Análisis de costes y resultados en la evaluación económica de las intervenciones sanitarias

National expert consensus on home-administered oncologic therapies in Spain

The diagnosis and treatment of cancer impose a significant emotional and psychological burden on patients, families, and caregivers. Patients undergo several interventions in a hospital setting, and the increasing number of patients requiring extended care and follow-up is driving the demand for additional clinical resources to address their needs. Hospital at Home (HaH) teams have introduced home-administered oncologic therapies that represent a new model of patient-centered cancer care. This approach can be integrated with traditional models and offers benefits to both patients and healthcare professionals (HCPs). Home-administered treatment programs have been successfully piloted globally, demonstrated as a preferred option for most patients and a safe alternative that could reduce costs and hospital burden. The document aims to establish the minimum recommendations for the home administration of oncologic therapies (ODAH) based on a national expert agreement. The expert panel comprised seven leading members from diverse Spanish societies and three working areas: clinical and healthcare issues, logistical and administrative issues, and economic, social, and legal issues. The recommendations outlined in this article were obtained after a comprehensive literature review and thorough discussions. This document may serve as a basis for the future development of home-administered oncologic therapy programs in Spain. .

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BACKGROUND

Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.

METHODS

Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.

RESULTS

DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.

CONCLUSIONS

When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.

TRIAL REGISTRATION

This trial has been registered at www.

CLINICALTRIALS

gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Economic evaluation of complete revascularization versus stress echocardiography-guided revascularization in the STEACS with multivessel disease

INTRODUCTION AND OBJECTIVES

Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial.

METHODS

We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography-guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N=306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system.

RESULTS

The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9±6236.8 € vs 14 038.7±4958.5 €; P <.001). There were no differences in the costs of the first year of follow-up rehospitalizations between both groups for (ComR 2423.5±4568.0 vs SelR 2653.9±5709.1; P=.697). Total cost was 22 081.3±7505.6 for the ComR arm and 16 692.6±7669.9 for the SelR group (P <.001).

CONCLUSIONS

In the CROSS-AMI trial, the initial extra economic costs of the ComR versus SelR were not offset by significant savings during follow-up. SelR seems to be more efficient than ComR in patients with ST-segment elevation acute coronary syndrome and multivessel disease treated by emergent angioplasty. Study registred at ClinicalTrial.gov (Identifier: NCT01179126).

Lumbar disc herniation surgery: Is it worth adding interspinous spacer or instrumented fusion with regard to disc excision alone?

BACKGROUND

Discectomy is sometimes associated with recurrence of disc herniation and pain after surgery. The evidence to use an interspinous dynamic stabilization system or instrumented fusion in association with disc excision to prevent pain and re-operation remains controversial. In this study, we analyzed if adding interspinous spacer or fusion, offers advantages in relation to microdiscetomy alone.

METHODS

Patients with lumbar disc herniation were divided in 3 groups; microdiscectomy alone (MD), microdiscectomy plus interspinous spacer (IS) and open discectomy plus posterior lumbar interbody fusion (PLIF). The clinical efficacy was measured using the Owestry Disability Index (ODI). Other outcome parameters including visual analogue scale for pain (VAS) back and legs, length of stay, direct in-hospital cost, 90-day complication rate, and 1-year re-operation rate were also evaluated.

RESULTS

A total of 103 patients whose mean age was 39.1 (±8.5) years were included. A significant improvement of the ODI and VAS back and legs pain baseline score was detected in the 3 groups. After 1 year, no significant differences in ODI, VAS back and legs pain were found between the 3 groups. There was an increase of 169% of the total direct in- hospital cost in IS group and 287% in PLIF group, in relation to MD (p < 0.001). Length of stay was 86% higher in the IS group and 384% longer in the PLIF group compared to MD (p < 0.001). The 1 year re-operation rates were 5.6%, 10% and 16.2% (p = 0.33). Discectomy seems to be the main responsible for the clinical improvement, without the interspinous spacer or fusion adding any benefit. The addition of interspinous spacer or fusion increased direct in-hospital cost, length of stay, and did not protect against re-operation.

