated by obtaining further information to reduce uncertainty in a health economic decision model. VOI has been suggested as a tool for research prioritisation and trial design as it can highlight economically valuable avenues for future research. Recent methodological advances have made it increasingly feasible to use VOI in practice for research; however, there are critical differences between the VOI approach and the standard methods used to design research studies such as clinical trials. We aimed to highlight key differences between the research design approach based on VOI and standard clinical trial design methods, in particular the importance of considering the full decision context. We present two hypothetical examples to demonstrate that VOI methods are only accurate when (1) all feasible comparators are included in the decision model when designing research, and (2) all comparators are retained in the decision model once the data have been collected and a final treatment recommendation is made. Omitting comparators from either the design or analysis phase of research when using VOI methods can lead to incorrect trial designs and/or treatment recommendations. Overall, we conclude that incorrectly specifying the health economic model by ignoring potential comparators can lead to misleading VOI results and potentially waste scarce research resources.

Cost-effectiveness analysis of emicizumab prophylaxis in patients with haemophilia A in India

INTRODUCTION

Emicizumab is the initial subcutaneously administered bispecific antibody approved as a prophylactic treatment for patients with haemophilia A (PwHA).

AIM

This study assessed the economic evaluation of emicizumab treatment for non-inhibitor severe haemophilia A (HA) patients in India.

METHODS

A Markov model evaluated the cost-effectiveness of emicizumab prophylaxis compared to on-demand therapy (ODT), low-dose prophylaxis (LDP; 1565 IU/kg/year), intermediate-dose prophylaxis (IDP; 3915 IU/kg/year) and high-dose prophylaxis (HDP; 7125 IU/kg/year) for HA patients without factor VIII inhibitors. Inputs from HAVEN-1 and HAVEN-3 trials included transition probabilities of different bleeding types. Costs and benefits were discounted at a 3.5% annual rate.

RESULTS

In the base-case analysis, emicizumab was cost-effective compared to HDP, with an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years (QALY) of Indian rupees (INR) 27,869. Compared to IDP, ODT and LDP, emicizumab prophylaxis could be considered a cost-effective option if the paying threshold is >1 per capita gross domestic product (GDP) with ICER/QALY values of INR 264,592, INR 255,876 and INR 305,398, respectively. One-way sensitivity analysis (OWSA) highlighted emicizumab cost as the parameter with the greatest impact on ICERs. Probabilistic sensitivity analysis (PSA) indicated that emicizumab had a 94.7% and 49.4% probability of being cost-effective at willingness-to-pay (WTP) thresholds of three and two-times per capita GDP.

CONCLUSION

Emicizumab prophylaxis is cost-effective compared to HDP and provides value for money compared to ODT, IDP, and LDP for severe non-inhibitor PwHA in India. Its long-term humanistic, clinical and economic benefits outweigh alternative options, making it a valuable choice in resource-constrained settings.

Comparison of partitioned survival modeling with state transition modeling approaches with or without consideration of brain metastasis: a case study of Osimertinib versus pemetrexed-platinum

BACKGROUND

The partitioned survival model (PSM) and the state transition model (STM) are widely used in cost-effectiveness analyses of anticancer drugs. Using different modeling approaches with or without consideration of brain metastasis, we compared the quality-adjusted life-year (QALY) estimates of Osimertinib and pemetrexed-platinum in advanced non-small cell lung cancer with epidermal growth factor receptor mutations.

METHODS

We constructed three economic models using parametric curves fitted to patient-level data from the National Health Insurance Review and Assessment claims database from 2009 to 2020. PSM and 3-health state transition model (3-STM) consist of three health states: progression-free, post-progression, and death. The 5-health state transition model (5-STM) has two additional health states (brain metastasis with continuing initial therapy, and with subsequent therapy). Time-dependent transition probabilities were calculated in the state transition models. The incremental life-year (LY) and QALY between the Osimertinib and pemetrexed-platinum cohorts for each modeling approach were estimated over seven years.

RESULTS

The PSM and 3-STM produced similar incremental LY (0.889 and 0.899, respectively) and QALY (0.827 and 0.840, respectively). However, 5-STM, which considered brain metastasis as separate health states, yielded a slightly higher incremental LY (0.910) but lower incremental QALY (0.695) than PSM and 3-STM.

CONCLUSIONS

Our findings indicate that incorporating additional health states such as brain metastases into economic models can have a considerable impact on incremental QALY estimates. To ensure appropriate health technology assessment decisions, comparison and justification of different modeling approaches are recommended in the economic evaluation of anticancer drugs.

The Cost-Effectiveness of Dolutegravir in Combination with Tenofovir and Lamivudine for HIV Therapy: A Systematic Review

The World Health Organization (WHO) recommends dolutegravir (DTG), a human immunodeficiency virus (HIV) medicine, as the first- and second-line treatment for all populations because, when compared to an efavirenz (EFV) regimen, plus two nucleoside reverse transcriptase inhibitors (NRTIs) has demonstrated significant effectiveness in HIV suppression in persons. This study aims to review evidence of the cost-effectiveness of DTG in combination with tenofovir and lamivudine compared with the standard of care for HIV therapy. The systematic review involved searching electronic databases for articles published between January 2018 and May 2022. Electronic database sources include PubMed, ScienceDirect, and EBSCO for articles on DTG in combination with tenofovir and lamivudine as subjects with cost-effectiveness outcomes. The inclusion criteria in this systematic review were studies about the cost-effectiveness analysis (CEA) of DTG in combination with tenofovir and lamivudine, written in English. A total of 145 articles were identified from three databases. After removing nine duplicates, 142 articles were screened by title and abstract, excluding 123 articles. After a full-text screening of 19 articles, five articles were selected for further analysis. Five articles reviewed in sub-Saharan Africa, India, and China implemented different modelling methods for CEA but produced similar results. The results of these studies demonstrate that it is more cost-effective than standard care for HIV treatment. The study conducted in sub-Saharan Africa from 2018 to 2020 showed a cost-effective result with disability-adjusted life years averted (DALY averted) by 83%; in India, it resulted in incremental cost-effectiveness ratio (ICER) $130 per year of live-saved (YLS); and a study in China found that dolutegravir plus tenofovir and lamivudine led to 0.006 incremental quality-adjusted life years (QALYs) with cost savings of $64. The DTG regimen is cost-effective and recommended for HIV therapy in all studies that provide results.

A new method of estimating prevalence of childhood cancer survivors (POCCS): example of the 20-year prevalence in The Netherlands

BACKGROUND

Estimating the number of childhood cancer survivors is crucial for cancer control, including clinical guidelines. To compare estimates across countries despite data sharing restrictions, we propose a new method of computing limited-duration prevalence of childhood cancer survivors (POCCS) using aggregated data.

METHODS

We developed a Markov model that simulates, for each calendar year and birth cohort in a population, the proportion of individuals in the following health states: healthy, newly diagnosed with cancer, surviving with cancer, and deceased. Transitions between health states were informed using annual sex- and age-specific incidence rates, conditional 1-year net survival probabilities from the Netherlands Cancer Registry (1989-2011), and annual mortality probability by sex and age group for The Netherlands from the Human Mortality Database. Applying a Markov model, we computed 20-year prevalence of childhood cancer survivors. The resulting POCCS estimates, stratified by sex, were compared with SEER*Stat estimates derived from individual cancer records from the same registry.

RESULTS

In 2011, POCCS predicted 654 males [95% confidence interval (95% CI): 637-672] and 539 females (95% CI: 523-555) per million persons living in The Netherlands after childhood cancer diagnosed within the previous 20 years. Using SEER*Stat, the 20-year prevalence was 665 males (95% CI: 647-683) and 544 females (95% CI: 529-560) per million persons on 1 July 2011.

CONCLUSIONS

Using the POCCS model and aggregated cancer data, our estimates of childhood cancer survivors limited-duration prevalence were consistent with those computed by a standard method requiring individual cancer records. The POCCS method provides relevant information for planning follow-up and care for childhood cancer survivors.

Cost-per-Response Analysis of Pure Hypochlorous Acid Among Patients with Chronic Venous Leg Ulcers: A Health Economic Analysis

OBJECTIVE

To estimate the total cost-per-wound healing response (CPR) and the per-day CPR of patients with chronic leg ulcers treated with pure hypochlorous acid (pHA) as part of their overall would healing regimen.

