Understanding the global measurement of willingness to pay in health

Review of the cost-effectiveness of surveillance for hereditary pancreatic cancer

Individuals with hereditary pancreatic cancer risk include high risk individuals (HRIs) with germline genetic susceptibility to pancreatic cancer (PC) and/or a strong family history of PC. Previously, studies have shown that PC surveillance in HRIs can downstage PC diagnosis and extend survival leading to pancreatic surveillance being recommended for certain HRIs. However, the optimal surveillance strategy remains uncertain, including which modalities should be used for surveillance, how frequently should surveillance be performed, and which sub-groups of HRIs should undergo surveillance. Additionally, in the ideal world PC surveillance should also be cost-effective. Cost-effectiveness analysis is a valuable tool that can consider the costs, potential health benefits, and risks among various PC surveillance strategies. In this review, we summarize the cost-effectiveness of various PC surveillance strategies for HRIs for hereditary pancreatic cancer and provide potential avenues for future work in this field. Additionally, we include cost-effectiveness studies among individuals with new-onset diabetes (NoD), a high-risk group for sporadic PC, as a comparison.

Cost Effectiveness of Systemic Treatment Intensification for Metastatic Hormone-sensitive Prostate Cancer: Is Triplet Therapy Cost Effective?

BACKGROUND AND OBJECTIVE

There has been a shift toward systemic treatment intensification for men with metastatic hormone-sensitive prostate cancer (mHSPC). Recent trials have demonstrated the efficacy of triplet therapy with an androgen receptor signalling inhibitor (ARSI), docetaxel, and androgen deprivation therapy (ADT). However, ARSI treatment is expensive. The objective was to determine the cost effectiveness of current treatments strategies for men with mHSPC.

METHODS

We developed a Markov state-transition model to simulate outcomes for men with newly diagnosed mHSPC. For the simulation, patients were entered in the model in the mHSPC disease state before progressing to castration-resistant disease and finally dying from prostate cancer. Costs were calculated from a USA health sector perspective in 2022 US dollars. Deterministic and probabilistic sensitivity analyses were conducted to account for uncertainty in the parameter estimates. We also performed scenario analyses for costs in the UK and Australian health sectors.

KEY FINDINGS AND LIMITATIONS

Treatment intensification with doublet and triplet therapy resulted in an improvement in quality-adjusted survival for all strategies in comparison to ADT monotherapy. However, only docetaxel doublet therapy was cost effective at standard thresholds, with an incremental cost-effectiveness ratio of $13 647. The cost of ARSIs needed to be discounted by 47-70% before they were cost effective. Only medication costs impacted the model results. If the generic price for abiraterone acetate is used, then triplet therapy with abiraterone is the best-value option. Similar results were obtained for analyses for the UK and Australian health sectors.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Treatment intensification with ARSIs in men with mHSPC results in better quality-adjusted survival but is not cost effective according to standard thresholds. The costs of these medications would need to be heavily discounted before they are cost effective. The cost of generic ARSIs, once available, would render these strategies cost effective.

PATIENT SUMMARY

This report examines whether increasing the number of systemic drugs used to treat a patient's metastatic hormone-sensitive prostate cancer is cost effective for the health care system. We found that the additional cost of triplet therapy does not justify the increase in patient benefit.

The epidemiologic and economic impact of varicella and herpes zoster vaccination in South Korea: A mathematical modelling study

BACKGROUND

In South Korea, the National Immunization Program has included one-dose varicella vaccination for 1-year-olds since 2005. This study examines the potential impact of introducing a two-dose varicella vaccination for children, along with zoster vaccination for adults, using either the zoster vaccine live (ZVL) or recombinant zoster vaccine (RZV).

METHODS

The investigation considered four strategies in a base case scenario. The first involved introducing zoster vaccination for 60-year-olds, with a 60 % coverage. The second strategy combined zoster vaccination with a second-dose varicella vaccination for 4-year-olds, with a 90 % coverage. An age-structured model spanning 50 years was employed, assuming a zoster vaccine catch-up campaign over the initial 5 years. Cost-effectiveness analyses were conducted, assessing incremental cost-effectiveness ratios (ICERs), incremental net monetary benefits (INMBs), and net loss under different ages at zoster vaccination (50, 60, 65, and 70 years) and varying willingness-to-pay (WTP) levels from ₩40 million ($34,998) to ₩84 million ($74,000).

