SYSTEMATIC REVIEWS OF ECONOMIC EVALUATIONS IN HEALTH TECHNOLOGY ASSESSMENT: A REVIEW OF CHARACTERISTICS AND APPLIED METHODS

Cost-effectiveness studies of vertebral augmentation for osteoporotic vertebral fractures: a systematic review

BACKGROUND CONTEXT

Osteoporotic vertebral fractures (OVF) dramatically increase with age and are serious life altering adverse events for seniors resulting in increased rates of institutionalization, morbidity and mortality. Given the expanding population of the elderly and increasing prevalence of OVFs, cost-effective treatment strategies need to be considered. Percutaneous vertebral augmentation (VA) procedures such as vertebroplasty (VP) or balloon kyphoplasty (BK) are increasingly employed to treat painful vertebral fractures not responding to conservative management (CM) of bedrest and analgesia. Both VA procedures have been shown to be effective treatments for OVFs in multiple systematic reviews of randomized controlled trials. In this systematic review, analytical strategies, designs and results were compared for health economic studies evaluating cost-effectiveness of VA procedures, VP or BK for OVFs. Furthermore, assessments of quality (risk of bias) were conducted for the systematic review and the individual studies with peer-reviewed checklists recommended for cost-effectiveness studies.

PURPOSE

To provide an up-to-date systematic review of peer-reviewed studies evaluating cost-effectiveness of VA procedures, VP or KP for OVFs to support treatment and health care funding decisions.

STUDY DESIGN

This study is a systematic literature review and structured narrative synthesis.

STUDY SAMPLE

Peer reviewed health economic studies reporting cost-effectiveness for VA procedures, VP or BK for OVFs OUTCOME MEASURES: The following information extracted from the studies included: report country and year, study design, comparators, population, perspective, health valuations, costing sources and cost-effectiveness measures. For economic studies involving modeling, information was also extracted for model type, time horizon, key model drivers, and handling of uncertainty. Incremental cost-effectiveness ratio (ICER), the ratio of differences between comparator treatment groups in costs and health benefits, was considered the main cost-effectiveness measure.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, CINAHL, ECONLIT, Cochrane Library and DARE databases up to the review date May 2021. Studies were reviewed for those reporting cost-effectiveness analyses on VA procedures including VP or BK for OVFs. Studies including only costs, abstracts, editorials, methodologies and reviews were not included. The selection of articles was reported in line with PRISMA guidance. A descriptive framework was developed to classify types of cost-effectiveness studies based on methodological differences and a structured narrative synthesis was used to summarize studies. Quality assessments were made with British Medical Journal checklist for individual cost-effectiveness studies and the CiCERO checklist for systematic reviews of cost-effectiveness studies.

RESULTS

In this systematic review, 520 references were identified through database searching and 501 were excluded as ineligible by titles and abstract based on prior eligibility criteria. From full-text reviews of 19 reports, ten were identified as eligible for the systematic review evaluating cost-effectiveness of VA procedures for OVFs. All references were published between 2008 and 2020. The ten cost-effectiveness studies, three for VP, three for BK and four for both VP and BK, all involved CM for OVFs as a treatment comparator. The studies involved different methods of economic analysis, modeling assumptions, cost and health valuations conducted in different health care setting over different time periods. A framework for the review outlines key features of cost-effectiveness study designs consisting of unmatched, matched, or randomized controls involving cost-effectiveness or cost-utility) analyses. Both VP and BK were cost-effective alternatives to CM for OVFs with earlier health gains and significantly shorter hospital stays. Cost-effectiveness estimates, ICERs, remained relatively stable and within willingness-to-pay thresholds under a range of sensitivity analyses. Comparisons between VP and BK were variable depending on modeling assumptions, but generally the procedures had similar health benefit gains with VP having lower acute procedural costs.

CONCLUSIONS

Both VP and BK, have been shown to be cost-effective alternatives to CM for osteoporotic vertebral fractures in diverse cost-effectiveness studies conducted in multiple health care settings. Trial-based cost-utility contributed the strongest evidence supporting cost-effectiveness determination for VP and BK for OVFs.

Assessing transferability in systematic reviews of health economic evaluations – a review of methodological guidance

Objective

For assessing cost-effectiveness, Health Technology Assessment (HTA) organisations may use primary economic evaluations (P-HEs) or Systematic Reviews of Health Economic evaluations (SR-HEs). A prerequisite for meaningful results of SR-HEs is that the results from existing P-HEs are transferable to the decision context (e.g, HTA jurisdiction). A particularly pertinent issue is the high variability of costs and resource needs across jurisdictions. Our objective was to review the methods documents of HTA organisations and compare their recommendations on considering transferability in SR-HE.

Methods

We systematically hand searched the webpages of 158 HTA organisations for relevant methods documents from 8th January to 31st March 2019. Two independent reviewers performed searches and selected documents according to pre-defined criteria. One reviewer extracted data in standardised and piloted tables and a second reviewer checked them for accuracy. We synthesised data using tabulations and in a narrative way.

Results

We identified 155 potentially relevant documents from 63 HTA organisations. Of these, 7 were included in the synthesis. The included organisations have different aims when preparing a SR-HE (e.g. to determine the need for conducting their own P-HE). The recommendations vary regarding the underlying terminology (e.g. transferability/generalisability), the assessment approaches (e.g. structure), the assessment criteria and the integration in the review process.

