Median-Based Incremental Cost-Effectiveness Ratio (ICER)

A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT.

METHODS

To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY.

CONCLUSIONS

MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.

Comparison of statistical methods for the analysis of patient-reported outcomes in randomised controlled trials: A simulation study

Patient-reported outcomes (PROs) that aim to measure patients' subjective attitudes towards their health or health-related conditions in various fields have been increasingly used in randomised controlled trials (RCTs). PRO data is likely to be bounded, discrete, and skewed. Although various statistical methods are available for the analysis of PROs in RCT settings, there is no consensus on what statistical methods are the most appropriate for use. This study aims to use simulation methods to compare the performance (in terms of bias, empirical standard error, coverage of the confidence interval, Type I error, and power) of three different statistical methods, multiple linear regression (MLR), Tobit regression (Tobit), and median regression (Median), to estimate a range of predefined treatment effects for a PRO in a two-arm balanced RCT. We assumed there was an underlying latent continuous outcome that the PRO was measuring, but the actual scores observed were equally spaced and discrete. This study found that MLR was associated with little bias of the estimated treatment effect, small standard errors, and appropriate coverage of the confidence interval under most scenarios. Tobit performed worse than MLR for analysing PROs with a small number of levels, but it had better performance when analysing PROs with more discrete values. Median showed extremely large bias and errors, associated with low power and coverage for most scenarios especially when the number of possible discrete values was small. We recommend MLR as a simple and universal statistical method for the analysis of PROs in RCT settings.

Three-month outcomes and cost-effectiveness of interferon gamma-1b in critically ill patients: a secondary analysis of the PREV-HAP trial

BACKGROUND

Interferon gamma‑1b has been proposed to treat critical illness-induced immunosuppression. We aimed to determine the effects on 90-day outcomes and the cost-effectiveness of interferon gamma‑1b compared to placebo in mechanically ventilated critically ill patients.

METHODS

A cost-effectiveness analysis (CEA) was embedded in the "PREV-HAP trial", a multicenter, placebo‑controlled, randomized trial, which randomly assigned critically ill adults under mechanical ventilation to receive interferon gamma or placebo. The CEA compared interferon-gamma with placebo using a collective perspective at a 90-day time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed in terms of adjusted cost per adjusted Quality-Adjusted Life-Years (QALYs) gained. QALYs were estimated from the responses of patients and proxy respondents to the health-related quality of life questionnaire EQ-5D-3L.

RESULTS

The 109 patients in the PREV-HAP trial were included in the CEA. At day 90, all-cause mortality rates were 23.6% in the interferon group and 25% in the placebo group (Odds Ratio (OR) = 0.88 (0.40 -1.93) p = 0.67). The difference in the mean adjusted costs per patient at 90 days was €-1.638 (95%CI €-17.534 to €11.968) in favor of interferon gamma-1b. The mean difference in adjusted QALYs between interferon gamma-1b and the placebo group was + 0.019 (95%CI -0.005 to 0.043). The probability that interferon gamma-1b was cost-effective ranged from 0.60 to 0.71 for a willingness to pay a QALY between €20k and €150k for the base case analysis.

CONCLUSION

Early administration of interferon gamma might be cost-effective in critically ill patients supporting the realization of other studies on this treatment. However, the generalization of the findings should be considered cautiously, given the small sample size due to the premature end of PREV-HAP. Trial registration ClinicalTrials.gov Identifier: NCT04793568, Registration date: 2021-02-24.

Cost-Effectiveness Analysis of Pneumococcal Vaccines in the Pediatric Population: A Systematic Review

Objectives: Pneumococcal disease, caused by Streptococcus pneumoniae, is the leading cause of mortality in children worldwide. The tremendous direct cost of hospital admissions and significant indirect costs from productivity loss contribute considerably to its economic burden, with vaccination being the only efficient protection against the illness. Our study aims to summarize the cost-effectiveness of the pneumococcal conjugate vaccine (PCV) implemented in the pediatric population. Methods: Employing the online databases PubMed, Embase, and Medline, we looked for economic evaluations from 2018 until March 2024. The Incremental Cost-Effectiveness Ratios (ICER) and Quality-Adjusted Life Years (QALY) were the primary outcomes for measuring the cost-effectiveness of PCVs. A 28-item CHEERS 2022 checklist was applied to assess the quality of the collected studies. Results: Of the 16 papers found, 9/16 discussed the lower-valent vaccines (PCV13, PCV10) and 7/16 examined the higher-valent vaccines (PCV20, PCV15). PCV13 and PCV10 involved greater costs and generated more QALY compared to no vaccination. Both PCV15 and PCV20 averted substantial healthcare costs and yielded greater quality of life than PCV13. Additionally, PCV20 was a dominant strategy compared to PCV15. Conclusions: Utilizing PCV13 is a very cost-effective option compared to not getting vaccinated. Transitioning from PCV13 to PCV20 would result in higher QALY gain and more cost-saving than switching to PCV15.

Cost effectiveness of interventions to prevent the occurrence and the associated economic impacts of child maltreatment: A systematic review

BACKGROUND

Child maltreatment is a pressing public health concern that poses long-lasting health and economic impacts on children and society. While several preventive interventions have demonstrated their effectiveness in reducing the occurrence of child maltreatment and its associated economic impacts, the cost-effectiveness of such interventions remains unclear.

OBJECTIVE

This study aims to provide a comprehensive overview and a narrative synthesis of the available economic evidence on child maltreatment preventive interventions in both high-income and low-middle-income countries.

METHOD

Systematic searches were conducted in MEDLINE, PsycINFO, Embase, CINAHL, Web of Science, and Econlit to identify full economic evaluations and return-on-investment studies on child maltreatment preventive interventions. The methodological quality of eligible studies was assessed using Drummond's 10-point checklist. This review adhered to the PRISMA guidelines, and summarized findings in a narrative synthesis.

RESULTS

Twenty-six studies met the inclusion criteria. Of these, eight evaluated home visiting, four evaluated early childhood education (ECE), four assessed multi-component (MC), and three examined group-based parent education (GPE) interventions. The remaining studies assessed interventions to prevent abusive head trauma (AHT; n = 2), child sexual abuse (n = 2), physical abuse at school (n = 1), as well as individualized intensive parenting (IIP; n = 2), and counseling (n = 1) interventions. Two studies were conducted in low-middle-income countries, while the others were all in high-income countries.

CONCLUSIONS

The included studies generally exhibited high methodological quality. Only AHT, ECE, IIP, and MC interventions demonstrated promising cost-effectiveness credentials in preventing child maltreatment. More economic evaluations are needed for interventions with mixed findings (e.g. GPE) and in low-middle-income countries.

Economic Evaluation of an Enhanced Post-Discharge Home-Based Care Program for Stroke Survivors

OBJECTIVES

To examine the cost-effectiveness of an enhanced postdischarge home-based care program for stroke survivors compared with usual care.

METHODS

This was a trial-based economic evaluation study. One hundred and sixteen patients with ischemic stroke were recruited from neurology units in a Chinese hospital and randomized into intervention (n = 58) or usual care groups (n = 58). The intervention commenced with predischarge planning and transitioned to home follow-up postdischarge. Trained nurse case managers supported by an interdisciplinary team provided comprehensive assessment, individualized goal setting, and skill training to support home-based rehabilitation for intervention group participants. Standard care was provided to usual care group participants. Total cost and quality-adjusted life-years gained at 3-month (T1), 6-month (T2), and 12-month (T3) follow-ups were calculated. The incremental cost-effectiveness ratios between the groups were obtained.

RESULTS

The intervention group showed a significant increase in utility compared with the usual care group at T1 (P = .003), T2 (P = .007), and T3 (P < .001). The average total QALY gain from baseline for the intervention group was higher than for the usual care group at all time points. The likelihood of being cost-effective ranged from 61.9% to 67.2% from the provider perspective, and from 59.7% to 66.8% from the societal perspective.