RESULTS

All strategies were cost-effective and significantly reduced herpes zoster (HZ) incidence, preventing approximately 3,077,000 to 7,609,000 cases, depending on the chosen strategy. The combined strategy prevented around 4,950,000 varicella and 653,000 HZ cases additionally. RZV outperformed ZVL by preventing twice as many HZ cases and offering greater QALY gains. However, ZVL was more cost-effective due to its lower cost. Probabilistic sensitivity analyses revealed that RZV became more cost-effective at higher WTP thresholds, exceeding ₩60.9 million ($53,193) in terms of ICER and ₩62.5 million ($54,591) for INMBs and net loss. The optimal age for zoster vaccination was 60 years concerning ICER but 50 years regarding INMB.

CONCLUSIONS

Combining RZV with a two-dose varicella vaccination strategy reduced the disease burden and improved QALY more effectively, though ZVL remained more cost-effective at lower WTP levels. Decisions regarding vaccination policies should be balanced between the public health needs and WTP levels.

Comparative cost-effectiveness analysis of CDK4/6 inhibitors in the first-line treatment of HR-positive and HER2-negative advanced breast cancer: a Markov's model-based evaluation

Introduction

CDK4/6 inhibitors are the first-line treatment for HR+/HER2- advanced breast cancer. Despite their clinical benefit, they can increase healthcare expenditure. To date, there is no thorough comparison among the three approved CDK4/6 inhibitors in terms of their cost-effectiveness.

Objective

To investigate and compare the cost-effectiveness of CDK4/6 inhibitors in combination with letrozole as a first-line treatment for advanced breast cancer with hormonal-receptor-positivity and HER-2-negativity versus one another and versus letrozole monotherapy.

Methods

A 10-year within-cycle-corrected Markov's model was employed from the healthcare payer perspective. Costs were obtained from the National Center for Cancer Care and Research (NCCCR) in Qatar. Utilities and transition probabilities were calculated from published landmark trials of PALOMA-2, MONALEESA-2, MONARCH-3, PO25, and other relevant literature. Costs, measured in Qatari Riyal (QAR), and effectiveness, measured in quality-adjusted-life-years (QALYs), were incremented and the incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold (WTP) of 1.5 Qatari GDP (448,758 QAR). A deterministic sensitivity analysis was implemented to account for uncertainties.

Results

Ribociclib was the most effective option, generating 4.420 QALYs, followed by palbociclib (4.406 QALYs), abemaciclib (4.220 QALYs), then letrozole monotherapy (2.093 QALYs). As for cost-effectiveness, ribociclib dominated palbociclib. However, it was not cost-effective compared to abemaciclib (ICER=1,588,545 QAR/QALY). Ribociclib remained dominant over palbociclib with all uncertainties. The base-case conclusion of ribociclib versus abemaciclib remained robust over all uncertainties.

Conclusion

From the healthcare payer perspective in Qatar, ribociclib is the most effective CDK4/6 inhibitor. It was dominant over palbociclib in terms of cost-effectiveness; however, it was not cost-effective compared to abemaciclib at current prices.

What defines the "value" of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center

The use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high-level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient-centered, value-based healthcare models and reimbursement systems that embrace cost-effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value-based care, with a focus on robotic surgery for gastrointestinal cancers.

Stratification of Barrett's esophagus surveillance based on p53 immunohistochemistry: a cost-effectiveness analysis by an international collaborative group

BACKGROUND

Surveillance of nondysplastic Barrett's esophagus (NDBE) is recommended to identify progression to dysplasia; however, the most cost-effective strategy remains unclear. Mutation of TP53 or aberrant expression of p53 have been associated with the development of dysplasia in BE. We sought to determine if surveillance intervals for BE could be stratified based on p53 expression.