METHODS

The authors developed a deterministic decision-tree model to estimate the incremental CPR for pHA. The analysis was performed using clinical data from a published single-arm prospective study. The outcome of interest was re-epithelialization at 90 days. Economic data for pHA were based on public prices of pHA per dressing change from the wound care center perspective. The following time points were assessed: 90, 60, and 30 days. Dressing changes occurred every 2.5 days. Sensitivity analysis was performed to gauge the robustness of the results.

RESULTS

A total of 31 patients (68% women) with 31 lesions (average age of wound, 29 months; range, 1-240 months) were included in the clinical study. Re-epithelialization occurred in 23 lesions (74%) at 90 days, 17 (55%) at 60 days, and 3 (10%) at 30 days. The total CPRs were $75.69, $68.27, and $193.44, and the per-day CPRs were $0.84, $1.13, and $6.45 at 90, 60, and 30 days, respectively. The sensitivity analysis revealed that CPRs ranged from $0.63 to $1.12 per day at 90 days.

CONCLUSIONS

Incorporating pHA into standard wound healing protocols is a minimal added expense and may yield a substantial economic savings of $2,695 at 90 days.

Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality

BACKGROUND

The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations.

METHODS

We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively.

RESULTS

In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common.

CONCLUSIONS

While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.

The value of correctly diagnosing axial spondyloarthritis for patients and society

OBJECTIVE

To demonstrate the value of diagnosing axSpA, by comparing health and costs associated with available diagnostic algorithms and perfect diagnosis.

METHODS

Using data from SPACE and other cohorts, a model was developed to estimate health (quality-adjusted life-years, QALYs) and costs (healthcare consumption and work productivity losses) of different diagnostic algorithms for axSpA amongst patients with low back pain referred to a rheumatologist, over a 60-year horizon. The model combined a decision-tree (diagnosis) with a state-transition model (treatment). The three algorithms (Berlin [BER, highest specificity], Modification 1 [M1; less strict inflammatory back pain (IBP) criterion] and Modification 2 [M2; IBP not mandatory as entry criterion, highest sensitivity]) were compared. Changes in sensitivity/specificity were explored and the value of perfect diagnosis was investigated.

RESULTS

For each correctly diagnosed axSpA patient, up to 4.7 QALYs and €60,000 could be gained/saved, considering a societal perspective. Algorithm M2 resulted in more health and lower costs per patient (24.23 QALYs; €157,469), compared to BER (23.96 QALYs; €159,423) and M1 (24.15 QALYs; €158,417). Hypothetical improvements in M2 sensitivity resulted in slightly more value compared to improvements in specificity. Perfect diagnosis can cost €7,500 per patient and still provide enough value.

CONCLUSION

Correct diagnosis of axSpA results in substantial health and cost benefits for patients and society. Not requiring IBP as mandatory for diagnosis of axSpA (algorithm M2) provides more value and would be preferable. A considerably more expensive diagnostic algorithm with better accuracy than M2 would still be considered good value for money.

Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework

BACKGROUND

Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework.

METHODS

We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity.

FINDINGS

We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates.

CONCLUSIONS

While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

Patient and Public Involvement in Health Economics Modelling Raises the Need for Normative Guidance

Patient and public involvement in health economics research and health technology assessment has been increasing for some time; however, patient and public involvement in health economics modelling is a more recent development. One reason to advance this type of involvement is to help appropriately manage the social and ethical value judgements that are required throughout model development and interpretation. At the same time, patient and public involvement in health economics modelling raises numerous practical and philosophical issues that invite discussion and debate. Recently, we attended an engagement event which invited patients, members of the public, researchers and decision-makers to discuss some of these issues. One priority that emerged in the discussion was to develop normative guidance for patient and public involvement in health economics modelling. In this article, we reflect on this goal from our own perspective, focusing on why normative guidance is needed and what questions that guidance should answer.

Cost-effectiveness and budget impact of pembrolizumab+axitinib versus sunitinib in patients with advanced clear-cell renal cell carcinoma in the Netherlands

Background

The phase 3 clinical trial KEYNOTE-426 suggested a higher efficacy regarding overall survival (OS) and progression-free survival (PFS) of pembrolizumab+axitinib compared to sunitinib as a first-line treatment for patients with advanced renal cell carcinoma. In this analysis, the potential cost-effectiveness of this combination treatment versus sunitinib for patients with advanced clear-cell renal cell carcinoma (accRCC) was examined from the societal perspective in the Netherlands.

Methods

For this analysis, a partitioned survival model was constructed. Clinical data were obtained from the published KEYNOTE-426 trial reports; data on costs and (dis-)utilities were derived from published literature. Costs outside of the healthcare sector included treatment-related travel, informal care and productivity loss. Next to a probabilistic scenario analysis, various scenario analyses were performed that aimed at survival extrapolation, different utility values, treatment duration and drug pricing, as well as restricting the cohort to patients with an intermediate or poor prognosis. Further, a budget impact analysis over three years was conducted, in which a sensitivity analysis concerning ranges in costs and the number of patients was applied. Moreover, a scenario concerning increasing market penetration of pembrolizumab+axitinib up to a market share of 80% in the third year was analyzed.

Results

The incremental cost-effectiveness ratio (ICER) of pembrolizumab+axitinib was estimated at €368,396/quality-adjusted life year (QALY) gained, with an incremental QALY gain of 0.55 over sunitinib. The probability of cost-effectiveness at a willingness-to-pay threshold of €80,000/QALY was estimated at 0%, a 50% probability was estimated at €340,000/QALY. Cost-effectiveness was not achieved in any of the applied scenarios. The budget impact over three years amounted to €417.3 million upon instantaneous and full replacement of sunitinib, and to €214.9 million with increasing market penetration.

Conclusion

Pembrolizumab+axitinib was not estimated to be cost-effective compared to sunitinib as a first-line treatment for patients with accRCC in the Netherlands from a societal perspective. In none of the analyzed scenarios, cost-effectiveness was achieved. However, price reductions and shorter treatment durations might lead to a more favorable ICER.

A Systematic Review of the Cost-Effectiveness Analyses of Anaplastic Lymphoma Kinase (ALK) Inhibitors in Patients with Locally Advanced or Metastatic Non-small Cell Lung Cancer (NSCLC)

BACKGROUND

The anaplastic lymphoma kinase (ALK) inhibitor treatment landscape is rapidly evolving, providing patients with ALK-positive (+) non-small cell lung cancer (NSCLC) with multiple therapy options, multiple lines of treatments, and prolonged survival. However, these recent treatment advances have resulted in additional increases in treatment costs. The objective of this article is to review the economic evidence of ALK inhibitors in patients with ALK+ NSCLC.

METHODS

The systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) systematic reviews of economic evaluation. The population included adult patients with locally advanced (stage IIIb/c) or metastatic (stage IV) NSCLC cancer with confirmed ALK fusions. The interventions included the ALK inhibitors alectinib, brigatinib, ceritinib, crizotinib, ensartinib, or lorlatinib. The comparators included the listed ALK inhibitors, chemotherapy, or best supportive care. The review considered cost-effectiveness analysis studies (CEAs) that reported incremental cost-effectiveness ratio in quality-adjusted life years and/or in life years gained. Published literature was searched in Medline (via Ovid) by 4 January 2023, in Embase (via Ovid) by 4 January 2023, in International Pharmaceutical Abstracts (via Ovid) by 4 January 2023, and in Cochrane library (via Wiley) by 11 January 2023. Preliminary screening of titles and abstracts was conducted against the inclusion criteria by two independent researchers followed by a full text of selected citations. Search results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. Critical appraisal was conducted using the validated Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS) tool as well as the Phillips et al. 2004 appraisal tool to assess the reporting and quality of the economic evaluations. Data were extracted from the final set of articles and presented in a table of characteristics of included studies, an overview of study methods of included studies, and a summarization of outcomes of included studies.