CONCLUSIONS

The results showed that the intervention program was cost-effective with significantly higher quality-adjusted life-years for stroke survivors when compared with usual care. It provides economic evidence to support the development of home-based stroke rehabilitation program, especially in the low- and middle-income countries.

Cost effectiveness and long-term outcomes of dexamethasone administration in major non-cardiac surgery

STUDY OBJECTIVES

Postoperative administration of dexamethasone has been proposed to reduce morbidity and mortality in patients undergoing major non-cardiac surgery. In this ancillary study of the PACMAN trial, we aimed to evaluate the cost effectiveness of dexamethasone in patients undergoing major non-cardiac surgery.

METHODS

Patients included in the multicentric randomized double-blind, placebo-controlled PACMAN trial were followed up for 12 months after their surgical procedure. Patients were randomized to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Cost effectiveness between the dexamethasone and placebo groups was assessed for the 12-month postoperative period from a health payer perspective.

RESULTS

Of 1222 randomized patients in PACMAN, 137 patients (11%) were followed up until 12 months after major surgery (71 in the DXM group and 66 in the placebo group). Postoperative dexamethasone administration reduced costs per patient at 1 year by €358.06 (95%CI -€1519.99 to €803.87). The probability of dexamethasone being cost effective was between 12% and 22% for a willingness to pay of €100,000 to €150,000 per life-year, which is the threshold that is usually used in France and was 52% for willingness to pay of €50,000 per life-year (threshold in USA). At 12 months, 9 patients (13.2%) in the DXM group and 10 patients (16.1%) in the placebo group had died. In conclusion, our study does not demonstrate the cost effectiveness of perioperative administration of DXM in major non-cardiac surgery.

Scale agreement, ceiling and floor effects, construct validity, and relative efficiency of the PROPr and EQ-5D-3L in low back pain patients

BACKGROUND

The PROMIS Preference score (PROPr) is a new health state utility (HSU) score that aims to comprehensively incorporate the biopsychosocial model of health and apply favorable psychometric properties from the descriptive PROMIS system to HSU measurements. However, minimal evidence concerning comparisons to the EQ-5D-3L and the PROPr's capability to differentiate clinical severity are available. Therefore, the aim of this study was to compare the PROPr to the EQ-5D-3L in terms of scale agreement, ceiling/floor effects, distribution, construct validity, discriminatory power, and relative efficiency (RE) in terms of the Oswestry Disability Index (ODI) for patients with low back pain (LBP).

METHODS

We used intra-class correlation coefficients (ICC) and Bland-Altman plots to compare the PROPr and EQ-5D-3L with regared to scale agreement in a cross-sectional routine sample of LBP patients. For distribution, we used the Pearson's coefficient for skewness and for ceiling/floor effects, a 15%-top/bottom threshold. For convergent validity, we used Pearson's correlation coefficients. For known-groups validity, we applied a linear regression with interaction terms (predictors sex, age, and ODI level) and an analysis of variance (ANOVA). For discriminatory power, we calculated the effect size (ES) using Cohen's d and the ratio of the area under the receiver-operating characteristics curves (AUROC-ratio = AUROCPROPr/AUROCEQ-5D-3L). RE was measured using the ratio of F-values (RE = FPROPr/FEQ-5D-3L).

RESULTS

Of 218 LBP patients, 50.0% were female and the mean age was 61.8 years. The mean PROPr (0.20, 95%CI: 0.18; 0.22) and EQ-5D-3L scores (0.55, 95%CI: 0.51; 0.58) showed low agreement (d = 0.35, p < 0.001; ICC 0.27, 95%CI: -0.09; 0.59). The PROPr's distribution was positively skewed, whereas the EQ-5D-3L's was negative. Neither tool showed ceiling/floor effects, but all EQ-5D-3L dimensions did. Pearson correlation was r = 0.66 (95%CI: 0.58; 0.73). Differences were invariant to sex and age but not to ODI severity: ESEQ-5D-3L > ESPROPr and RE < 1 in higher ODI severity; ESEQ-5D-3L < ESPROPr and RE > 1 in lower ODI severity. AUROC-ratios did not show significant differences in terms of ODI severity.

CONCLUSIONS

All PROPr and EQ-5D-3L biopsychosocial dimensions of health showed impairment in LPB patients. The capability of EQ-5D-3L and PROPr to differentiate ODI levels depends on ODI severity. Joint application of both tools may provide additional information.

Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study

Introduction

The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery.

Materials and methods

The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis.

Results

The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines.

Conclusion

The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.

Cost and effectiveness analyses of the anti-osteoporosis medication in patients with hip fracture in Taiwan: A population-based national claims database analysis

BACKGROUND

Real-world cost and effectiveness analyses of the anti-osteoporosis medications (AOM) using a nationwide database in Asia were limited. The aim of this study was to evaluate the cost and effectiveness of AOMs therapy under the reimbursement of National Health Insurance in Taiwan.

METHODS

Using Taiwan's National Health Insurance Research Database, patients who had hospitalization due to incident hip fractures with related operation between 2008 and 2017 were identified as our study population. Patients who initiated AOMs within 1 year post incident hip fracture were matched with those did not according to the propensity score. The direct medical cost and subsequent fracture within three years were estimated. Statistically significant differences of risk for subsequent fracture between the AOM and non-AOM groups were estimated using the COX proportional hazards model. All costs were presented as New Taiwan Dollars (NTD).

RESULTS

There were 27,357 new hip fracture patients who initiated AOMs, and 76% of them were women with a mean age of 77.7 years. Among patients ages ≥70 who encountered hip fractures, those who initiated AOMs experienced fewer non-vertebral fractures (HR = 1.07 (1.02-1.13), p = 0.0114 for those ages 70-79 years old; HR = 1.11 (1.06-1.17), p < 0.0001 for those ages ≥80 years) and mortality (HR = 1.18 (1.14-1.22), p < 0.0001 for those ages 70-79; HR = 1.20 (1.16-1.23), p < 0.0001) within 3 years post incident fracture; meanwhile, consuming fewer medical resources in the national insurance healthcare system. (Increment cost = -16011.2 NTD, p = 0.0248 for those ages 70-79; Increment cost = -17257.9 NTD, p = 0.0032 for those ages ≥80 years) CONCLUSION: Overall, under Taiwan's national health insurance, the use of AOMs is cost-saving, especially in the population aged ≥70 years. The finding of this research was valuable for policymakers in considering healthcare policy promotion and resource allocation in the future.

Assessing the cost-effectiveness of waiting list reduction strategies for a breast radiology department: a real-life case study

BACKGROUND

A timely diagnosis is essential for improving breast cancer patients' survival and designing targeted therapeutic plans. For this purpose, the screening timing, as well as the related waiting lists, are decisive. Nonetheless, even in economically advanced countries, breast cancer radiology centres fail in providing effective screening programs. Actually, a careful hospital governance should encourage waiting lists reduction programs, not only for improving patients care, but also for minimizing costs associated with the treatment of advanced cancers. Thus, in this work, we proposed a model to evaluate several scenarios for an optimal distribution of the resources invested in a Department of Breast Radiodiagnosis.

MATERIALS AND METHODS

Particularly, we performed a cost-benefit analysis as a technology assessment method to estimate both costs and health effects of the screening program, to maximise both benefits related to the quality of care and resources employed by the Department of Breast Radiodiagnosis of Istituto Tumori "Giovanni Paolo II" of Bari in 2019. Specifically, we determined the Quality-Adjusted Life Year (QALY) for estimating health outcomes, in terms of usefulness of two hypothetical screening strategies with respect to the current one. While the first hypothetical strategy adds one team made up of a doctor, a technician and a nurse, along with an ultrasound and a mammograph, the second one adds two afternoon teams.

RESULTS

This study showed that the most cost-effective incremental ratio could be achieved by reducing current waiting lists from 32 to 16 months. Finally, our analysis revealed that this strategy would also allow to include more people in the screening programs (60,000 patients in 3 years).