METHODS

A Markov model was developed for NDBE. Patients with NDBE underwent p53 immunohistochemistry (IHC) and those with abnormal p53 expression underwent surveillance endoscopy at 1 year, while patients with normal p53 expression underwent surveillance in 3 years. Patients with dysplasia underwent endoscopic therapy and surveillance.

RESULTS

On base-case analysis, the strategy of stratifying surveillance based on abnormal p53 IHC was cost-effective relative to conventional surveillance and a natural history model, with an incremental cost-effectiveness ratio (ICER) of $8258 for p53 IHC-based surveillance. Both the conventional and p53-stratified surveillance strategies dominated the natural history model. On probabilistic sensitivity analysis, the p53 IHC strategy ($28 652; 16.78 quality-adjusted life years [QALYs]) was more cost-effective than conventional surveillance ($25 679; 16.17 QALYs) with a net monetary benefit of $306 873 compared with conventional surveillance ($297 642), with an ICER <$50 000 in 96% of iterations. The p53-stratification strategy was associated with a 14% reduction in the overall endoscopy burden and a 59% increase in dysplasia detection.

CONCLUSION

A surveillance strategy for BE based on abnormal p53 IHC is cost-effective relative to a conventional surveillance strategy and is likely to be associated with higher rates of dysplasia diagnosis.

Employing Real-World Evidence for the Economic Evaluation of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation in Thailand

BACKGROUND

This study aimed to assess the cost-effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) in comparison with warfarin using data from real practice based on the perspective of the health care system in Thailand.

METHODS

A four-state Markov model encompassing well-controlled atrial fibrillation (AF), stroke and systemic embolism, major bleeding and death was utilised to forecast clinical and economic outcomes. Transitional probabilities, direct medical costs and utilities were derived from the real-world data of the 'COOL-AF Thailand' registry, Thailand's largest nationwide registry spanning 27 hospitals. The cohort comprised AF patients. The primary outcomes assessed were total costs, life years, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio. All costs and outcomes were subject to an annual discount rate of 3.0%. A spectrum of sensitivity analyses was conducted.

RESULTS

The mean age of the cohort was 68.8 ± 10.7 years. The NOACs group incurred a marginally lower total lifetime cost than the warfarin group (247,857 Thai baht [THB] vs 253,654 THB or 7137 USD vs 7304 USD) and experienced gains of 0.045 life years and 0.043 QALYs over the warfarin group. Given the lower cost and higher benefits associated with NOACs, this implies that NOAC treatment is a dominant strategy compared to warfarin for AF patients. At a ceiling ratio of 160,000 THB (4607 USD) per QALY, NOACs presented a 61.2% probability of being cost effective.

CONCLUSIONS

Non-vitamin K antagonist oral anticoagulants represent a cost-saving alternative to warfarin in the real clinical practice. However, with a probability of being cost effective below 65%, it suggests some parameter uncertainty regarding their overall cost effectiveness compared to warfarin.

Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies

INTRODUCTION

The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.

AREAS COVERED

In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.

EXPERT OPINION

Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.

Cost-effectiveness of maribavir versus conventional antiviral therapies for post-transplant refractory cytomegalovirus infection with or without genotypic resistance: A US perspective

This study evaluated the cost-effectiveness of maribavir versus investigator-assigned therapy (IAT; valganciclovir/ganciclovir, foscarnet, or cidofovir) for post-transplant refractory cytomegalovirus (CMV) infection with or without resistance. A two-stage Markov model was designed using data from the SOLSTICE trial (NCT02931539), real-world multinational observational studies, and published literature. Stage 1 (0-78 weeks) comprised clinically significant CMV (csCMV), non-clinically significant CMV (n-csCMV), and dead states; stage 2 (78 weeks-lifetime) comprised alive and dead states. Total costs (2022 USD) and quality-adjusted life years (QALYs) were estimated for the maribavir and IAT cohorts. An incremental cost-effectiveness ratio was calculated to determine cost-effectiveness against a willingness-to-pay threshold of $100 000/QALY. Compared with IAT, maribavir had lower costs ($139 751 vs $147 949) and greater QALYs (6.04 vs 5.83), making it cost-saving and more cost-effective. Maribavir had higher acquisition costs compared with IAT ($80 531 vs $65 285), but lower costs associated with administration/monitoring ($16 493 vs $27 563), adverse events (AEs) ($11 055 vs $16 114), hospitalization ($27 157 vs $33 905), and graft loss ($4516 vs $5081), thus making treatment with maribavir cost-saving. Maribavir-treated patients spent more time without CMV compared with IAT-treated patients (0.85 years vs 0.68 years), leading to lower retreatment costs for maribavir (cost savings: -$42 970.80). Compared with IAT, maribavir was more cost-effective for transplant recipients with refractory CMV, owing to better clinical efficacy and avoidance of high costs associated with administration, monitoring, AEs, and hospitalizations. These results can inform healthcare decision-makers on the most effective use of their resources for post-transplant refractory CMV treatment.