RESULTS

A total of 19 studies met all inclusion criteria. The majority of the studies were in the first-line treatment setting (n = 15). Included CEAs varied in the interventions and comparators being evaluated and were conducted from different country perspectives, limiting their comparability. Outcomes from the included CEAs showed that ALK inhibitors may be considered a cost-effective treatment option for patients with ALK+ NSCLC in the first-line and subsequent lines of treatment setting. However, the probability of cost effectiveness of ALK inhibitors ranged from 46 to 100% and were mostly achieved at willingness-to-pay thresholds of $100,000 USD or higher (> $30,000 or higher in China) in the first-line treatment setting and at thresholds of $50,000 USD or higher in subsequent lines of treatment setting. The number of published full-text CEAs is low and the studies represent a handful of country perspectives. The source of survival data was dependent on data from randomized controlled trials (RCTs). Where RCT data were not available, indirect treatment comparisons or matched adjusted indirect comparisons were performed using efficacy data from different clinical studies. Real world evidence was rarely used for efficacy and costing data inputs.

CONCLUSION

The findings summarized available evidence on cost effectiveness of ALK inhibitors for the treatment of patients with locally advanced or metastatic ALK+ NSCLC across lines of treatment settings and generated a valuable overview of analytical approaches utilized to support future economic analyses. To help further inform treatment and policy decisions, this review emphasizes the need for comparative cost effectiveness of multiple ALK inhibitors simultaneously using real-world data sources with broad representation of settings.

A Framework for a Health Economic Evaluation Model for Patients with Sickle Cell Disease to Estimate the Value of New Treatments in the United States of America

BACKGROUND

Sickle cell disease (SCD) is an inherited blood disorder associated with lifelong morbidity and increased risk of mortality that affects approximately 100,000 individuals in the United States (US), primarily of African-American descent. Due to these complications, individuals with SCD typically incur high healthcare costs. With a number of costly but potentially curative SCD therapies on the horizon, understanding the progression of SCD and economic burden to insurers and patients is vital.

OBJECTIVE

The aim is to develop a framework to understand the progression and costs of SCD that could be used to estimate how new treatments can impact the progression and costs of the disease.

METHODS

We detail how we will create a simulation model that represents the natural history of a population and allows for the characterization of the impact of novel therapies on the disease, associated costs, and outcomes in comparison to current management.

CONCLUSION

In this report, we describe a conceptual approach to modeling SCD to determine the relative clinical and economic impact of new gene therapies compared to conventional therapies with a goal of providing a flexible approach that could inform the clinical management of SCD for patients, payers, and policy makers.

Economics and Precision Medicine

Introducing precision medicine strategies into routine practice will require robust economic evidence. Decision-makers need to understand the value of a precision medicine strategy compared with alternative ways to treat patients. This chapter describes health economic analysis techniques that are needed to generate this evidence. The value of any precision medicine strategy can be demonstrated early to inform evidence generation and improve the likelihood of translation into routine practice. Advances in health economic analysis techniques are also explained and their relevance to precision medicine is highlighted. Ensuring that constraints on delivery are resolved to increase uptake and implementation will improve the value of a new precision medicine strategy. Empirical methods to quantify stakeholders' preferences can be effective to inform the design of a precision medicine intervention or service delivery model. A range of techniques to generate relevant economic evidence are now available to support the development and translation of precision medicine into routine practice. This economic evidence is essential to inform resource allocation decisions and will enable patients to benefit from cost-effective precision medicine strategies in the future.

Causal evidence in health decision making: methodological approaches of causal inference and health decision science

Objectives

Public health decision making is a complex process based on thorough and comprehensive health technology assessments involving the comparison of different strategies, values and tradeoffs under uncertainty. This process must be based on best available evidence and plausible assumptions. Causal inference and health decision science are two methodological approaches providing information to help guide decision making in health care. Both approaches are quantitative methods that use statistical and modeling techniques and simplifying assumptions to mimic the complexity of the real world. We intend to review and lay out both disciplines with their aims, strengths and limitations based on a combination of textbook knowledge and expert experience.

Methods

To help understanding and differentiating the methodological approaches of causal inference and health decision science, we reviewed both methods with the focus on aims, research questions, methods, assumptions, limitations and challenges, and software. For each methodological approach, we established a group of four experts from our own working group to carefully review and summarize each method, followed by structured discussion rounds and written reviews, in which the experts from all disciplines including HTA and medicine were involved. The entire expert group discussed objectives, strengths and limitations of both methodological areas, and potential synergies. Finally, we derived recommendations for further research and provide a brief outlook on future trends.

Results

Causal inference methods aim for drawing causal conclusions from empirical data on the relationship of pre-specified interventions on a specific target outcome and apply a counterfactual framework and statistical techniques to derive causal effects of exposures or interventions from these data. Causal inference is based on a causal diagram, more specifically, a directed acyclic graph (DAG), which encodes the assumptions regarding the causal relations between variables. Depending on the type of confounding and selection bias, traditional statistical methods or more complex g-methods are needed to derive valid causal effects. Besides the correct specification of the DAG and the statistical model, assumptions such as consistency, positivity, and exchangeability must be checked when aiming at causal inference. Health decision science aims for guiding policy decision making regarding health interventions considering and balancing multiple competing objectives of a decision based on data from multiple sources and studies, for example prevalence studies, clinical trials and long-term observational routine effectiveness studies, and studies on preferences and costs. It involves decision analysis, a systematic, explicit and quantitative framework to guide decisions under uncertainty. Decision analyses are based on decision-analytic models to mimic the course of disease as well as aspects and consequences of the intervention in order to quantitatively optimize the decision. Depending on the type of decision problem, decision trees, state-transition models, discrete event simulation models, dynamic transmission models, or other model types are applied. Models must be validated against observed data, and comprehensive sensitivity analyses must be performed to assess uncertainty. Besides the appropriate choice of the model type and the valid specification of the model structure, it must be checked if input parameters of effects can be interpreted as causal parameters in the model. Otherwise results will be biased.

Conclusions

Both causal inference and health decision science aim for providing best causal evidence for informed health decision making. The strengths and limitations of both methods differ and a good understanding of both methods is essential for correct application but also for correct interpretation of findings from the described methods. Importantly, decision-analytic modeling should be combined with causal inference when developing guidance and recommendations regarding decisions on health care interventions.

An ex-ante cost-utility analysis of the deemed consent legislation compared to expressed consent for kidney transplantations in Nova Scotia

Background

This study was an ex-ante cost-utility analysis of deemed consent legislation for deceased organ donation in Nova Scotia, a province in Canada. The legislation became effective in January 2021. The study's objective was to assess the conditions necessary for the legislation change’s cost-effectiveness compared to expressed consent, focusing on kidney transplantation (KT).

Method

We performed a cost-utility analysis using a Markov model with a lifetime horizon. The study was from a Canadian payer perspective. The target population was patients with end-stage kidney disease (ESKD) in Atlantic Canada waitlisted for KT. The intervention was the deemed consent and accompanying health system transformations. Expressed consent (before the change) was the comparator. We simulated the minimum required increase in deceased donor KT per year for the cost-effectiveness of the deemed consent. We also evaluated how changes in dialysis and maintenance immunosuppressant drug costs and living donor KT per year impacted cost-effectiveness in sensitivity analyses.

Results

The expected lifetime cost of an ESKD patient ranged from $177,663 to $553,897. In the deemed consent environment, the expected lifetime cost per patient depended on the percentage increases in the proportion of ESKD patients on the waitlist getting a KT in a year. The incremental cost-utility ratio (ICUR) increased with deceased donor KT per year. Cost-effectiveness of deemed consent compared to expressed consent required a minimum of a 1% increase in deceased donor KT per year. A 1% increase was associated with an ICUR of $32,629 per QALY (95% CI: − $64,279, $232,488) with a 81% probability of being cost-effective if the willingness-to-pay (WTP) was $61,466. Increases in dialysis and post-KT maintenance immunosuppressant drug costs above a threshold impacted value for money. The threshold for immunosuppressant drug costs also depended on the percent increases in deceased donor KT probability and the WTP threshold.

Conclusions

The deemed consent legislation in NS for deceased organ donation and the accompanying health system transformations are cost-effective to the extent that they are anticipated to contribute to more deceased donor KTs than before, and even a small increase in the proportion of waitlist patients receiving a deceased donor KT than before the change represents value for money.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00390-z.

Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom

BACKGROUND

Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients.

OBJECTIVE

We assess the relative cost-effectiveness of screening programmes compared with no- screening.

METHODS

A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective.

RESULTS

In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs.

CONCLUSION

The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.