Economic impact of health resource optimisation in the approach to patients with hepatitis C

TThe incorporation of direct-acting antiviral agents to the treatment of chronic hepatitis C infection has simplified diagnosis and follow-up, allowing optimisation of health resources (consultations and tests) dedicated to the management of the disease. The aim of this study was to estimate the economic impact of this simplification. Health resource optimisation was estimated through the Delphi method, based on a panel of 36 experts, consisting of Spanish clinicians, and on clinical practice guidelines. The unit costs (€ in 2017) of the health resources included were obtained from Spanish sources. Simplification of the process, as well as liaison between the medical specialist, nurses and the pharmacy service, would generate savings of €591.17 per patient. Likewise, the mean length of consultations would be shorter with regimens of only 1 tablet daily compared with regimens of more than 1 tablet daily. Supplement information: This article is part of a supplement entitled "The value of simplicity in hepatitis C treatment", which is sponsored by Gilead. © 2019 Elsevier España, S.L.U. All rights reserved.

Clinical trials: their contribution to the efficiency of the clinical management of rheumatoid arthritis

Background

This article presents a descriptive analysis of our Clinical Research Unit (CRU) at the Rheumatology Department in the University and Polytechnic Hospital La Fe (RD-UPH La Fe), Valencia (Spain), as well as an estimation of the economic impact of conducting clinical trials for the Spanish Health System in terms of avoided costs.

Methods

During the period 2011–2015, a retrospective observational study was conducted based on the trials performed in our CRU, along with a cost analysis from the health authority perspective.

Results

Most of the trials conducted during this period were phase III studies in patients with rheumatic disorders, particularly rheumatoid arthritis. An economic evaluation study showed that the implementation of these studies in our CRU resulted in an annual saving of €13,935.30 per patient.

Conclusion

Our CRU is an efficacy and efficiency tool for cost saving in the healthcare system.

[Economic evaluation of pneumococcal vaccination in adults aged over 65 years in Castilla y León (SPAIN)]

INTRODUCTION

The burden of disease due to pneumonia in older adults has a major impact on health systems. The aim of this study is to carry out an economic evaluation of the vaccination strategy against Streptococcus pneumoniae using the 13-valent pneumococcal conjugate vaccine.

MATERIAL AND METHODS

A simulated economic model has been developed in the form of a decision tree to evaluate the cost of the vaccination strategy in the population over 65 years of the Valladolid-East Health Area, versus non-vaccination, using a Monte Carlo probabilistic analysis.

RESULTS

Streptococcus pneumoniae annually generates 557.24 cases of pneumococcal disease in the Valladolid-East Health Area, and 506.60 episodes have pneumonia symptoms. Vaccination of the cohort over 65 years of age is an efficient measure from the third year, with a cost per quality-adjusted life years (QALY) of 20,496.20 €. The number of QALYs gained in a decade is 86.07 and an amount of 216.252.89 € with this vaccination strategy would be saved.

CONCLUSIONS

The evaluation of the different incremental costs (QALY,euros) in the years of follow-up, the pneumococcus vaccination program in people over 65 in Castilla y León is cost-effective.

Cost analysis of telerehabilitation after arthroscopic subacromial decompression

Background Subacromial impingement syndrome poses a substantial socioeconomic burden, leading to significant consumption of healthcare. Health systems are calling for greater evidence of economic impacts of particular healthcare services. Telerehabilitation programmes have the potential to reduce costs and improve patient access as an alternative to traditional care. Cost analysis has been traditionally included in study protocols and results, although the reliability and research methodology have frequently been under debate. The aim of this study was to compare costs related to a telerehabilitation programme versus conventional physiotherapy following subacromial decompression surgery (ASD). Methods The study was embedded in a randomised controlled trial. The economic analysis was based on the perspective of the health sector and the human capital method. Only the costs associated with the provision of physiotherapy services were taken into account. Costs were measured during the intervention period between baseline and 12 weeks for both groups. Student's t-test was used to compare independent variables between the two groups, with a 95% confidence interval for the estimates and real costs. Results The estimated total cost analysis shows a preliminary cost differential in favour of the telerehabilitation group, meaning that for each participant's total intervention, telerehabilitation saves 29.8% of the costs. Real cost analysis, only for received treatments, shows a cost differential in favour of telerehabilitation, meaning that for each participant's total intervention, telerehabilitation saves 22.15% of the costs incurred for conventional rehabilitation. Conclusions Our study provides direct and meaningful information about telerehabilitation opportunities and can be an essential component in further cost evaluations for different strategies after surgical procedures. This study demonstrates that there was a trend towards lower healthcare costs after ASD. Managers now have the responsibility to decide whether to implement telerehabilitation based on clinical and economic data.