RETRACTED: Cost-effectiveness of chemotherapy and dostarlimab for advanced or recurrent endometrial cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/policies/article-withdrawal). This article has been retracted at the request of the Authors. The authors have independently identified an error in the formula that was utilized to calculate the Quality Adjusted Life Years which invalidates the data and the conclusion of the paper. The authors have contacted the journal requesting to retract the article. Apologies are offered to the readers of the journal for any confusion or inconvenience that may have resulted from the publication of this article.

An economic evaluation of community pharmacy-dispensed naloxone in Canada

Aims

To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada.

Methods

We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted.

Results

Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone.

Conclusion

Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

Modelling cost-effectiveness of replacement strategies for ambulance services in the Ministry of Health Malaysia

BACKGROUND

Emergency Medical Service (EMS) is a very crucial aspect of the healthcare system in providing urgent management and transportation of patients during emergencies. The sustainability of the services is however greatly impacted by the quality and age of ambulances. While this has led to numerous replacement policy recommendations, the implementations are often limited due to a lack of evidence and financial constraints. This study thus aims to develop a cost-effectiveness model and testing the model by evaluating the cost-effectiveness of 10-year and 15-year compulsory ambulance replacement strategies in public healthcare for the Malaysian Ministry of Health (MOH).

METHODS

A Markov model was developed to estimate the cost and outcomes ambulance replacement strategies over a period of 20 years. The model was tested using two alternative strategies of 10-year and 15-year. Model inputs were derived from published literature and local study. Model development and economic analysis were accomplished using Microsoft Excel 2016. The outcomes generated were costs per year, the number of missed trips and the number of lives saved, in addition to the Incremental Cost-Effectiveness Ratio (ICER). One-Way Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were conducted to identify the key drivers and to assess the robustness of the model.

RESULTS

Findings showed that the most expensive strategy, which is the implementation of 10 years replacement strategy was more cost-effective than 15 years ambulance replacement strategy, with an ICER of MYR 11,276.61 per life saved. While an additional MYR 13.0 million would be incurred by switching from a 15- to 10-year replacement strategy, this would result in 1,157 deaths averted or additional live saved per year. Sensitivity analysis showed that the utilization of ambulances and the mortality rate of cases unattended by ambulances were the key drivers for the cost-effectiveness of the replacement strategies.

CONCLUSIONS

The cost-effectiveness model developed suggests that an ambulance replacement strategy of every 10 years should be considered by the MOH in planning sustainable EMS. While this model may have its own limitation and may require some modifications to suit the local context, it can be used as a guide for future economic evaluations of ambulance replacement strategies and further exploration of alternative solutions.

At-home bleaching versus whitening toothpastes for treatment of tooth discoloration: a cost-effectiveness analysis

OBJECTIVES

This study aimed to analyze the cost-effectiveness of whitening toothpastes and at-home bleaching for the treatment of tooth discoloration.

METHODOLOGY

A cost-effectiveness economic analysis was conducted, and eight randomized clinical trials were selected based on the whitening agent product used: blue covarine dentifrices (BCD), hydrogen peroxide dentifrices (HPD), dentifrices without bleaching agents (CD, negative control), and 10% carbamide peroxide (CP10, positive control) for at-home bleaching. The consumer/patient perspective was adopted, macro-costing techniques were used and a decision tree model was performed considering the costs in the American and Brazilian markets. The color change evaluation (ΔE*ab) was used to calculate the effectiveness of tooth bleaching. A probabilistic analysis was performed using a Monte Carlo simulation and incremental cost-effectiveness ratios were obtained.