Accounting for Intergenerational Cascade Testing in Economic Evaluations of Clinical Genomics: A Scoping Review

OBJECTIVES

Clinical genomics is emerging as a diagnostic tool in the identification of blood relatives at risk of developing heritable diseases. Our objective was to identify how genetic cascade screening has been incorporated into health economic evaluations.

METHODS

A scoping review was conducted to identify how multiple generations of a family were included in economic evaluations of clinical genomic sequencing, how many and which relatives were included, and uptake rates. Databases were searched for full economic evaluations of genetic interventions that screened multiple generations of families and were in English language, and no restrictions were made for disease or publication type. Data were synthesized using a narrative approach.

RESULTS

Twenty-five studies were included covering a range of diseases in various countries. Markov cohort models were mostly used with hypothetical populations and unsupported by clinical evidence. Cascade testing was either the primary intervention or secondary to the index cases. The number and type of relatives were based on assumptions or identified through population or family records, clinical registry data, or clinical literature. Studies included only immediate family members and the uptake of testing ranged between 20% and 100%. All interventions were reported as cost-effective, and a higher number of relatives was a key driver.

CONCLUSIONS

Several economic evaluations have considered the impacts of cascade testing interventions within clinical genomics. Ideally, models supported with high-quality clinical data are needed and, in their absence, transparent and justifiable assumptions of uptake rates and choices about including relatives. Consideration of more appropriate modeling types is required.

Cost-effectiveness analysis of using oral magnesium supplementation in the treatment of prediabetes

INTRODUCTION

Evidence from clinical trials supports the efficacy of oral magnesium supplementation in the treatment of glucose-related disorders. Thus, we evaluate the cost-effectiveness of using oral magnesium chloride (MgCl₂) in prediabetes treatment.

METHODS

A cost-effectiveness analysis was performed. For such purpose, we used original information from a randomized controlled clinical trial. Analysis was carried out based on a health services provider perspective, a 10-year time horizon, and 3% discount rate for costs and effectiveness. Taking into account risk factor profiles, a Markov micro-simulation model was used, and a probabilistic sensibility analysis was performed.

RESULTS

The oral MgCl₂ was dominant with lower cost and greater effectiveness as compared with placebo. As compared with placebo, 22.3% and 22.0% of men using MgCl₂ did not develop diabetes or cardiovascular disease. The cost per person of using MgCl₂ as compared with placebo, in the individuals without complications, was $2206 versus $4048 USD for men, and $1984 versus $3272 USD for women. The sensitivity analysis confirmed the robustness of the base case.

CONCLUSIONS

Our results suggest that using oral MgCl₂ for at least 4 months, in adults with prediabetes and hypomagnesemia, is a cost-effective option for reducing complications and direct medical costs.

M2HepPrEP: study protocol for a multi-site multi-setting randomized controlled trial of integrated HIV prevention and HCV care for PWID

Background

Opioid use is escalating in North America and comes with a multitude of health consequences, including HIV and hepatitis C virus (HCV) outbreaks among persons who inject drugs (PWID). HIV pre-exposure prophylaxis (PrEP) and HCV treatment regimens have transformative potential to address these co-occurring epidemics. Evaluation of innovative multi-modal approaches, integrating harm reduction, opioid agonist therapy (OAT), PrEP, and HCV treatment is required. The aim of this study is to assess the effectiveness of an on-site integrated care model where delivery of PrEP and HCV treatment for PWID takes places at syringe service programs (SSP) and OAT programs compared with referring PWID to clinical services in the community through a patient navigation model and to examine how structural factors interact with HIV prevention adherence and HCV treatment outcomes.

Methods

The Miami-Montreal Hepatitis C and Pre-Exposure Prophylaxis trial (M²HepPrEP) is an open-label, multi-site, multi-center, randomized, controlled, superiority trial with two parallel treatment arms. A total of 500 persons who injected drugs in the prior 6 months and are eligible for PrEP will be recruited in OAT clinics and SSP in Miami, FL, and Montréal, Québec. Participants will be randomized to either on-site care, with adherence counseling, or referral to off-site clinics assisted by a patient navigator. PrEP will be offered to all participants and HCV treatment to those HCV-infected. Co-primary endpoints will be (1) adherence to pre-exposure prophylaxis medication at 6 months post-randomization and (2) HCV sustained virological response (SVR) 12 weeks post-treatment completion among participants who were randomized within the HCV stratum. Up to 100 participants will be invited to participate in a semi-structured interview regarding perceptions of adherence barriers and facilitators, after their 6-month assessment. A simulation model-based cost-effectiveness analysis will be performed to determine the comparative value of the strategies being evaluated.

Discussion

The results of this study have the potential to demonstrate the effectiveness and cost-effectiveness of offering PrEP and HCV treatment in healthcare venues frequently attended by PWID. Testing the intervention in two urban centers with high disease burden among PWID, but with different healthcare system dynamics, will increase generalizability of findings.

Trial registration

Clinicaltrials.gov NCT03981445. Trial registry name: Integrated HIV Prevention and HCV Care for PWID (M2HepPrEP). Registration date: June 10, 201.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06085-3.

Variation in Model-Based Economic Evaluations of Low-Dose Computed Tomography Screening for Lung Cancer: A Methodological Review

OBJECTIVES

There is significant heterogeneity in the results of published model-based economic evaluations of low-dose computed tomography (LDCT) screening for lung cancer. We sought to understand and demonstrate how these models differ.

METHODS

An expansion and update of a previous systematic review (N = 19). Databases (including MEDLINE and Embase) were searched. Studies were included if strategies involving (single or multiple) LDCT screening were compared with no screening or other imaging modalities, in a population at risk of lung cancer. More detailed data extraction of studies from the previous review was conducted. Studies were critically appraised using the Consensus Health Economic Criteria list.

RESULTS

A total of 16 new studies met the inclusion criteria, giving a total of 35 studies. There are geographic and temporal differences and differences in screening intervals and eligible populations. Studies varied in the types of models used, for example, decision tree, Markov, and microsimulation models. Most conducted a cost-effectiveness analysis (using life-years gained) or cost-utility analysis. The potential for overdiagnosis was considered in many models, unlike with other potential consequences of screening. Some studies report considering lead-time bias, but fewer mention length bias. Generally, the more recent studies, involving more complex modeling, tended to meet more of the critical appraisal criteria, with notable exceptions.

CONCLUSIONS

There are many differences across the economic evaluations contributing to variation in estimates of the cost-effectiveness of LDCT screening for lung cancer. Several methodological factors and evidence needs have been highlighted that will require consideration in future economic evaluations to achieve better agreement.

Early Health Economic Modeling of Novel Therapeutics in Age-Related Hearing Loss

Background

Health systems face challenges to accelerate access to innovations that add value and avoid those unlikely to do so. This is very timely to the field of age-related sensorineural hearing loss (ARHL), where a significant unmet market need has been identified and sizeable investments made to promote the development of novel hearing therapeutics (NT). This study aims to apply health economic modeling to inform the development of cost-effective NT.

Methods

We developed a decision-analytic model to assess the potential costs and effects of using regenerative NT in patients ≥50 with ARHL. This was compared to the current standard of care including hearing aids and cochlear implants. Input data was collected from systematic literature searches and expert opinion. A UK NHS healthcare perspective was adopted. Three different but related analyses were performed using probabilistic modeling: (1) headroom analysis, (2) scenario analyses, and (3) threshold analyses.

Results

The headroom analysis shows an incremental net monetary benefit (iNMB) of £20,017[£11,299–£28,737] compared to the standard of care due to quality-adjusted life-years (QALY) gains and cost savings. Higher therapeutic efficacy and access for patients with all degrees of hearing loss yields higher iNMBs. Threshold analyses shows that the ceiling price of the therapeutic increases with more severe degrees of hearing loss.

Conclusion

NT for ARHL are potentially cost-effective under current willingness-to-pay (WTP) thresholds with considerable room for improvement in the current standard of care pathway. Our model can be used to help decision makers decide which therapeutics represent value for money and are worth commissioning, thereby paving the way for urgently needed NT.

Preventing COVID-19 outbreaks through surveillance testing in healthcare facilities: a modelling study

BACKGROUND

Surveillance testing within healthcare facilities provides an opportunity to prevent severe outbreaks of coronavirus disease 2019 (COVID-19). However, the quantitative impact of different available surveillance strategies and their potential to decrease the frequency of outbreaks are not well-understood.