Cost-effectiveness of Continuous Positive Airway Pressure Treatment in Moderate-Severe Obstructive Sleep Apnea Syndrome

INTRODUCTION

The socioeconomic impact of obstructive sleep apnea-hypopnea syndrome (OSAHS) is considerable. The aim of this study was to evaluate the cost-effectiveness of treating OSAHS with continuous positive airway pressure (CPAP) and the impact of CPAP compliance.

METHODS

This was a retrospective, case-crossover study of 373 patients with OSAHS receiving CPAP. We compared changes in costs, Epworth score and health-related quality of life (EQ-5D questionnaires) between the year before treatment and the year after treatment. The incremental cost-effectiveness ratio (ICER) for the first year of treatment was estimated, and projections were made for the second year, using different effectiveness and cost scenarios.

RESULTS

The visual analog scale score for the EQ-5D questionnaire increased by 5 points and the Epworth score fell by 10 points during the year of CPAP treatment. Mean gain in quality-adjusted life years (QALY) was 0.05 per patient per year (P<.001): 0.07 among compliers and -0.04 among non-compliers. ICER was €51,147/QALY during the first year of CPAP treatment and €1,544/QALY during the second year.

CONCLUSION

CPAP treatment in patients with moderate-severe OSAHS improves the quality of life of compliant patients, and is cost-effective as of the second year.

Assessment of pharmacological strategies for management of major depressive disorder and their costs after an inadequate response to first-line antidepressant treatment in primary care

BACKGROUND

The aim of the study was to determine the most common treatment strategies and their costs for patients with an inadequate response to first-line antidepressant treatment (AD) in primary care.

METHOD

A retrospective cohort study of medical records from six primary care centers was conducted. Adults with a major depressive disorder diagnosis, at least 8 weeks of AD treatment after the first prescription, and patient monitoring for 12 months were analyzed. Healthcare (direct cost) and non-healthcare costs (indirect costs; work productivity losses) were described.

RESULTS

A total of 2,260 patients were studied. Forty-three percent of patients (N = 965) presented an inadequate response to treatment. Summarizing the different treatment approaches: 43.2% were switched to another AD, 15.5% were given an additional AD, AD dose was increased in 14.6%, and 26.7% remained with the same antidepressant agent. Healthcare/annual costs were 451.2 Euros for patients in remission vs. 826.1 Euros in those with inadequate response, and productivity losses were 991.4 versus 1,842.0 Euros, respectively (p < 0.001).

CONCLUSION

Antidepressant switch was the most common therapeutic approach performed by general practitioners in naturalistic practice. A delay in treatment change when no remission occurs and a significant heterogeneity in management of these patients were also found.

[Costs and associated factors with optimal and suboptimal responses to the treatment of major depressive disorder]

OBJECTIVE

To evaluate the compliance, persistence and costs of the treatment of major depressive disorder (MDD) in the setting of Primary Care, placing emphasis on the different aspects of those patients with an initial suboptimal response to antidepressant treatment.

DESIGN

A retrospective observational study using the population registers of Badalona Healthcare Services. The inclusion criteria consisted of; age ≥18 years, initial episode during 2008-2009, and to be on antidepressant treatment for at least 8 weeks after the first prescription. The follow-up was 12 months. Two study groups were formed, patients with suboptimal response, and remission.

MAIN MEASUREMENTS

Sociodemographic data, compliance and adherence to treatment, health costs (direct and indirect).

RESULTS

A total of 2,260 subjects were analysed (mean age 58.8 years, 74% women). Just under half (42.7%, 95% CI; 40.0-46.4%) had a suboptimal response to the treatment. These patients had a higher mean age, a higher proportion of women, and pensioners, as well as higher comorbidity, compared to the remission group. They also had poorer compliance percentages (65.1% vs. 67.7%) and treatment persistence at 12 months (31.8% vs. 53.2%), respectively, P<.001. The annual health costs were, 826.1€ for patients with a suboptimal response vs. 451.2€ in patients in remission; loss of productivity 1,842.0€ vs. 991.4€, respectively; P<.001. The factors associated to a suboptimal response were; lack of compliance (OR=1.7), years with the disorder (OR=1.2), age (OR=1.1) and presence of comorbidity (OR=1.1).