RESULTS

CP10 resulted in the highest cost-effectiveness compared to the use of dentifrices in both markets. In Brazil, HPD was more cost-effective than BCD and CD. In the US, the increased costs of HPD and BCD did not generate any whitening benefit compared to CD.

CONCLUSIONS

CP10 was more cost-effective than BCD and HPD for tooth bleaching from the perspectives of the Brazilian and American markets. Decision-making should consider the use of CP10 for treating tooth discoloration.

Arthroscopic Bankart repair versus nonoperative management for first-time anterior shoulder instability: A cost-effectiveness analysis

Purpose

Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment.

Methods

This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000.

Results

The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations.

Discussion

ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.

Cost-Effectiveness of the Second COVID-19 Booster Vaccination in the USA

OBJECTIVE

To assess the cost effectiveness of the second COVID-19 booster vaccination with different age groups.

METHODS

We developed a decision-analytic Susceptible-Exposed-Infected-Recovered (SEIR)-Markov model by five age groups (0-4 years, 5-11 years 12-17 years, 18-49 years, and 50+ years) and calibrated the model by actual mortality in each age group in the USA. We conducted five scenarios to evaluate the cost effectiveness of the second booster strategy and incremental benefits if the strategy would expand to 18-49 years and 12-17 years, from a health care system perspective. The analysis was reported according to the Consolidated Health Economic Evaluation Reporting Standards 2022 statement.

RESULTS

Implementing the second booster strategy for those aged ≥ 50 years cost $823 million but reduced direct medical costs by $1166 million, corresponding to a benefit-cost ratio of 1.42. Moreover, the strategy also resulted in a gain of 2596 quality-adjusted life-years (QALYs) during the 180-day evaluation period, indicating it was dominant. Further, vaccinating individuals aged 18-49 years with the second booster would result in an additional gain of $1592 million and 8790 QALYs. Similarly, expanding the vaccination to individuals aged 12-17 years would result in an additional gain of $16 million and 403 QALYs. However, if social interaction between all age groups was severed, vaccination expansion to ages 18-49 and 12-17 years would no longer be dominant but cost effective with an incremental cost-effectiveness ratio (ICER) of $37,572 and $26,705/QALY gained, respectively.

CONCLUSION

The second booster strategy was likely to be dominant in reducing the disease burden of the COVID-19 pandemic. Expanding the second booster strategy to ages 18-49 and 12-17 years would remain dominant due to their social contacts with the older age group.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses

Background

Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening.

Purpose

To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening.

Materials and methods

The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed.

Results

Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes.

Conclusion

Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Evaluation of the cost-effectiveness of a multicomponent fall prevention program in hospitalized patients

The aim of this pre- and post-interventional study was to analyze the cost-effectiveness of the multicomponent fall prevention program in hospitalized patients. To achieve this aim, cost-effectiveness analysis performed using decision tree modeling was compared with the implementation of the fall prevention program and usual care. The primary outcome was the number of patient falls. The uncertainty in cost and effectiveness data was evaluated using one-way sensitivity analysis, best-worst-case scenario analysis, and probabilistic sensitivity analysis. According to cost-effectiveness analysis, implementation of the fall prevention program was dominantly cost-effective. As a result of the probabilistic sensitivity analysis, it was revealed that, even if willing-to-pay per-fall prevented value was 0, the probability of being cost-effective was 54.4% for the fall prevention program. Economic evaluation results showed that implementing the multicomponent fall prevention program was dominantly cost-effective in hospitalized patients. Nurses and nurse managers can benefit from economic evaluations in their decision-making processes to implement fall prevention programs.

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.