Cost effectiveness of a telerehabilitation intervention vs home based care for adults with severe neurologic disability: A randomized clinical trial

Context

Several options are available for the care of neurological conditions including care delivered in rehabilitation centres, at home or remotely. While economic studies are available comparing centres and homes, very little economic data relates to mobile teams comparing face-to-face and remote care.

Objective

To conduct an economic study comparing face-to-face care at home and care delivered remotely (tele-rehabilitation).

Method

A randomised clinical study with two groups; a control group receiving home care and an experimental group receiving tele-rehabilitation. The primary outcome measure was the ICER (Incremental Cost Effectiveness Ratio).

Participants

Patients with severe neurological disabilities.

Results

80 patients were enrolled in the study; 77 were analysed to calculate the ICER, which was positive and located in the SW quadrant. A bootstrap with 1000 replications was positioned at 72.8% in the SW quadrant.

Conclusion

Tele-rehabilitation is an acceptable alternative to the management of neurological patients at home. In the mildest cases, remote-rehabilitation may even be dominant. More extensive studies are needed to specify the indications.

Health state utility differed systematically in breast cancer patients between the EORTC QLU-C10D and the PROMIS Preference Score

BACKGROUND AND OBJECTIVES

The EORTC Quality of Life Utility Core 10 Dimensions (QLU-C10D) and the Patient-Reported Outcome Measurement Information System Preference Score (PROPr) are new health state utility (HSU) scores for quality-adjusted life years in cost-effectiveness analyses. Both are expected to measure HSU more comprehensively than existing measures in cancer patients by including cancer-related health domains such as fatigue. The aim of this study is to compare both scores in a sample of breast cancer patients.

METHODS

We collected QLU-C10D and PROPr from 291 patients 90 days after treatment in the outpatient clinic of the breast cancer center at Charité - University Medicine Berlin between June 2018 and April 2021. We assessed both scores' convergent and known-groups validity, agreement, and ceiling and floor effects.

RESULTS

The mean QLU-C10D score [0.71, 95% confidence interval (CI) 0.69-0.74] and the mean PROPr score (0.43, 95% CI 0.41-0.46) differed systematically (0.28, 95% CI 0.27-0.30) and showed fair agreement (intraclass correlation coefficient 0.46, 95% CI 0.32-0.57). The Pearson correlation coefficient was 0.83 (95% CI 0.79-0.86). Both scores showed similar discrimination across known groups of age, treatment, cancer stage, marital status, and education. The QLU-C10D showed relevant ceiling effects.

CONCLUSION

QLU-C10D and PROPr measure HSU differently as a result of different utility models. The choice between QLU-C10D and PROPr should be informed by context, population, disease, and treatment.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents' hospitalisations

BACKGROUND

Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care.

METHODS

The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies' costs, time and other resources from the NHs' perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs' losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention's effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs' perspective.

RESULTS

Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH's needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22'595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate.

CONCLUSIONS

As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03590470 ).

Cost-effectiveness analysis of Ado-trastuzumab emtansine for the treatment of residual invasive HER2-positive breast cancer

Objective

Methods

Results

Conclusion

Comparison of the PROMIS Preference Score (PROPr) and EQ-5D-5L Index Value in General Population Samples in the United Kingdom, France, and Germany

OBJECTIVES

The Patient-Reported Outcome Measurement Information System (PROMIS) Preference score (PROPr) can be used to assess health state utility (HSU) and estimate quality-adjusted life-years in cost-effectiveness analyses. It is based on item response theory and promises to overcome limitations of existing HSU scores such as ceiling effects. The PROPr contains 7 PROMIS domains: cognitive abilities, depression, fatigue, pain, physical function, sleep disturbance, and ability to participate in social roles and activities. We aimed to compare the PROPr with the 5-level EQ-5D (EQ-5D-5L) in terms of psychometric properties using data from 3 countries.

METHODS

We collected PROMIS-29 profile and EQ-5D-5L data from 3 general population samples (United Kingdom = 1509, France = 1501, Germany = 1502). Given that cognition is not assessed by the PROMIS-29, it was predicted by the recommended linear regression model. We compared the convergent validity, known-groups construct validity, and ceiling and floor effects of the PROPr and EQ-5D-5L.

RESULTS

The mean PROPr (0.48, 0.53, 0.48; P<.01) and EQ-5D-5L scores (0.82, 0.85, 0.83; P<.01) showed significant differences of similar magnitudes (d = 0.34; d = 0.32; d = 0.35; P<.01) across all samples. The differences were invariant to sex, income, occupation, education, and most conditions but not for age. The Pearson correlation coefficients between both scores were r = 0.74, r = 0.69, and r = 0.72. PROPr's ceiling and floor effects both were minor to moderate. The EQ-5D-5L's ceiling (floor) effects were major (negligible).

CONCLUSIONS

Both the EQ-5D-5L and the PROPr assessed by the PROMIS-29 show high validity. The PROPr yields considerably lower HSU values than the EQ-5D-5L. Consequences for quality-adjusted life-year measurements should be investigated in future research.

Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations

PURPOSE

No clear consensus exists on which anterior surgical technique is most cost-effective for treating cervical degenerative disk disease (CDDD). One of the most common treatment options is anterior cervical discectomy with fusion (ACDF). Anterior cervical discectomy with arthroplasty (ACDA) was developed in an effort to reduce the incidence of clinical adjacent segment pathology and associated additional surgeries by preserving motion. This systematic review aims to evaluate the evidence regarding the cost-effectiveness of anterior surgical decompression techniques used to treat radiculopathy and/or myelopathy caused by CDDD.

METHODS

The search was conducted in PubMed, EMBASE, Web of Science, CINAHL, EconLit, NHS-EED and the Cochrane Library. Studies were included if healthcare costs and utility or effectivity measurements were mentioned.

RESULTS

A total of 23 studies were included out of the 1327 identified studies. In 9 of the 13 studies directly comparing ACDA and ACDF, ACDA was the most cost-effective technique, with an incremental cost effectiveness ratio ranging from $2.900/QALY to $98.475/QALY. There was great heterogeneity between the costs of due to different in- and exclusion criteria of costs and charges, cost perspective, baseline characteristics, and calculation methods. The methodological quality of the included studies was moderate.

CONCLUSION

The majority of studies report ACDA to be a more cost-effective technique in comparison with ACDF. The lack of uniform literature impedes any solid conclusions to be drawn. There is a need for high-quality cost-effectiveness research and uniformity in the conduct, design and reporting of economic evaluations concerning the treatment of CDDD.

TRIAL REGISTRATION

PROSPERO Registration: CRD42020207553 (04.10.2020).

Psychometric properties of the PROMIS Preference score (PROPr) in patients with rheumatological and psychosomatic conditions

Background

The PROMIS Preference score (PROPr) is a new generic preference-based health-related quality of life (HRQoL) score that can be used as a health state utility (HSU) score for quality-adjusted life years (QALYs) in cost-utility analyses (CUAs). It is the first HSU score based on item response theory (IRT) and has demonstrated favorable psychometric properties in first analyses. The PROPr combines the seven PROMIS domains: cognition, depression, fatigue, pain, physical function, sleep disturbance, and ability to participate in social roles and activities. It was developed based on preferences of the US general population. The aim of this study was to validate the PROPr in a German inpatient sample and to compare it to the EQ-5D.

Methods

We collected PROPr and EQ-5D-5L data from 141 patients undergoing inpatient treatment in the rheumatology and psychosomatic departments. We evaluated the criterion and convergent validity, and ceiling and floor effects of the PROPr and compared those characteristics to those of the EQ-5D.

Results

The mean PROPr (0.26, 95% CI: 0.23; 0.29) and the mean EQ-5D (0.44, 95% CI: 0.38; 0.51) scores differed significantly (d = 0.18, p < 0.001). Compared to the EQ-5D, the PROPr scores were less scattered across the measurement range which has resulted in smaller confidence intervals of the mean scores. The Pearson correlation coefficient between the two scores was r = 0.72 (p < 0.001). Both scores showed fair agreement with an Intraclass Correlation Coefficient (ICC) of 0.48 (p < 0.05). The PROPr and EQ-5D demonstrated similar discrimination power across sex, age, and conditions. While the PROPr showed a floor effect, the EQ-5D showed a ceiling effect.