Conclusion

Only few HTA organisations address the assessment of transferability in their methodological recommendations for SR-HEs. Transferability considerations are related to different purposes. The assessment concepts and criteria are heterogeneous. Developing standards to consider transferability in SR-HEs is desirable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01536-6.

Cost-effectiveness of prehabilitation prior to elective surgery compared to usual preoperative care: protocol for a systematic review of economic evaluations

INTRODUCTION

Preoperative functional capacity is an important predictor of postoperative outcomes. Prehabilitation aims to optimise patients' functional capacity before surgery to improve postoperative outcomes. As prolonged hospital stay and postoperative complications present an avoidable use of healthcare resources, prehabilitation might also save costs.The aim of this systematic review is to investigate the cost-effectiveness of prehabilitation programmes for patients awaiting elective surgery compared with usual preoperative care. The results will be useful to inform decisions about the implementation of prehabilitation programmes and the design of future economic evaluations of prehabilitation programmes.

METHODS AND ANALYSIS

We will search PubMed, Embase, the Centre for Reviews and Dissemination Database, the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov for full or partial economic evaluations of preoperative prehabilitation programmes conducted in any population compared with usual preoperative care. Studies will be included regardless of the type, design and perspective of the economic evaluation, and their publication year, language or status. Initial searches were performed between 30 April and 4 May 2020.Study selection, data extraction and assessment of the included studies' risk of bias and methodological quality will initially be performed by two independent reviewers and, if agreement was sufficiently high, by one reviewer. We will extract data regarding the included studies' basic characteristics, economic evaluation methods and cost-effectiveness results.A narrative synthesis will be performed. The primary endpoint will be cost-effectiveness based on cost-utility analyses. We will discuss heterogeneity between the studies and assess the risk of publication bias. The certainty of the evidence will be determined using the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethics approval is not required as the systematic review will not involve human participants. We plan to present our findings at scientific conferences, pass them on to relevant stakeholder organisations and publish them in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020182813.

Challenges of Systematic Reviews of Economic Evaluations: A Review of Recent Reviews and an Obesity Case Study

Decision makers increasingly require cost-effectiveness evidence to inform resource allocation and the need for systematic reviews of economic evaluations (SREEs) has grown accordingly. The objective of this article is to describe current practice and identify unique challenges in conducting and reporting SREEs. Current guideline documents for SREEs were consulted and summarised. A rapid review of English-language SREEs, using MEDLINE and EMBASE, published in 2017/2018, containing at least 20 studies was undertaken to describe current practice. Information on data extraction methods, quality assessment (QA) tools and reporting methods were narratively summarised. Lessons learned from a recently conducted SREE of weight loss interventions for severely obese adults were discussed. Sixty-three publications were included in the rapid review. Substantial heterogeneity in review methods, reporting standards and QA approaches was evident. Our recently conducted SREE on weight loss interventions identified scope to improve process efficiency, opportunity for more transparent and succinct reporting, and potential to improve consistency of QA. Practical solutions may include (1) using pre-piloted data extraction forms linked explicitly to results tables; (2) consistently reporting on key assumptions and sensitivity analyses that drive results; and (3) using checklists that include topic-specific items where relevant and allow reviewers to distinguish between reporting, justification and QA. The lack of a mutually agreed, standardised set of best practice guidelines has led to substantial heterogeneity in the conduct and reporting of SREEs. Future work is required to standardise the approach to conducting SREEs so that they can generate efficient, timely and relevant evidence to support decision-making. We suggest only data extracting information that will be reported, focusing discussion around the key drivers of cost-effectiveness, and improving consistency in QA by distinguishing between what is reported, justified by authors and deemed appropriate by the reviewer.

A systematic review of economic evaluations of the use of memantine alone or combined with donepezil for moderate to severe Alzheimer’s disease

Abstract Objective: To synthesize the available evidence and state of the art of economic evaluations which evaluate the use of memantine, whether alone or combined with donepezil, for moderate to severe Alzheimer’s disease (AD), focusing on the analytical decision models built. Method: The electronic databases MEDLINE, EMBASE, NHS EED, CEA Registry and LILACS were searched for references. After duplicates were removed, two independent reviewers evaluated the titles and abstracts and subsequently the full texts. The Drummond M. tool was used to evaluate the quality of the studies. Results: After the application of the eligibility criteria, twelve complete economic evaluations were included. One evaluation was a clinical trial, two involved simulations and nine used Markov models. The main outcome measure adopted was dominated by cost per quality adjusted life year (QALY). The use of memantine was considered cost-effective and dominant in eight studies; while in a single study, its use was dominated when compared to donepezil for moderate AD. Sensitivity analyzes were systematically performed, with robust results. The quality assessment indicated that the methodological quality of the studies was good. Conclusion: Although there is some controversy regarding the benefits derived from the use of memantine, whether combined or not with donepezil, the evidence collected suggests that it is cost-effective in the countries where the studies were performed. However, local economic studies need to be performed, given the significant variability derived from the different parameters adopted in the evaluations.