A Systematic Review of the Economic Burden of Proton Therapy in Head and Neck Cancer

BACKGROUND

Radiation therapy is used to treat head and neck cancer (HNC) patients. Proton beam therapy (PBT) is one of the newer treatment options. This systematic review will describe the cost and cost-effectiveness of PBT compared with other first-line treatment options based on available literature and provide a better understanding of its usage in HNC in the future.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches were conducted in PUBMED, EMBASE and SCOPUS till February 2022. Original pharmacoeconomic articles written in English that considered PBT for HNC were included; the title, abstract and full text of the search items were screened. The included studies were critically appraised using the Drummond Checklist followed by data extraction.

RESULTS

Eight of the ten included studies were of good quality; most were cost-effectiveness or cost comparison studies and used the Markov model and lifetime horizon. The dominant comparator was intensity-modulated radiotherapy. The willingness to pay threshold ranged from $30,828 to $150,000 per QALY. The incremental cost-effectiveness ratio (ICER) was between $4,436.1 and $695,000 per QALY. In HNC patients with human papillomavirus infection, the ICER was lower ($288,000/QALY) from the payer's perspective, but much higher ($390,000/QALY) from the societal perspective.

CONCLUSION

Our systematic review showed that appropriate patient selection can make PBT cost-effective. HPV-associated tumors can be cost-effectively treated with PBT. From the payer's perspective, PBT is a cost-effective treatment option. In younger patients, PBT can result in lesser incidence of adverse effects, and hence, can reduce the subsequent need for long-term supportive care. Lower fractionation schedules can also make PBT a cost-effective treatment.

Basics of health economics for clinical trials in orthopaedic trauma

With the rise in global healthcare spending, medical decision-making is increasingly based on health economics outcomes. This narrative review aims to provide an overview of cost-effectiveness analysis (CEA) and cost-utility analysis (CUA), including their advantages and limitations, and outline practical aspects for implementing health economics in clinical trials for orthopaedic trauma. Both CEA and CUA offer several advantages. Firstly, they consider the costs as well as benefits of an intervention, providing a more comprehensive picture of its economic impact. Secondly, they provide a clear and straightforward metric for comparing interventions, which can help decision-makers make informed choices. However, there are methodological shortcomings that must be acknowledged, such as the lack of standardized instruments for assessing health utility measures, which can result in a wide range of cost-benefit ratios. In addition, a consensus on the willingness-to-pay threshold still needs to be reached to develop decision rules for cost-effectiveness similar to clinical effectiveness. Methods such as CEA and CUA should be incorporated into clinical trials in orthopaedic trauma research. Practical aspects for this include planning in advance, preferably in cooperation with a health economist. Selecting appropriate outcome measures is crucial, and both the medical effects of interventions and quality of life instruments should be carefully chosen to ensure comparability with previous studies. Additionally, the potential impact on clinical practice and healthcare policies should be considered. Direct as well as indirect costs should be assessed, and quality assurance with well-established checklists should be confirmed.

Cost-effectiveness of granulocyte colony-stimulating factors (G-CSFs) for the prevention of febrile neutropenia (FN) in patients with cancer

PURPOSE

Clinical practice guidelines recommend the use of all approved granulocyte colony-stimulating factors (G-CSFs), including filgrastim and pegfilgrastim, as primary febrile neutropenia (FN) prophylaxis in patients receiving high- or intermediate-risk regimens (in those with additional patient risk factors). Previous studies have examined G-CSF cost-effectiveness by cancer type in patients with a high baseline risk of FN. This study evaluated patients with breast cancer (BC), non-small cell lung cancer (NSCLC), or non-Hodgkin's lymphoma (NHL) receiving therapy who were at intermediate risk for FN and compared primary prophylaxis (PP) and secondary prophylaxis (SP) using biosimilar filgrastim or biosimilar pegfilgrastim in Austria, France, and Germany.

METHODS

A Markov cycle tree-based model was constructed to evaluate PP versus SP in patients with BC, NSCLC, or NHL receiving therapy over a lifetime horizon. Cost-effectiveness was evaluated over a range of willingness-to-pay (WTP) thresholds for incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analyses evaluated uncertainty.