Conclusion

The PROPr measures HSU considerably lower than the EQ-5D as a result of different construction, anchors and measurement ranges. Because QALYs derived with the EQ-5D are widely considered state-of-the-art, application of the PROPr for QALY measurements would be problematic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00245-3.

Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study

BACKGROUND

Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia.

METHODS

This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin.

RESULTS

The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25.

CONCLUSIONS

The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.

Toward collaborative cost-inclusive evaluation: Adaptations and transformations for evaluators and economists

As evaluators and economists expand their domains of research, consulting, teaching, and publication, they find themselves needing each other more and yet increasingly at odds. Often surprised at the resistance they encounter from one another, sometimes dismissive of contributions the other can make, all should consider adaptations and transformations of roles, approaches, methods, analyses, and decision-making algorithms that would allow better collaboration. The particularly multidisciplinary area of cost-inclusive evaluation requires (a) changes in approaches and methods used by evaluators and economists, (b) changes that evaluators need to make when working with economists, and (c) changes that economists need to make when working with evaluators. Some of the changes needed are illustrated with examples drawn from proposals and manuscripts for contemporary cost-inclusive evaluations. A key reframing needed is that cost-effectiveness and cost-benefit analyses are "and" rather than "or" activities: cost-inclusive evaluation works best, and perhaps only really works, when evaluators and economists interweave their efforts to support and learn from each other. So may most future endeavors to which multiple disciplines contribute.

Health economics and effectiveness analysis of generic anti-diabetic medication from jan aushadhi: An ambispective study in community pharmacy

BACKGROUND AND AIMS

The pharmacotherapy of diabetes mellitus has a colossal economic burden, which demands cost-effective therapy, as the patients have to be on treatment lifelong. Thus, our study aimed to study cost variation and effectiveness analysis among type 2 diabetic patients.

METHODOLOGY

We conducted ambi-spective research for the adult type 2 diabetes patients who underwent substitution of branded anti-diabetic therapy with the generic alternative from "Jan Aushadhi" for more than one month and were not using any other anti-diabetic medicines.

RESULTS

Among the monotherapy, glimepiride (2500%) and vildagliptin (20%) were found to have wide and narrow percentage cost variation respectively whereas, metformin Hcl 500 mg plus voglibose 0.2 mg was estimated to have the highest (891.7%), and teneligliptin 20 mg plus metformin 500 mg with the lowest (137.29%) cost variation in case of combined therapy. Similarly, generic substitutions were cost-effective in most patients, whereas the increased cost of brand drugs didn't justify its effectiveness. There was no significant difference between glycated hemoglobin (HbA1c) of brand and generic anti-diabetic drugs (t = 0.774, p = 0.22).

CONCLUSION

The adaptation of generic drugs can significantly reduce the economic burden of treatment. Thus, healthcare professionals should promote generic medicines by prescribing & dispensing generic drugs and erasing misconceptions prevailing among patients.

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.

Empiric Versus Clarithromycin Resistance-Guided Therapy for Helicobacter pylori Based on Polymerase Chain Reaction Results in Patients With Gastric Neoplasms or Gastric Mucosa-Associated Lymphoid Tissue Lymphoma: A Randomized Controlled Trial

We investigated to compare the effect of empirical therapy vs clarithromycin resistance–guided tailored therapy (tailored therapy) for eradication of Helicobacter pylori.

Comparison of (Partial) economic evaluations of transforaminal lumbar interbody fusion (TLIF) versus Posterior lumbar interbody fusion (PLIF) in adults with lumbar spondylolisthesis: A systematic review

Introduction

The demand for spinal fusion surgery has increased over the last decades. Health care providers should take costs and cost-effectiveness of these surgeries into account. Open transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are two widely used techniques for spinal fusion. Earlier research revealed that TLIF is associated with less blood loss, shorter surgical time and sometimes shorter length of hospital stay, while effectiveness of both techniques on back and/or leg pain are equal. Therefore, TLIF could result in lower costs and be more cost-effective than PLIF. This is the first systematic review comparing direct and indirect (partial) economic evaluations of TLIF with PLIF in adults with lumbar spondylolisthesis. Furthermore, methodological quality of included studies was assessed.

Methods

Searches were conducted in eight databases for reporting on eligibility criteria; TLIF or PLIF, lumbar spondylolisthesis or lumbar instability, and cost. Costs were converted to United States Dollars with reference year 2020. Study quality was assessed using the bias assessment tool of the Cochrane Handbook for Systematic Reviews of Interventions, the Level of Evidence guidelines of the Oxford Centre for Evidence-based Medicine and the Consensus Health Economic Criteria (CHEC) list.

Results

Of a total of 693 studies, 16 studies were included. Comparison of TLIF and PLIF could only be made indirectly, since no study compared TLIF and PLIF directly. There was a large heterogeneity in health care and societal perspective costs due to different in-, and exclusion criteria, baseline characteristics and the use of costs or charges in calculations. Health care perspective costs, calculated with hospital costs, ranged from $15,867-$43,217 in TLIF-studies and $32,662 in one PLIF-study. Calculated with hospital charges, it ranged from $8,964-$51,469 in TLIF-studies and $21,838-$93,609 in two PLIF-studies. Societal perspective costs and cost-effectiveness, only mentioned in TLIF-studies, ranged from $5,702/QALY-$48,538/QALY and $50,092/QALY-$90,977/QALY, respectively. Overall quality of studies was low.

Conclusions

This systematic review shows that TLIF and PLIF are expensive techniques. Moreover, firm conclusions about the preferable technique, based on (partial) economic evaluations, cannot be drawn due to limited studies and heterogeneity. Randomized prospective trials and full economical evaluations with direct TLIF and PLIF comparison are needed to obtain high levels of evidence. Furthermore, development of guidelines to perform adequate economic evaluations, specified for the field of interest, will be useful to minimize heterogeneity and maximize transferability of results.

Trial registration

Prospero-database registration number: CRD42020196869.

Qualitative comparative analysis of health economic evaluation guidelines for health technology assessment in European countries

OBJECTIVE

To classify, analyze, and compare published guidelines for economic evaluation within health technology assessment (HTA) in European countries and highlight differences and similarities.

METHODS

We performed a literature review to identify published guidance for the conduct and assessment of economic evaluation studies that are undertaken within the context of HTA processes in European countries. Organizations and working groups were identified via the ISPOR, INAHTA, and EUnetHTA databases. Following the identification of official documents, we performed a qualitative content analysis to highlight discrepancies or common practices under the following categories: comparator, perspective on costs/benefits, time horizon, economic evaluation method, instrument used for utility measurement, outcome measure, source for efficacy, modeling, sensitivity analysis, discounting, and incremental cost-effectiveness ratio.

RESULTS

A total of nineteen guidance documents were identified (in English) providing data for the analysis in nineteen countries. The comparative content analysis identified common practices in most countries regarding the approaches to the choice of comparator, source of data, the preferred economic evaluation method, the option for a lifetime analytical horizon, discounting, and the choice of key outcome measure-for which, most countries recommend the use of the EQ-5D instrument. Differences were mainly found in the choice of perspective, dealing with uncertainty and sensitivity analysis, the use of end points, and the required use of modeling.

CONCLUSIONS

The use of economic evaluation constitutes one of the key pillars of the HTA process in Europe. Although a methodological convergence has occurred during the last few years, notable differences still remain.

On the Use of Markov Models in Pharmacoeconomics: Pros and Cons and Implications for Policy Makers

We present an overview of the main methodological features and the goals of pharmacoeconomic models that are classified in three major categories: regression models, decision trees, and Markov models. In particular, we focus on Markov models and define a semi-Markov model on the cost utility of a vaccine for Dengue fever discussing the key components of the model and the interpretation of its results. Next, we identify some criticalities of the decision rule arising from a possible incorrect interpretation of the model outcomes. Specifically, we focus on the difference between median and mean ICER and on handling the willingness-to-pay thresholds. We also show that the life span of the model and an incorrect hypothesis specification can lead to very different outcomes. Finally, we analyse the limit of Markov model when a large number of states is considered and focus on the implementation of tools that can bypass the lack of memory condition of Markov models. We conclude that decision makers should interpret the results of these models with extreme caution before deciding to fund any health care policy and give some recommendations about the appropriate use of these models.