METHODS

We establish an individual-based model representative of a mental health hospital yielding generalizable results. Attributes and features of this facility were derived from a prototypical hospital, which provides psychiatric, psychosomatic and psychotherapeutic treatment. We estimate the relative reduction of outbreak probability for three test strategies (entry test, once-weekly test and twice-weekly test) relative to a symptom-based baseline strategy. Based on our findings, we propose determinants of successful surveillance measures.

RESULTS

Entry Testing reduced the outbreak probability by 26%, additionally testing once or twice weekly reduced the outbreak probability by 49% or 67% respectively. We found that fast diagnostic test results and adequate compliance of the clinic population are mandatory for conducting effective surveillance. The robustness of these results towards uncertainties is demonstrated via comprehensive sensitivity analyses.

CONCLUSIONS

We conclude that active testing in mental health hospitals and similar facilities considerably reduces the number of COVID-19 outbreaks compared to symptom-based surveillance only.

Cost-effectiveness of vibegron for the treatment of overactive bladder in the United States

AIMS

To evaluate the cost-effectiveness of vibegron compared with other oral pharmacologic therapies as treatment for overactive bladder (OAB).

METHODS

A semi-Markov model with monthly cycles was developed to support a lifetime horizon of vibegron 75 mg from a US commercial payor or Medicare perspective. The model incorporated efficacy (reductions in daily micturitions and urinary incontinence episodes), adverse events, OAB-related comorbidities, drug-drug interactions, anticholinergic burden, and treatment persistence. Direct costs and quality-adjusted life years (QALY) were accumulated over time. The primary outcome was the cost per QALY incremental cost-effectiveness ratio (ICER). One-way (OWSA) and probabilistic sensitivity analyses (PSA) were performed.

RESULTS

For commercial payors, vibegron was cost-effective at a willingness-to-pay (WTP) threshold of $50,000/QALY versus mirabegron 50 mg (ICER, $9,311) and at a WTP threshold of $150,000/QALY versus mirabegron 25 mg (ICER, $141,957) and versus an anticholinergic basket based on market share (ICER, $118,121). For Medicare, vibegron was cost-effective at a WTP threshold of $50,000/QALY versus mirabegron 50 mg (ICER, $12,154) and at a WTP threshold of $100,000/QALY versus mirabegron 25 mg (ICER, $99,150) and versus an anticholinergic market basket (ICER, $60,756). For commercial payors and Medicare, OWSAs for vibegron versus mirabegron indicated cost-effectiveness was most sensitive to vibegron persistence at 1 and 12 months. PSAs indicated that vibegron was cost-effective versus mirabegron 50 mg 98.6% and 100% of the time at $50,000/QALY for commercial payors and Medicare payors, respectively.

LIMITATIONS

Due to lack of real-world data available on persistence, vibegron was assumed to have the same persistence as mirabegron 50 mg. Long-term efficacy was assumed to be sustained beyond 52 weeks in the absence of clinical trials longer than 52 weeks.

CONCLUSIONS

Vibegron is cost-effective from a commercial payor (WTP threshold $150,000/QALY) and Medicare (WTP threshold $100,000/QALY) perspective when compared with other oral pharmacologic treatments for OAB.

Development of a United Kingdom-centric cost-effectiveness model for denture cleaning strategies

STATEMENT OF PROBLEM

Denture stomatitis is a prevalent condition in denture wearers. Economic evaluations of health care can help stakeholders, including patients, make better decisions about treatments for a given condition. Economic models to assess the costs and benefits of different options for managing denture stomatitis are lacking.

PURPOSE

The purpose of this study was to explore the feasibility of developing a cost-effectiveness model to assess denture cleaning strategies aimed at preventing denture stomatitis from a denture-wearer perspective in the United Kingdom.

MATERIAL AND METHODS

A model was developed to identify and estimate the costs and effects associated with 3 denture cleaning strategies. These were low care (LC)-cleaning by brushing and soaking overnight in water; medium care (MC)-brushing with toothpaste and soaking overnight in water; and optimum care (OC)-brushing and soaking overnight in water and antimicrobial denture cleanser. Costs, outcome measures (denture stomatitis-free days), and probabilities (incidence of stomatitis, unscheduled dentist visits, prescription charges, self-medication) associated with each strategy were defined. A sensitivity analysis was used to identify key drivers and test the robustness of the model.

RESULTS

The model showed that the total costs for 2015 ranged from £1.07 (LC) to £18.42 (OC). Costs associated with LC were derived from unscheduled dentist visits and use of medication and/or prescription charges. Incremental costs per denture stomatitis-free day were £0.64 (MC) and £1.81 (OC) compared with LC. A sensitivity analysis showed that varying either or both key parameters (baseline incidence of denture stomatitis and relative effectiveness of MC and OC strategies) had a substantial effect. Incremental cost-effectiveness ratios ranged from £4.11 to £7.39 (worst-case scenario) and from £0.21 to £0.61 (best-case scenario).

CONCLUSIONS

A model was developed to assess the relative cost-effectiveness of different denture cleaning strategies to help improve denture hygiene. An important finding of the study was the lack of evidence on the relative effectiveness of different cleaning strategies, meaning that several assumptions had to be incorporated into the model. The model output would therefore likely be considerably improved and more robust if these evidence gaps were filled.

Cost-Effectiveness of Hypochlorous Acid Preserved Wound Cleanser versus Saline Irrigation in Conjunction with Ultrasonic Debridement for Complex Wounds

Objective: Low-frequency ultrasound debridement with irrigation is an effective method of wound bed preparation. A recent clinical study compared hypochlorous acid preserved wound cleanser (HAPWOC) to saline and found HAPWOC to be a more effective adjunct to low frequency ultrasound debridement. However, HAPWOC has an added cost. The primary objective of this study was to assess the cost-effectiveness of HAPWOC as an irrigation modality with low-frequency ultrasound debridement for the treatment of severely complex wounds that were destined to be closed primarily via a flap. The secondary objective of this study was to estimate the number needed to treat (NNT) to avoid a wound-related complication and its expected cost per NNT. Methods: A patient-level Monte-Carlo simulation model was used to conduct a cost-effectiveness analysis from the US health system perspective. All clinical data were obtained from a prospective clinical trial. Cost data were obtained from the publicly available data sources in 2021 US dollars. The effect measure was the avoidance of wound-related complications at 14-days post-debridement. The primary outcome was the incremental cost-effectiveness ratio (ICER), a measure of the additional cost per benefit. The secondary outcomes were the NNT and expected cost per NNT to avoid one complication (complementary to the ICER in assessing cost-effectiveness). Deterministic and probabilistic sensitivity analyses (PSA) were performed to gauge the robustness and reliability of the results. Results: The ICER for HAPWOC versus saline irrigation was US$90.85 per wound complication avoided. The expected incremental cost per patient in the study and effect was US$49.97 with 55% relative reduction in wound-related complications at day 14 post debridement procedure. The NNT and cost per NNT were 2 and US$99.94, respectively. Sensitivity analyses demonstrated that these results were robust to variation in model parameters. Conclusion: HAPWOC was a cost-effective strategy for the treatment of complex wounds during ultrasonic debridement. For every two patients treated with HAPWOC, one complication was avoided.

Aspects of economic costs and evaluation of health surveillance systems after a radiation accident with a focus on an ultrasound thyroid screening programme for children

Health surveillance initiatives targeted at populations evacuated from, and residing in, areas affected by radiation contamination were implemented by international institutions as well as national and local governments after the nuclear accidents of Chernobyl and Fukushima Dai-ichi nuclear power plants. Most of these initiatives included a component of childhood thyroid cancer monitoring, with the more comprehensive schemes corresponding to national programmes of health monitoring for adults and children around general health and wellbeing. This article provides a short overview of available data on the costs and resources associated with surveillance responses to two recent nuclear accidents: Chernobyl and the Fukushima Dai-Ichi nuclear plant accidents. Moreover, because the balance of costs and benefits of health surveillance after a nuclear accident can influence decisions on implementation, we also present a brief overview of the principles of economic evaluation for collecting and presenting data on costs and outcomes of a surveillance programme after a nuclear accident. We apply these principles in a balance sheet analysis of a post-accident ultrasound thyroid screening programme for children.