CONCLUSIONS

The patients with an initial suboptimal response to antidepressant treatment had a higher comorbidity, lower therapeutic compliance, and incurred higher total costs, particularly in losses in work productivity.

Pharmacoeconomic assessment of implementing a universal PCV-13 vaccination programme in the Valencian public health system (Spain)

BACKGROUND

Heptavalent pneumococcal conjugate vaccine (PCV-7) was licensed to provide immunity against pneumococcal disease caused by seven serotypes of S. pneumoniae. Thirteen-valent pneumococcal conjugate vaccine (PCV-13) includes 6 additional serotypes for preventing invasive pneumococcal disease.

OBJECTIVE

The objective of this study was to estimate the potential health benefits, costs, and cost-effectiveness of vaccination with PCV-13 in the Community of Valencia and to generate valuable information for policy makers at regional and country levels.

METHODS

A decision tree was designed to determine the health and economic outcomes in hypothetical cohorts of vaccinated and unvaccinated children followed over their lifetime. Information about disease incidence and serotype distribution were gathered from local databases and from published and unpublished local records. PCV-13 effectiveness was extrapolated from PCV-7 efficacy data. A 5% of herd effect and a serotype replacement of 25% were considered for the base case scenario. Only direct costs were taken into account and results were expressed in terms of life-years gained (LYG) and quality adjusted life years (QALY).

RESULTS

Implementing a universal PCV-13 vaccination program in the Community of Valencia would decrease the number of hospital admitted pneumonia to less than 4571 cases while avoiding 310 cases of IPD and 82,596 cases of AOM throughout the cohort lifetime. A total of 190 S. pneumoniae related deaths would be averted over the same period. Total medical costs of non-vaccinating the cohort of newborns would reach up to 403,850.859€ compared to 438,762.712€ that would represent vaccinating the cohort. The incremental cost of vaccinating the children was estimated in 12,794€/LYG and 10,407€/QALY, respectively.

CONCLUSIONS

A universal PCV-13 vaccination program in the Community of Valencia would be a cost-effective intervention from the payer perspective after preventing for pneumococcal infections and for decreasing its associated mortality and morbidity.

[A proposed guideline for economic evaluation of health technologies]

Over the last few years, economic evaluation of health technologies has become a major tool used by European health policy decision-makers to create strategies for prioritizing the allocation of health resources and the approval of new technologies. Spain was a pioneer in proposing the standardization of methodology applicable to economic evaluation studies. However, because health policy decision-makers refused to support the initiative, the methodology was never put into practice. In the medium term, evidence of the economic value of new health technologies financed by the national health system will probably be increasingly required. At that time, stakeholders and decision-makers will have to agree upon a clear and concise set of rules on the technical and methodological issues that must be followed by economic evaluations of health technologies. Consequently, we have provided guidelines and recommendations for producing first-rate economic evaluations. The recommendations appear under seventeen headings or sections. In each case, the recommended requirements to be satisfied by an economic evaluation of health technologies are provided and each recommendation is followed by a commentary, providing a justification and comparing and contrasting the proposal with other available alternatives.

Can the Spanish care system assume the new costs of medications against cancer?

Cancer is a high incidence disease, forcing healthcare systems to assign a significant amount of resources to its treatment. New developments have arisen recently: development of new agents that act at specific steps of cellular differentiation and proliferation and identification of predictive genetic markers which allow sub-groups of patients that will benefit from these agents, alone or in combination with chemotherapy, to be targeted. The majority of new drugs coming to the market combine greater clinical benefit and higher costs. Constraints on healthcare budgets worldwide make it necessary to rationalise the expense by prioritising allocation of available resources to the most efficient interventions, so that the best possible clinical result can be obtained at a reasonable cost and with the best quality of life for the patient. Economic evaluation studies represent the only tool available to scientifically determine the cost-effectiveness of new treatments and the budgetary impact of their introduction to the therapeutic arsenal available for the treatment of cancer.