Progressive Resistance Plus Balance Training for Older Australians Receiving In-Home Care Services: Cost-Effectiveness Analyses Alongside the Muscling Up Against Disability Stepped-Wedge Randomized Control Trial

In this article, the authors assessed the cost-effectiveness of center-based exercise training for older Australians. The participants were recipients of in-home care services, and they completed 24 weeks of progressive resistance plus balance training. Transport was offered to all participants. A stepped-wedge randomized control trial produced pre-, post-, and follow-up outcomes and cost data, which were used to calculate incremental cost-effectiveness ratios per quality-adjusted life year gained. Analyses were conducted from a health provider perspective and from a government perspective. From a health-service provider perspective, the direct cost of program provision was $303 per person, with transport adding an additional $1,920 per person. The incremental cost-utility ratio of the program relative to usual care was $70,540 per quality-adjusted life year over 6 months, decreasing to $37,816 per quality-adjusted life year over 12 months. The findings suggest that Muscling Up Against Disability offers good value for the money within commonly accepted threshold values.

A Comparative Analysis of Survival and Funding Discrepancies in Cancers With High Mortality

OBJECTIVE

Comparative analyses of survival and funding statistics in cancers with high mortality were performed to quantify discrepancies and identify areas for intervention.

BACKGROUND

Discrepancies in research funding may contribute to stagnant survival rates in pancreatic ductal adenocarcinoma (PDAC).

METHODS

The Surveillance, Epidemiology, and End Results database was queried for survival statistics. Funding data were obtained from the National Cancer Institute (NCI). Clinical trial data were obtained from www.clinicaltrials.gov. Cancers with high mortality were included for analyses.

RESULTS

Since 1997, PDAC has received lesser funding ($1.41 billion) than other cancers such as breast ($10.52 billion), prostate ($4.93 billion), lung ($4.80 billion), and colorectal ($4.50 billion). Similarly, fewer clinical trials have been completed in PDAC (n = 608) compared with breast (n = 1904), lung (n = 1629), colorectal (n = 1080), and prostate (n = 1055) cancer. Despite this, since 1997, dollars invested in PDAC research produced a greater return on investment with regards to 5-year overall survival (5Y-OS) compared with breast, prostate, uterine, and ovarian cancer. Incremental cost-effectiveness analysis demonstrates that millions (liver, non-Hodgkin lymphoma, and melanoma) and billions (colorectal and lung) of dollars were required for each additional 1% increase in 5Y-OS compared with PDAC. Funding of research towards early diagnosis of PDAC has decreased by 19% since 2007. For nearly all cancers, treatment-related research receives the highest percentage of NCI funding.

CONCLUSIONS

Funding of PDAC research is significantly less than other cancers, despite its higher mortality and greater potential to improve 5Y-OS. Increased awareness and lobbying are required to increase funding, promote research, and improve survival.

Cost- Effectiveness of Mammography Screening Program in a Resource-Limited Post-Soviet Country of Kazakhstan

OBJECTIVES

To conduct cost effectiveness and benefit-cost analyses of the organized mammography-screening program in the Republic of Kazakhstan comparing women who developed breast cancer in screened and unscreened scenario.

METHODS

389,352 screened women were included in the study. Among these, 895 women were further diagnosed with breast cancer. Outcomes measures include life years saved, quality-adjusted life years, incremental cost-effectiveness ratio, and value of statistical life year. Sensitivity analyses were performed to assess uncertainty.

RESULTS

Compared to no screening scenario, an organized mammography yielded an additional 1,253 life years and 790 quality-adjusted life years in 2016. The incremental cost-effectiveness ratio was equal to 3,157 USD per one QALY saved, which is two times less than the GDP per capita in Kazakhstan in 2016. Sensitivity analysis showed that the mammography remains cost-effective in the majority of the scenarios.

CONCLUSION

Mammography screening in Kazakhstan was found to be highly cost-effective, associated with treatment cost savings, and can be an efficient use of limited resources in Kazakhstan.

The cost-effectiveness and cost-utility analysis of the use of enoxaparin compared with heparin for venous thromboembolism prophylaxis in medical inpatients in Iran

BACKGROUND

Moderate to high risk medical inpatients are at increased risk of Venous Thromboembolism (VTE). The present study aims to investigate the cost-effectiveness and cost-utility of using Enoxaparin compared to Heparin in VTE prophylaxis in medical inpatients, from Iranian payer's perspective.

METHODS

Decision tree modeling technique was used to evaluate cost-effectiveness and cost-utility of the compared interventions. The main considered outcomes were Life Years Gained (LYG) for Cost-Effectiveness Analysis (CEA) and Quality-Adjusted Life Years (QALY) for Cost-Utility Analysis (CUA). Costs and consequences of the interventions were evaluated for a three-month period and reported as Incremental Cost-Effectiveness Ratios (ICERs). One-way and Probabilistic Sensitivity Analysis (PSA) were conducted to evaluate the robustness of the model due to uncertainty in the input data.

RESULTS

In base case scenario (i.e. public tariff), incremental cost was $10.32, and incremental QALY and incremental LYG were 0.0001 and 0.0002 per patients respectively. Base case ICERs were 60,376 USD/QALY and 71,077 USD/LYG per patient. The results of the sensitivity analysis showed the robustness of the model.

CONCLUSION

As the estimated ICER per QALY is more than three times the reported Gross Domestic Product (GDP) per capita by world bank for Iran in 2017 ($5415), the use of Enoxaparin for VTE prophylaxis in medical in patients doesn't seem to be a cost-effective intervention compared to the use of Heparin in Iran.

A guided and unguided internet- and mobile-based intervention for chronic pain: health economic evaluation alongside a randomised controlled trial

OBJECTIVE

This study aims at evaluating the cost-effectiveness and cost-utility of a guided and unguided internet-based intervention for chronic pain patients (ACTonPain_guided and ACTonPain_unguided) compared with a waitlist control group (CG) as well as the comparative cost-effectiveness of the guided and the unguided version.

DESIGN

This is a health economic evaluation alongside a three-arm randomised controlled trial from a societal perspective. Assessments were conducted at baseline, 9 weeks and 6 months after randomisation.

SETTING

Participants were recruited through online and offline strategies and in collaboration with a health insurance company.

PARTICIPANTS

302 adults (≥18 years, pain for at least 6 months) were randomly allocated to one of the three groups (ACTonPain_guided, ACTonPain_unguided, CG).

INTERVENTIONS

ACTonPain consists of seven modules and is based on Acceptance and Commitment Therapy. ACTonPain_guided and ACTonPain_unguided only differ in provision of human support.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes of the cost-effectiveness and the cost-utility analyses were meaningful change in pain interference (treatment response) and quality-adjusted life years (QALYs), respectively. Economic evaluation estimates were the incremental cost-effectiveness and cost-utility ratio (ICER/ICUR).

RESULTS

At 6-month follow-up, treatment response and QALYs were highest in ACTonPain_guided (44% and 0.280; mean costs = €6,945), followed by ACTonPain_unguided (28% and 0.266; mean costs = €6,560) and the CG (16% and 0.244; mean costs = €6,908). ACTonPain_guided vs CG revealed an ICER of €45 and an ICUR of €604.ACTonPain_unguided dominated CG. At a willingness-to-pay of €0 the probability of being cost-effective was 50% for ACTonPain_guided (vs CG, for both treatment response and QALY gained) and 67% for ACTonPain_unguided (vs CG, for both treatment response and QALY gained). These probabilities rose to 95% when society's willingness-to-pay is €91,000 (ACTonPain_guided) and €127,000 (ACTonPain_unguided) per QALY gained. ACTonPain_guided vs ACTonPain_unguided revealed an ICER of €2,374 and an ICUR of €45,993.