A Delphi Consensus Approach for Difficult-to-Treat Patients with Severe Hemophilia A without Inhibitors

Introduction

Over the past decade, there has been an increase in novel therapeutic options to treat hemophilia A. It is still unclear how these novel treatments are used in the management of patients with hemophilia A, particularly those with challenging clinical scenarios who are typically excluded in clinical trials.

Purpose

This study aimed to understand the areas of consensus and disagreement among hematologists regarding the preferences toward therapeutic approaches for difficult-to-treat patients with severe hemophilia A without inhibitors.

Patients and Methods

During February-June 2020, a three-round modified Delphi study was conducted to generate consensus among 13 US experts in the field of hemophilia. Experts were asked about their preferences toward therapeutic options for patients with challenging clinical situations, including age-related morbidities (eg, myocardial infarction, joint arthropathy), increasing demand for high-impact physical activities, early onset osteoporosis, and newborns with hemophilia A. Consensus was defined as ≥75% agreement between the panelists.

Results

Consensus was reached on many, but not all cases, leaving uncertainty about appropriateness of therapeutic approaches for some patients where clinical evidence is not available or driven by physicians' or patients' preferences toward therapeutic options. A majority of panelists preferred FVIII replacement therapy rather than emicizumab prophylaxis for the challenging cases presented due to established evidence on safety, efficacy, and level of bleed protection for FVIII treatment.

Conclusion

Recommendations emerging from this study may help guide practicing hematologists in the management of challenging hemophilia A cases. Future studies are needed to address treatment options in the clinical cases where no consensus was reached.

The Polish Version of the Nursing Delirium Screening Scale (NuDESC PL)-Experience of Using in Nursing Practice in Cardiac Surgery Intensive Care Unit

Introduction: Delirium is a common complication of patients hospitalized in Intensive care units (ICU). The risk of delirium is estimated at approximately 80% in intensive care units. In the case of cardiac surgery ICU, the risk of delirium increases due to the type of procedures performed with the use of extracorporeal circulation. The aim of this study was to provide an official translation and evaluation of Nursing Delirium Screening Scale (NuDESC) into Polish. The NuDESC scale is a scale used by nurses around the world to detect delirium at an early stage in treatment. Methods: The method used in the study was the NuDESC tool, which was translated into Polish. The study was conducted by Cardiac ICU nurses during day shift (at 8 a.m.), night shift (at 8 p.m.) and in other situations where the patients showed delirium-like symptoms. Results: Statistically significant differences were observed between the first and second day in the studied group of patients in the case of illusions/hallucinations. Delirium occurred more frequently during the night, but statistical significance was demonstrated for both daytime and nighttime shifts. It was not demonstrated in relation to the NuDESC scale in the case of insomnia disorders. The diagnosis of delirium and disorientation was the most common diagnosis observed in patients on the first day of their stay in the ICU, followed by problems with communication. Delirium occurred on the first day, mainly at night. On the second day, delirium was much less frequent during the night; the biggest problem was disorientation and problems with communication. Conclusion: This study contributed to the development of the Polish version of the scale (NuDESC PL) which is now used as the Polish screening tool for delirium detection. The availability of an easy-to-use nurse-based delirium instrument is a prerequisite for widespread implementation.

StrokeCog Markov Model: Projected Prevalent and Incident Cases of Stroke and Poststroke Cognitive Impairment to 2035 in Ireland

BACKGROUND AND PURPOSE

Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning.

METHODS

We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death.

RESULTS

We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8-23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1-9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2-4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7-2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1-1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5-0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3-24.5) for women and 20.7 (95% CI, 19.5-21.9) for men.

CONCLUSIONS

This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.

Value judgments in a COVID-19 vaccination model: A case study in the need for public involvement in health-oriented modelling

Scientific modelling is a value-laden process: the decisions involved can seldom be made using ‘scientific’ criteria alone, but rather draw on social and ethical values. In this paper, we draw on a body of philosophical literature to analyze a COVID-19 vaccination model, presenting a case study of social and ethical value judgments in health-oriented modelling. This case study urges us to make value judgments in health-oriented models explicit and interpretable by non-experts and to invite public involvement in making them.

Users' Guide to Medical Decision Analysis

Clinicians regularly have to trade benefits and harms to choose between testing and treatment strategies. This process is often done by making global and implicit judgments. A decision analysis is an analytic method that makes this process more explicit, reproducible, and evidence-based. While clinicians are unlikely to conduct their own decision analysis, they will read publications of such analyses or use guidelines based on them. This review outlines the anatomy of a decision tree and provides clinicians with the tools to critically appraise a decision analysis and apply its results to medical decision making. Clinicians reading about a decision analysis can make two judgments. The first judgment is about the credibility of the methods, such as whether the decision analysis addressed a relevant clinical question, included all important outcomes, used the current best evidence to derive variables in the model, and adopted the appropriate time horizon. The second judgment is about rating confidence in the preferred course of action by determining the certainty in the model variables, whether the results are robust in sensitivity analyses and if the results are applicable to a specific patient. Results from a valid and robust decision analysis can inform both guideline panels and the patient-clinician dyad engaged in shared decision-making.

Tobacco Control Policy Simulation Models: Protocol for a Systematic Methodological Review

Background

Tobacco control models are mathematical models predicting tobacco-related outcomes in defined populations. The policy simulation model is considered as a subcategory of tobacco control models simulating the potential outcomes of tobacco control policy options. However, we could not identify any existing tool specifically designed to assess the quality of tobacco control models.

Objective

The aims of this systematic methodology review are to: (1) identify best modeling practices, (2) highlight common pitfalls, and (3) develop recommendations to assess the quality of tobacco control policy simulation models. Crucially, these recommendations can empower model users to assess the quality of current and future modeling studies, potentially leading to better tobacco policy decision-making for the public. This protocol describes the planned systematic review stages, paper inclusion and exclusion criteria, data extraction, and analysis.

Methods

Two reviewers searched five databases (Embase, EconLit, PsycINFO, PubMed, and CINAHL Plus) to identify eligible studies published between July 2013 and August 2019. We included papers projecting tobacco-related outcomes with a focus on tobacco control policies in any population and setting. Eligible papers were independently screened by two reviewers. The data extraction form was designed and piloted to extract model structure, data sources, transparency, validation, and other qualities. We will use a narrative synthesis to present the results by summarizing model trends, analyzing model approaches, and reporting data input and result quality. We will propose recommendations to assess the quality of tobacco control policy simulation models using the findings from this review and related literature.

Results

Data collection is in progress. Results are expected to be completed and submitted for publication by April 2021.

Conclusions

This systematic methodological review will summarize the best practices and pitfalls existing among tobacco control policy simulation models and present a recommendation list of a high-quality tobacco control simulation model. A more standardized and quality-assured tobacco control policy simulation model will benefit modelers, policymakers, and the public on both model building and decision making.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020178146; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178146

International Registered Report Identifier (IRRID)

DERR1-10.2196/26854

Patient Flows, Patient Distribution Computations and Medicines Accounting in the Pharmacoeconomic Models Through Procurement Perspective

Purpose

Stimulating cost reduction of pharmaceutical companies to optimize the structure of distribution of patients by the level of treatment costs in various programs.

Patients and Methods

In this article, we rise up the issues of pharmacoeconomic modeling related to the description of the patient flows in the pharmacoeconomic model and methods to determining the course dose of drugs under the restriction of integer computations. We established two possible ways of distributing patients through treatment regimens in pharmacoeconomic models, also analyzed the effects of simultaneous and uniform entry of patients into the model. Also, we considered the limitations and possibilities of calculations based on the active substance and packaging, as well as the transition factor of the remainder of the drug in the next time period.

Results

A mathematical model of the analysis of the system assessment of patients by the level of risk of abandoning a healthy lifestyle in connection with the growing problems of the difficult-to-control process is developed. The use of a rational data convolution mode allowed us to obtain a criterion for the optimality of the process and a logical point of stability of the pharmaceutical company by rationally applying treatment methods according to established standards (percentage base). This approach makes it possible to influence the management of private clinics through clear ideas on the algorithms for prescribing drugs in each group of patients and their zoning in the vector recovery mode.

Conclusion

Initial data and sample size: 552 measurements of the intervals of changes in the subject's indicators in seconds (smoothing and scaling the data to the level of the base (analytical) period or the final (barrier) period). Regular use of this approach makes it possible to reserve the resources of the body of a healthy and physically active person in a timely manner for a very reliable functioning of all body systems, taking into account the dosed intake of prescribed drugs and the conditions of comfortable (decent) maintenance of patients during the course of treatment according to the method chosen by the doctor.

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions

BACKGROUND

As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders.

OBJECTIVE

To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice.

METHODS

The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders.

CONCLUSIONS

Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.

Estimating the epidemic consequences of HIV prevention gaps among key populations

INTRODUCTION

HIV epidemic appraisals are used to characterize heterogeneity and inequities in the context of the HIV pandemic and the response. However, classic measures used in appraisals have been shown to underestimate disproportionate risks of onward transmission, particularly among key populations. In response, a growing number of modelling studies have quantified the consequences of unmet prevention and treatment needs (prevention gaps) among key populations as a transmission population attributable fraction over time (tPAFt ). To aid its interpretation and use by programme implementers and policy makers, we outline and discuss a conceptual framework for understanding and estimating the tPAFt via transmission modelling as a measure of onward transmission risk from HIV prevention gaps; and discuss properties of the tPAFt .

DISCUSSION

The distribution of onward transmission risks may be defined by who is at disproportionate risk of onward transmission, and under which conditions. The latter reflects prevention gaps, including secondary prevention via treatment: the epidemic consequences of which may be quantified by the tPAFt . Steps to estimating the tPAFt include parameterizing the acquisition and onward transmission risks experienced by the subgroup of interest, defining the most relevant counterfactual scenario, and articulating the time-horizon of analyses and population among whom to estimate the relative difference in cumulative transmissions; such steps could reflect programme-relevant questions about onward transmission risks. Key properties of the tPAFt include larger onward transmission risks over longer time-horizons; seemingly mutually exclusive tPAFt measures summing to greater than 100%; an opportunity to quantify the magnitude of disproportionate onward transmission risks with a per-capita tPAFt ; and that estimates are conditional on what has been achieved so far in reducing prevention gaps and maintaining those conditions moving forward as the status quo.

CONCLUSIONS

The next generation of HIV epidemic appraisals has the potential to support a more specific HIV response by characterizing heterogeneity in disproportionate risks of onward transmission which are defined and conditioned on the past, current and future prevention gaps across subsets of the population.

Impact of reducing alcohol consumption through price-based policies on cancer incidence in Germany 2020-50-a simulation study

BACKGROUND AND AIMS

Alcohol is a major cancer risk factor and contributes considerably to the cancer burden in Germany. We aimed to provide projections of preventable cancer cases under different price-based alcohol policy scenarios.

DESIGN

A macro-simulation approach was used to estimate numbers and proportions of cancer cases prevented under different price-based alcohol policy scenarios.

SETTING AND PARTICIPANTS

Published price elasticities for main alcoholic beverages were applied to the mean daily intake of pure alcohol in the German population calculated from the German Health Interview and Examination Survey for Adults 2008-11 (DEGS1) to obtain hypothetical exposure distributions of alcohol consumption under different scenarios of changing price for alcoholic beverages.

MEASUREMENTS

Age, sex and cancer site-specific potential impact fractions were calculated for different scenarios of changing the price of alcohol (single price increases, repeated price increases, volumetric price increase) for each year of a 30-year study period (2020-50).

FINDINGS

Over a 30-year horizon, an estimated 4.7% (men = 10.1%, women = 1.4%) of alcohol-related cancer cases could be prevented in Germany, if alcohol intake above risk thresholds were reduced to levels below risk thresholds. Accordingly, the burden of new cancers would be reduced by approximately 244 000 cases (men = 200 000, women = 44 000). Of all price-based alcohol policy scenarios, a 100% price increase on alcoholic beverages was estimated to be most effective with approximately 213 000 (4.1%; men = 167 000; women = 47 000) preventable alcohol-related cancer cases, followed by 5-yearly 25% price increases (2.8%; men = 115 000, women = 29 000) and a volumetric price increase according to the beverage-specific alcohol content (1.9%; men = 72 000, women = 24 000).

CONCLUSIONS

Simulations suggest that a substantial number of alcohol-related cancer cases could be avoided in Germany by applying price-based policies to reduce consumption of alcoholic beverages.

A systematic review of the quality and scope of decision modelling studies in child oral health research

Background

Decision analytic models are often used in economic evaluations to estimate long-term costs and effects of treatment which span beyond the time-frame of a clinical trial, therefore providing a better understanding of the long-term implications of decisions that conventional trial-based economic evaluations fail to provide. This is particularly relevant for considering oral health interventions in children as treatments may affect adult oral health. However, in the field of child oral health there has not been an evaluation of the quality and scope of decision analytical models which extend into adulthood. The aim of this review is to examine the scope and quality of decision modelling studies, with horizons extending into adulthood, within the field of child oral health.

Methods

The following databases were searched: NHS Economic Evaluation Database (CRD York), MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, the Cochrane Library and Econlit. Full economic evaluations, in the field of child oral health, published after 1997 which included a decision model with a horizon that extended beyond the age of 18 years old were included. Included studies were appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by calibrated reviewers.

Results

Four hundred studies were identified, of which nine met the inclusion criteria. Of the nine, eight were cost-effectiveness models. The majority focussed on the prevention or management of dental caries. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 82% (median = 85%, range = 54–100%). Discounting of costs and performing an incremental analysis were noted as key methodological weaknesses. The mean percentage of applicable CHEERS criteria met by each study was 82% (median = 87%, range = 32–96%). Justifying the type of model, analytical methods used, and sources of funding were most commonly unreported.

Conclusions

There is a paucity of decision analytical models in the field of child oral health. Most of those that are available are of high methodological and reporting quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01680-3.

Cost-effectiveness analysis of the SAPIEN 3 transcatheter aortic valve implant in patients with symptomatic severe aortic stenosis

INTRODUCTION AND OBJECTIVES

Transcatheter aortic valve implant has become a widely accepted treatment for inoperable patients with aortic stenosis and patients at high surgical risk. Its indications have recently been expanded to include patients at intermediate and low surgical risk. Our aim was to evaluate the efficiency of SAPIEN 3 vs conservative medical treatment (CMT) or surgical aortic valve replacement (SAVR) in symptomatic inoperable patients at high or intermediate risk.

METHODS

We conducted a cost-effectiveness analysis of SAPIEN 3 vs SAVR/CMT, using a Markov model (monthly cycles) with 8 states defined by the New York Heart Association and a time horizon of 15 years, including major complications and management after hospital discharge, from the perspective of the National Health System. Effectiveness parameters were based on the PARTNER trials. Costs related to the procedure, hospitalization, complications, and follow-up were included (euros in 2019). An annual discount rate of 3% was applied to both costs and benefits. Deterministic and probabilistic sensitivity analyses (Monte Carlo) were performed.

RESULTS

Compared with SAVR (high and intermediate risk) and CMT (inoperable), SAPIEN 3 showed better clinical results in the 3 populations and lower hospital stay. Incremental cost-utility ratios (€/quality-adjusted life years gained) were 5471 (high risk), 8119 (intermediate risk) and 9948 (inoperable), respectively. In the probabilistic analysis, SAPIEN 3 was cost-effective in more than 75% of the simulations in the 3 profiles.

CONCLUSIONS

In our health system, SAPIEN 3 facilitates efficient management of severe aortic stenosis in inoperable and high- and intermediate-risk patients.

Health economic evaluations of medical tests: Translating laboratory information into value - A case study example

Health-care providers and funders are focused on identifying value in all their services and that includes laboratories. This means that in order to gain a share of scarce resources, laboratory professionals must also understand and assess the value of tests and that includes their economic impact. This can be assessed using health economic modelling tools which, when used in conjunction with a detailed value proposition for the test, can translate laboratory information into value. While a variety of health economic assessment tools are available, this review will focus on the use of decision analytic models which essentially compare the outcomes from pathways with and without the new test, the value of which is being assessed. A step-by-step framework is provided to guide laboratory professionals through the essential steps of conducting the evaluation. Initial steps include mapping the clinical pathway, understanding the goal of the evaluation, identifying the key stakeholders and their needs and determining a suitable analytical model. Following collection of the actual data, the validity of the model must be checked, and the robustness of the outcomes tested through sensitivity analysis. The last step is to translate the findings into measures of value which can then inform appropriate decisions by the stakeholders. This review of basic health economic modelling should enable laboratory professionals to have an understanding of how modelling can be applied to tests in their own environment and help deliver their potential value.