CONCLUSIONS

Depending on society's willingness-to-pay, ACTonPain is a potentially cost-effective adjunct to established pain treatment. ACTonPain_unguided (vs CG) revealed lower costs at better health outcomes. However, uncertainty has to be considered. Direct comparison of the two interventions does not indicate a preference for ACTonPain_guided.

TRIAL REGISTRATION NUMBER

DRKS00006183.

Increased Volume of Surgery for Lumbar Spinal Stenosis and Changes in Surgical Methods and Outcomes: A Nationwide Cohort Study with a 5-Year Follow-Up

OBJECTIVE

Examining spine surgery patterns over time is crucial to provide insights into variations and changes in clinical decision making. Changes in the number of surgeries, surgical methods, reoperation rates, and cost-effectiveness were analyzed for all patients who underwent surgery for lumbar spinal stenosis without spondylolisthesis in 2003 (2003 cohort) and 2008 (2008 cohort).

METHODS

The national health insurance database was used to create the 2003 cohort (n = 10,990) and 2008 cohort (n = 27,942). The surgical methods were classified into decompression and fusion surgery. The cumulative reoperation probability between those surgeries was calculated using the Kaplan-Meier method in the 2003 cohort and 2008 cohort. Comparison of the incremental cost-effectiveness ratios showed the additional direct cost of a 1% change in the reoperation probability.

RESULTS

The surgical volume increased 2.54-fold in the 2008 cohort. The age-adjusted number of surgeries per 1 million people increased 2.6-fold (from 154 in the 2003 cohort to 399 in the 2008 cohort) in aged patients and 1.9-fold (from 154 in the 2003 cohort to 291 in the 2008 cohort) in patients 20-59 years old in the 2008 cohort. The proportion of fusion surgeries increased from 20.3% in the 2003 cohort to 37.0% in the 2008 cohort. In total, the 5-year reoperation probabilities increased from 8.1% in the 2003 cohort to 11.2% in the 2008 cohort. Fusion decreased the reoperation probability by 1% at the cost of 1,711 U.S. dollars.

CONCLUSIONS

The increased numbers of spinal surgeries, fusion surgeries, and surgeries in older patients in a recent cohort were noteworthy. However, the increased surgical volume and fusion surgeries did not reduce the reoperation rate.

MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care

BACKGROUND

South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams.

METHODS

In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model.

RESULTS

In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective.

CONCLUSION

Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.

Increased Volume of Lumbar Surgeries for Herniated Intervertebral Disc Disease and Cost-Effectiveness Analysis: A Nationwide Cohort Study

STUDY DESIGN

Retrospective cohort study of a nationwide database.

OBJECTIVE

The primary objective was to summarize the use of surgical methods for lumbar herniated intervertebral disc disease (HIVD) at two different time periods under the national health insurance system. The secondary objective was to perform a cost-effectiveness analysis by utilizing incremental cost-effectiveness ratio (ICER).

SUMMARY OF BACKGROUND DATA

The selection of surgical method for HIVD may or may not be consistent with cost effectiveness under national health insurance system, but this issue has rarely been analyzed.

METHODS

The data of all patients who underwent surgeries for HIVD in 2003 (n = 17,997) and 2008 (n = 38,264) were retrieved. The surgical methods included open discectomy (OD), fusion surgery, laminectomy, and percutaneous endoscopic lumbar discectomy (PELD). The hospitals were classified as tertiary-referral hospitals (≥300 beds), medium-sized hospitals (30-300 beds), or clinics (<30 beds). ICER showed the difference in the mean total cost per 1% decrease in the reoperation probability among surgical methods. The total cost included the costs of the index surgery and the reoperation.

RESULTS

In 2008, the number of surgeries increased by 2.13-fold. The number of hospitals increased by 34.75% (731 in 2003 and 985 in 2008). The proportion of medium-sized hospitals increased from 62.79% to 70.86%, but the proportion of surgeries performed at those hospitals increased from 61.31% to 85.08%. The probability of reoperation was highest after laminectomy (10.77%), followed by OD (10.50%), PELD (9.20%), and fusion surgery (7.56%). The ICERs indicated that PELD was a cost-effective surgical method. The proportion of OD increased from 71.21% to 84.12%, but that of PELD decreased from 16.68% to 4.57%.

CONCLUSION

The choice of surgical method might not always be consistent with cost-effectiveness strategies, and a high proportion of medium-sized hospitals may be responsible for this change.

LEVEL OF EVIDENCE

4.

Cost-effectiveness of a potential vaccine candidate for Haemophilus influenzae serotype 'a'

The preceding decade has witnessed the emergence of severe community-acquired acute infections caused by Haemophilus influenzae serotype a (Hia), with alarming incidence rates in North America, particularly among indigenous populations. The remarkable success of Hib conjugate vaccine over the past 20 years signify the development of an Hia vaccine candidate as a prevention measure to reduce the incidence of invasive Hia disease. However, quantifications of the long-term epidemiologic and economic impacts of vaccination are needed to inform decision on investment in Hia vaccine development and immunization programs. We sought to evaluate the cost-effectiveness of an Hia vaccine with a similar routine infant immunization schedules currently in practice for Hib in Canada. We developed and parameterized an agent-based simulation model using age-specific incidence rates reported for Nunavut, a Canadian territory with predominantly aboriginal populations. Our results, based on statistical analyses of the incremental cost-effectiveness ratio, show that an Hia conjugate vaccine is highly cost-effective. Sustaining an immunization program with vaccine coverages of 77% for primary series and 93% for booster dose over a 10-year period reduces the incidence of invasive disease by 63.8% on average from 9.97 to 3.61 cases, per 100,000 population. The overall costs of disease management in year 10 are reduced by 53.4% from CDN $1.863 million (95% CI: $1.229-$2.519 M) to CDN $0.868 million (95% CI: $0.627-$1.120 M). The findings suggest an important role for a conjugate vaccine in managing Hia disease as a growing public health threat.

Evaluating quality of life and cost implications of prophylactic radiotherapy in mesothelioma: Health economic analysis of the SMART trial

BACKGROUND

The SMART trial is a UK-based, multicentre RCT comparing prophylactic radiotherapy and symptom-based (deferred) radiotherapy in 203 patients with Malignant Pleural Mesothelioma who had undergone large bore pleural interventions. Using costs and quality of life data collected alongside the clinical trial, we will estimate the cost-effectiveness of prophylactic radiotherapy compared to deferred radiotherapy over a 1-year period.

METHODS

Healthcare utilization and costs were captured during the trial. Utility weights produced by the EQ-5D questionnaire were used to determine quality-adjusted life-years (QALY) gained. The incremental cost-effectiveness ratio was calculated over the one-year trial period.

RESULTS

Costs were similar in the immediate and deferred radiotherapy groups: £5480.40 (SD = £7040; n = 102) and £5461.40 (SD = £7770; n = 101) respectively. There was also no difference in QALY: 0.498 (95% CI: [0.45, 0.547]) in the prophylactic radiotherapy group versus 0.525 (95% CI: [0.471, 0.580]) in the deferred group. At a willingness to pay threshold of £30,000/QALY there was only a 24% chance that prophylactic radiotherapy was cost-effective compared to deferred radiotherapy.

CONCLUSIONS

There was no significant effect of prophylactic radiotherapy on quality of life in the intervention group, nor was there any discernable decrease in healthcare costs. There is little evidence to suggest that prophylactic radiotherapy is a cost-effective intervention in this population.

TRIAL REGISTRATION

ISRCTN72767336 with ISRCTN.

Surgical reconstruction is a cost-efficient treatment option for isolated PCL injuries

PURPOSE AND HYPOTHESIS

The main purpose of the study is to put focus on the costs related to treating posterior cruciate ligament (PCL) injuries and the possible implications of chosen treatment strategy to the respective institutions and society.