The real-world cost-effectiveness of bariatric surgery for the treatment of severe obesity: a cost-utility analysis

BACKGROUND

Severe obesity is associated with adverse health outcomes and increased risk of death. This study evaluates the real-world cost-utility of therapy for severe obesity, from the publicly funded health care system and societal perspectives.

METHODS

We conducted a cost-utility analysis using primary data from a prospective observational cohort of adults living with severe obesity (BMI ≥ 35 kg/m² and a major medical comorbidity or BMI ≥ 40 kg/m²) who were enrolled in a regional obesity program over 2 years. We extrapolated 10-year and lifetime Markov models, validated and supplemented with literature sources, to compare medical, surgical and standard care therapies. We performed deterministic and probabilistic sensitivity analyses.

RESULTS

The cohort included 500 adults living with severe obesity, 150 of whom received laparoscopic surgical therapy. From a publicly funded health system perspective, at 2 years, surgical therapy had an incremental cost-effectiveness ratio (ICER) of $54 456 per quality-adjusted life-year (QALY) compared with standard care therapy. Over a lifetime, it had an ICER of $14 056 per QALY. From the societal perspective, at 2 years, surgical therapy had an ICER of $340 per QALY; over a lifetime, it was the dominant option. The results were robust to sensitivity analysis.

INTERPRETATION

From a public health care perspective, surgery for severe obesity is cost effective, and when approached from a societal perspective, it becomes cost saving. Real-world data support using surgical therapy for severe obesity, and our results contribute to the health economic and clinical literature with regard to a robust analysis from a societal perspective.

Benefits and Harms of a Prevention Program for Iodine Deficiency Disorders: Predictions of the Decision-Analytic EUthyroid Model

Background: Iodine deficiency is one of the most prevalent causes of intellectual disability and can lead to impaired thyroid function and other iodine deficiency disorders (IDDs). Despite progress made on eradicating iodine deficiency in the last decades in Europe, IDDs are still prevalent. Currently, evidence-based information on the benefit/harm balance of IDD prevention in Europe is lacking. We developed a decision-analytic model and conducted a public health decision analysis for the long-term net benefit of a mandatory IDD prevention program for the German population with moderate iodine deficiency, as a case example for a European country. Methods: We developed a decision-analytic Markov model simulating the incidence and consequences of IDDs in the absence or presence of a mandatory IDD prevention program (iodine fortification of salt) in an open population with current demographic characteristics in Germany and with moderate ID. We collected data on the prevalence, incidence, mortality, and quality of life from European studies for all health states of the model. Our primary net-benefit outcome was quality-adjusted life years (QALYs) predicted over a period of 120 years. In addition, we calculated incremental life years and disease events over time. We performed a systematic and comprehensive uncertainty assessment using multiple deterministic one-way sensitivity analyses. Results: In the base-case analysis, the IDD prevention program is more beneficial than no prevention, both in terms of QALYs and life years. Health gains predicted for the open cohort over a time horizon of 120 years for the German population (82.2 million inhabitants) were 33 million QALYs and 5 million life years. Nevertheless, prevention is not beneficial for all individuals since it causes additional hyperthyroidism (2.7 million additional cases). Results for QALY gains were stable in sensitivity analyses. Conclusions: IDD prevention via mandatory iodine fortification of salt increases quality-adjusted life expectancy in a European population with moderate ID, and is therefore beneficial on a population level. However, further ethical aspects should be considered before implementing a mandatory IDD prevention program. Costs for IDD prevention and treatment should be determined to evaluate the cost effectiveness of IDD prevention.

Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis

BACKGROUND

Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only.

OBJECTIVES

We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area.

DESIGN

We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial.

DATA SOURCES

We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019.

REVIEW METHODS

The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years.

RESULTS

Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management.

LIMITATIONS

The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified.

CONCLUSIONS

Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders.

FUTURE WORK

We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017064093.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.

A Systematic Review on Cost-effectiveness Analyses of Therapeutic Drug Monitoring for Patients with Inflammatory Bowel Disease: From Immunosuppressive to Anti-TNF Therapy

BACKGROUND

There is a growing body of primary evidence on the cost-effectiveness of applying therapeutic drug monitoring (TDM) for inflammatory bowel disease (IBD) management with various drug therapies and strategies.

OBJECTIVES

The aim of this study was to conduct a systematic review on model-based cost-effectiveness analyses of applying TDM for IBD management.

METHODS

Literature search was conducted (up to October 2019) in Medline (Ovid), Embase (Ovid), Web of Science, Scopus, CINAHL Complete, and the Centre for Reviews and Dissemination. Studies published in the English language that met inclusion criteria were included: (1) patients with IBD, (2) TDM-based treatment was compared with a comparator, (3) types of analysis were cost-benefit, cost-consequence, cost-effectiveness, cost-utility, or cost analysis, and (4) analyses conducted by model-based evaluation. The study quality was assessed using Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

Six studies on drug monitoring for IBD patients (1 azathioprine and 5 infliximab) published in 2005 to 2019 were included. All studies targeted on patients with Crohn's disease and reported TDM strategies to save cost when comparing with standard care. Four analyses evaluated both economic and clinical outcomes. Three analyses found the TDM strategies (for treatment initiation, advancement of therapy, or proactive monitoring) to improve clinical outcomes. One study found TDM strategies (reflex testing and concurrent testing) to gain lower quality-adjusted life years than standard care. Four of six (66.7%) studies achieved good to excellent rankings in quality assessment.

CONCLUSIONS

Compared with standard treatment without TDM, the TDM-guided strategies were consistently found to be cost-saving or cost-effective.

Health care costs associated with chronic hepatitis C virus infection in Ontario, Canada: a retrospective cohort study

BACKGROUND

High-quality estimates of health care costs are required to understand the burden of illness and to inform economic models. We estimated the costs associated with hepatitis C virus (HCV) infection from the public payer perspective in Ontario, Canada.

METHODS

In this population-based retrospective cohort study, we identified patients aged 18-105 years diagnosed with chronic HCV infection in Ontario from 2003 to 2014 using linked administrative data. We allocated the time from diagnosis until death or the end of follow-up (Dec. 31, 2016) to 9 mutually exclusive health states using validated algorithms: no cirrhosis, no cirrhosis (RNA negative) (i.e., cured HCV infection), compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, both decompensated cirrhosis and hepatocellular carcinoma, liver transplantation, terminal (liver-related) and terminal (non-liver-related). We estimated direct medical costs (in 2018 Canadian dollars) per 30 days per health state and used regression models to identify predictors of the costs.

RESULTS

We identified 48 239 patients with chronic hepatitis C, of whom 30 763 (63.8%) were men and 35 891 (74.4%) were aged 30-59 years at diagnosis. The mean 30-day costs were $798 (95% confidence interval [CI] $780-$816) (n = 43 568) for no cirrhosis, $661 (95% CI $630-$692) (n = 6422) for no cirrhosis (RNA negative), $1487 (95% CI $1375-$1599) (n = 4970) for compensated cirrhosis, $3659 (95% CI $3279-$4039) (n = 3151) for decompensated cirrhosis, $4238 (95% CI $3480-$4996) (n = 550) for hepatocellular carcinoma, $8753 (95% CI $7130-$10 377) (n = 485) for both decompensated cirrhosis and hepatocellular carcinoma, $4539 (95% CI $3746-$5333) (n = 372) for liver transplantation, $11 202 (95% CI $10 645-$11 760) (n = 3201) for terminal (liver-related) and $8801 (95% CI $8331-$9271) (n = 5278) for terminal (non-liver-related) health states. Comorbidity was the most significant predictor of total costs for all health states.

INTERPRETATION

Our findings suggest that the financial burden of HCV infection is substantially higher than previously estimated in Canada. Our comprehensive, up-to-date cost estimates for clinically defined health states of HCV infection should be useful for future economic evaluations related to this disorder.