METHODS

Costs of treating PCL injuries nonoperatively and for both single-bundle (SB) and double-bundle (DB) reconstruction were estimated. These costs were translated into equivalent quality-adjusted life years (QALY) given a threshold value of Euro (€) 70,000 per QALY. Expected gain in knee osteoarthritis outcome score (KOOS) quality of life (QoL) following surgery based on KOOS data from 112 patients was used as a basis for calculating the cost efficiency ratio.

RESULTS

The average calculated cost of nonoperative treatment was €3382. Incremental cost for SB PCLR was €8585 (154%) and another increment of €5220 (61%) for DB PCLR using numbers from a European hospital. This is equivalent to increments of 0.074 (SB) and another 0.075 (DB) QALYs given the €70,000 threshold. For DB to be as cost efficient as SB reconstruction, the incremental gain in KOOS QoL has to be at the same level as for SB reconstruction compared to nonoperative treatment.

CONCLUSION

Though surgical reconstruction adds a substantial cost to nonoperative treatment alone, it can be considered cost-effective. Double-bundle reconstruction is less cost efficient than SB reconstruction, but should probably still be considered the treatment of choice for certain patient categories. Randomized controlled trials looking at outcome following nonoperative, SB and DB PCL reconstruction are needed. The clinical relevance of this is that surgical reconstruction of PCL injuries is a cost-efficient treatment alternative in patients with an isolated PCL injury. This finding should be taken into consideration when deciding on how to treat these injuries.

LEVEL OF EVIDENCE

III.

Cost-Effectiveness of Cetuximab as First-line Treatment for Metastatic Colorectal Cancer in the United States

PURPOSE

We conducted a cost-effectiveness analysis incorporating recent phase III clinical trial (FIRE-3) data to evaluate clinical and economic tradeoffs associated with first-line treatments of KRAS wild-type (WT) metastatic colorectal cancer (mCRC).

MATERIALS AND METHODS

A cost-effectiveness model was developed using FIRE-3 data to project survival and lifetime costs of FOLFIRI plus either cetuximab or bevacizumab. Hypothetical KRAS-WT mCRC patients initiated first-line treatment and could experience adverse events, disease progression warranting second-line treatment, or clinical response and hepatic metastasectomy. Model inputs were derived from FIRE-3 and published literature. Incremental cost-effectiveness ratios (ICERs) were reported as US$ per life year (LY) and quality-adjusted life year (QALY). Scenario analyses considered patients with extended RAS mutations and CALGB/SWOG 80405 data; 1-way and probabilistic sensitivity analyses were conducted.

RESULTS

Compared with bevacizumab, KRAS-WT patients receiving first-line cetuximab gained 5.7 months of life at a cost of $46,266, for an ICER of $97,223/LY ($122,610/QALY). For extended RAS-WT patients, the ICER was $77,339/LY ($99,584/QALY). Cetuximab treatment was cost-effective 80.3% of the time, given a willingness-to-pay threshold of $150,000/LY. Results were sensitive to changes in survival, treatment duration, and product costs.

CONCLUSIONS

Our analysis of FIRE-3 data suggests that first-line treatment with cetuximab and FOLFIRI in KRAS (and extended RAS) WT mCRC patients may improve health outcomes and use financial resources more efficiently than bevacizumab and FOLFIRI. This information, in combination with other studies investigating comparative effectiveness of first-line options, can be useful to clinicians, payers, and policymakers in making treatment and resource allocation decisions for mCRC patients.

On the censored cost-effectiveness analysis using copula information

Background

Information and theory beyond copula concepts are essential to understand the dependence relationship between several marginal covariates distributions. In a therapeutic trial data scheme, most of the time, censoring occurs. That could lead to a biased interpretation of the dependence relationship between marginal distributions. Furthermore, it could result in a biased inference of the joint probability distribution function. A particular case is the cost-effectiveness analysis (CEA), which has shown its utility in many medico-economic studies and where censoring often occurs.

Methods

This paper discusses a copula-based modeling of the joint density and an estimation method of the costs, and quality adjusted life years (QALY) in a cost-effectiveness analysis in case of censoring. This method is not based on any linearity assumption on the inferred variables, but on a punctual estimation obtained from the marginal distributions together with their dependence link.

Results

Our results show that the proposed methodology keeps only the bias resulting statistical inference and don’t have anymore a bias based on a unverified linearity assumption. An acupuncture study for chronic headache in primary care was used to show the applicability of the method and the obtained ICER keeps in the confidence interval of the standard regression methodology.

Conclusion

For the cost-effectiveness literature, such a technique without any linearity assumption is a progress since it does not need the specification of a global linear regression model. Hence, the estimation of the a marginal distributions for each therapeutic arm, the concordance measures between these populations and the right copulas families is now sufficient to process to the whole CEA.

Effectiveness, toxicity, and economic evaluation of ipilimumab for the treatment of patients with metastatic melanoma in the Spanish outpatient setting

To evaluate the effectiveness and toxicity profile of ipilimumab treatment and to examine the cost-effectiveness relation in a real-world sample of patients with metastasic melanoma. This was a multicenter, observational, retrospective cohorts study. To assess the effectiveness and safety of ipilimumab treatment progression-free survival (PFS), overall survival (OS) and adverse events were registered. An economic evaluation was performed and cost-effectiveness ratios (CERs) were calculated. Eleven patients were included, mean age 59 (SD=11) years. The median PFS was 3.83 months (95% confidence interval 0.98-9.80) and the median OS was 5.15 months (95% confidence interval 1.70-8.48). None of the patients included in the study achieved an objective response. A stable disease was achieved in four (36%) patients. The most commonly reported analytical adverse event was anemia, with all patients developing anemia in any grade. The most severe adverse event was neutropenia (n=6; 55%), with three patients developing grade 4 neutropenia (3/11; 27%). The total cost of ipilimumab treatment was &OV0556;483 397, with a median of 43 033 (interquartile range=9555) euros per patient. The median-based CER was 136 675 (28 539-474 865) euros per progression-free year gained and the median-based CER was 100 112 (23 107-374 893) euros per life-year gained. PFS observed in real-world patients was higher than that reported in clinical trials and OS was lower. The incidence of adverse events was higher. The additional cost per progression-free year gained was ∼&OV0556;136 675. The data from this study fill an important need for information on the relative value of this treatment in terms of cost-effectiveness.

Development of a home-based training program for post-ward geriatric rehabilitation patients with cognitive impairment: study protocol of a randomized-controlled trail

Background

Geriatric patients with cognitive impairment (CI) show an increased risk for a negative rehabilitation outcome and reduced functional recovery following inpatient rehabilitation. Despite this obvious demand, evidence-based training programs at the transition from rehabilitation to the home environments are lacking. The aim of this study is to evaluate the efficacy of a feasible and cost-effective home-based training program to improve motor performance and to promote physical activity, specifically-tailored for post-ward geriatric patients with CI.

Methods

A sample of 101 geriatric patients with mild to moderate stage CI following ward-based rehabilitation will be recruited for a blinded, randomized controlled trial with two arms. The intervention group will conduct a 12 week home-based training, consisting of (1) Exercises to improve strength/power, and postural control; (2) Individual walking trails to enhance physical activity; (3) Implementation of patient-specific motivational strategies to promote behavioral changes. The control group will conduct 12 weeks of unspecific flexibility exercise. Both groups will complete a baseline measurement before starting the program, at the end of the intervention, and after 24 weeks for follow-up. Sensor-based as well as questionnaire-based measures will be applied to comprehensively assess intervention effects. Primary outcomes document motor performance, assessed by the Short Physical Performance Battery, and level of physical activity (PA), as assessed by duration of active episodes (i.e., sum of standing and walking). Secondary outcomes include various medical, psycho-social, various PA and motor outcomes, including sensor-based assessment as well as cost effectiveness.

Discussion

Our study is among the first to provide home-based training in geriatric patients with CI at the transition from a rehabilitation unit to the home environment. The program offers several unique approaches, e.g., a comprehensive and innovative assessment strategy and the integration of individually-tailored motivational strategies. We expect the program to be safe and feasible in geriatric patients with CI with the potential to enhance the sustainability of geriatric rehabilitation programs in patients with CI.

Trial registration

International Standard Randomized Controlled Trial (#ISRCTN82378327). Registered: August 10, 2015.

Value-Based Calculators in Cancer: Current State and Challenges

The ASCO Value Framework, National Comprehensive Cancer Network Evidence Blocks, Memorial Sloan Kettering's DrugAbacus, and Institute for Clinical and Economic Review incremental cost-effectiveness ratio calculator are value-based methodologies that attempt to address the disproportionate increase in cancer care spending. These calculators can be used as an initial step for discussing cost versus value, but they fall short in recognizing the importance of the cancer journey because they do not fully factor the patient's perspective or the global cost of care. This timely review highlights both the limitations and the advantages of each value calculator and suggests opportunities for refinement. Practicing oncologists, payers, and manufacturers should be familiar with value-based calculators because the role these tools play in cost containment is likely to be hotly debated.

Cost-effectiveness analysis of different devices used for the closure of small-to-medium-sized patent ductus arteriosus in pediatric patients

Aims:

In this study, we examined the differences in cost and effectiveness of various devices used for the closure of small to medium sized patent ductus arteriosus (PDA).

Setting and Design:

We retrospectively studied 116 patients who underwent closure of small PDAs between January 2010 and January 2015.

Subjects and Methods:

Three types of devices were used: the Amplatzer duct occluder (ADO) II, the cook detachable coil and the Nit Occlud coil (NOC). Immediate and late complications were recorded and patients were followed up for 3 months after the procedure.

Statistical Methods:

All statistical calculations were performed using Statistical Package for the Social Science software. P <0.05 were considered significant.

Results:

We successfully deployed ADO II devices in 33 out of 35 cases, cook detachable coils in 36 out of 40 cases and NOCs in 38 out of 41 cases. In the remaining nine cases, the first device was unsuitable or embolized and required retrieval and replacement with another device. Eleven patients (9.5%) developed vascular complications and required anticoagulation therapy. Patients who had hemolysis or vascular complications remained longer in the intensive care unit, with consequently higher total cost (P = 0.016). Also, the need for a second device increased the cost per patient.

Conclusions:

The cook detachable coil is the most cost-effective device for closure of small-to medium-sized PDAs. Calculations of the incremental cost-effectiveness. (ICE) revealed that the Cook detachable coil had less ICE than the ADO II and NOC. The NOC was more effective with fewer complications.

Tolerance limits and tolerance intervals for ratios of normal random variables using a bootstrap calibration

This paper addresses the problem of deriving one-sided tolerance limits and two-sided tolerance intervals for a ratio of two random variables that follow a bivariate normal distribution, or a lognormal/normal distribution. The methodology that is developed uses nonparametric tolerance limits based on a parametric bootstrap sample, coupled with a bootstrap calibration in order to improve accuracy. The methodology is also adopted for computing confidence limits for the median of the ratio random variable. Numerical results are reported to demonstrate the accuracy of the proposed approach. The methodology is illustrated using examples where ratio random variables are of interest: an example on the radioactivity count in reverse transcriptase assays and an example from the area of cost-effectiveness analysis in health economics.

Cost-effectiveness of Corticosteroid Nasal Spray vs Surgical Therapy in Patients With Severe to Extreme Anatomical Nasal Obstruction

IMPORTANCE

Health insurance companies commonly require a trial of corticosteroid nasal spray prior to authorizing nasal surgery, even in patients with severe to extreme anatomical nasal obstruction, despite lack of data supporting such medical therapy.

OBJECTIVES

To provide a model for the comparative analysis of medical vs surgical treatment for nasal obstruction to help maximize health care benefit per dollar spent and to explore the cost-effectiveness of corticosteroid nasal spray in patients with severe to extreme nasal airway obstruction on Nasal Obstruction Symptom Evaluation (NOSE) scores.

DESIGN, SETTING, AND PARTICIPANTS

A cost-efficiency frontier economic evaluation was performed. The economic perspective was that of the health care third-party payer. Effectiveness data were obtained from NOSE score questionnaires in 179 patients. An incremental cost-effectiveness ratio was determined from the cost and efficacy data. Comparative treatment groups were medical therapy with corticosteroid nasal spray vs surgical therapy for nasal airway obstruction. The study was conducted between January 1, 2011, and December 30, 2013. The time horizon included 1, 2, and 5 years. Data analysis was completed June 1, 2015.

MAIN OUTCOMES AND MEASURES

The primary outcome was cost per quality-adjusted life-year (QALY). A modified Markov decision tree model was used. Costs were obtained from the Medicare 2015 physician fee schedule, and the mean was determined (owing to geographic disparity) along with wholesale and generic pharmaceutical pricing.

RESULTS

Among 100 men and 79 women evaluated (mean [SD] age, 37.9 [12.9] years), surgical repair of severe nasal airway obstruction cost $6537 and produced a total of 1.15 QALYs at 1 year. Medical treatment involved a trial of corticosteroid nasal sprays, which cost $520 and produced a total of 1.03 QALYs. The surgical approach was markedly more effective but at greater short-term cost. In cases of extreme nasal obstruction, medical treatment cost $520.73 with 1.004 QALYs, demonstrating an incremental cost-effectiveness ratio (ICER) of $354 693 per QALY compared with no treatment. Conversely, surgical treatment cost $6536.64 and produced 1.136 QALYs, with an ICER of $45 633 compared with medical therapy. At 5 years, the ICER decreased from $45 634 to $8110 per QALY for surgical treatment of extreme nasal obstruction. The medical treatment ICER decreased from $354 693 per QALY at 1 year to $273 704 per QALY at 5 years. An ICER was performed and demonstrated a cost threshold of $50 554 per QALY for surgical treatment compared with $67 518 per QALY for medical treatment at 1 year for severe nasal obstruction. If the evaluation is extended to 5 years, surgical treatment cost $8984 per QALY compared with $52 571 per QALY for medical treatment. Owing to the improved effectiveness outcomes, greater cost savings per ICER was demonstrated in patients with extreme nasal obstruction.

CONCLUSIONS AND RELEVANCE

Surgical treatment for patients with severe to extreme anatomical nasal obstruction demonstrates increased short-term expense but is cost-effective in the long term. These data suggest that treatment with corticosteroid nasal spray in patients with documented severe to extreme anatomical nasal obstruction is unnecessary and results in a delay in treatment.

LEVEL OF EVIDENCE

NA.

Reducing neuropsychiatric symptoms in persons with dementia and associated burden in family caregivers using tailored activities: Design and methods of a randomized clinical trial

Among over 5million people in the USA with dementia, neuropsychiatric symptoms (NPS) are almost universal, occurring across disease etiology and stage. If untreated, NPS can lead to significant morbidity and mortality including increased cost, distress, depression, and faster disease progression, as well as heightened burden on families. With few pharmacological solutions, identifying nonpharmacologic strategies is critical. We describe a randomized clinical trial, the Dementia Behavior Study, to test the efficacy of an activity program to reduce significant existing NPS and associated caregiver burden at 3 and 6months compared to a control group intervention. Occupational therapists deliver 8 in-home sessions over 3months to assess capabilities and interests of persons with dementia, home environments, and caregiver knowledge, and readiness from which activities are developed and families trained in their use. Families learn to modify activities for future declines and use strategies to address care challenges. The comparison group controls for time and attention and involves 8 in-home sessions delivered by health educators who provide dementia education, home safety recommendations, and advanced care planning. We are randomizing 250 racially diverse families (person with dementia and primary caregiver dyads) recruited from community-based social services, conferences and media announcements. The primary outcome is change in agitation/aggression at 3 and 6months. Secondary outcomes assess quality of life of persons with dementia, other behaviors, burden and confidence of caregivers, and cost and cost effectiveness. If benefits are supported, this activity intervention will provide a clinically meaningful approach to prevent, reduce, and manage NPS.