RESULTS

Results demonstrated that using biosimilar filgrastim as PP compared to SP resulted in incremental cost-effectiveness ratios (ICERs) well below the most commonly accepted WTP threshold of €30,000. Across all three countries, PP in NSCLC had the lowest cost per QALY, and in France, PP was both cheaper and more effective than SP. Similar results were found using biosimilar pegfilgrastim, with ICERs generally higher than those for filgrastim.

CONCLUSIONS

Biosimilar filgrastim and pegfilgrastim as primary prophylaxis are cost-effective approaches to avoid FN events in patients with BC, NSCLC, or NHL at intermediate risk for FN in Austria, France, and Germany.

Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking.

OBJECTIVE

To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up.

METHODS

A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility.

CONCLUSION

Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.

Hip arthroplasty practice across the Organisation for Economic Co-operation and Development (OECD) over the last decade

INTRODUCTION

There are large variations in the number of hip replacements performed between countries, demonstrating large health inequalities; however, there has been limited research on this variation. The aims of this paper were to compare rates of hip replacements using Organisation for Economic Co-operation and Development (OECD) data for the period 2008-2018. The study also compared changes in the number of hip replacements in the total population and in only those aged over 65, and looked for a correlation of health expenditure and gross domestic product (GDP) with rates of hip replacements.

METHODS

The OECD collects annual data from all member countries on the numbers of hip replacements, healthcare expenditure and GDP. Data analysis was undertaken using STATA. Descriptive statistics and Pearson's correlation coefficient were performed.

RESULTS

The mean number of hip replacements performed in OECD countries in 2018 was 191.5 per 100,000 population per year. The largest number was 310.6 in Germany and the lowest was 8.6 in Mexico. There has been a 21.7% increase in the mean number of hip replacements across OECD countries. There was a moderate and significant Pearson coefficient of 0.468 (p = 0.009) between the number of hip replacements performed per 100,000 population in 2018 and GDP per person, and a strong and significant correlation with health expenditure (R = 0.784, p < 0.001). There was a moderate correlation (R = 0.645, p = 0.003) between the percentage change in the number of hip replacements performed per 100,000 population and the percentage change in healthcare expenditure per person between 2008 and 2018.

CONCLUSIONS

There is 36-fold variation in the practice of hip replacements across the OECD and the number of hip replacements has increased by more than 20% over the past decade. The number of hip replacements performed appears to be correlated with health expenditure in each country and may indicate a need that can only be met by increasing health expenditure.

10 Years of AMNOG: What is the Willingness-to-Pay for Pharmaceuticals in Germany?

OBJECTIVES

The German Pharmaceutical Market Restructuring Act (AMNOG, 2011) is a two-stage process to regulate the price of new pharmaceuticals in which price negotiations are conducted based on evidence-based medical benefit assessments using data from prior clinical trials. Although the act does not explicitly set a willingness-to-pay (WTP) threshold, the process itself implicitly establishes a WTP for health improvement. We evaluated the implicit WTP for prescription pharmaceuticals post-AMNOG in the German healthcare system from the decision-maker/payer perspective.

METHODS

We extracted data on patient-group-specific annual treatment costs and endpoints from 2011 to 2021 from the dossiers assessed by the German Federal Joint Committee (FJC; Gemeinsamer Bundesausschuss). Using incremental cost-effectiveness ratios (ICERs), we calculated a WTP for the indications (I) diabetes, (II) cardiovascular disease, and (III) psoriasis weighted according to patient group size, first from the perspective of the decision-maker (approach A), and second from the perspective of the industry (approach B). To put clinical outcome measures into relation to one another, minimum clinically important differences (MCIDs) were derived from the literature and compared.

RESULTS

The annual treatment costs of newly authorized drugs were substantially higher (both pre- and post-negotiation) than that of their comparators (e.g., psoriasis, pre-negotiation: €20,601.59, post-negotiation: €16,763.57; comparators: €5178.00). However, although newly launched drugs were more expensive than their comparators, they brought greater medical benefits and were more aligned with value (r = 0.59, P < 0.001) than older drugs. We estimated WTP to vary widely by indication group [€33,814.08 per 1 percentage point hemoglobin A1c (HbA1c) reduction for diabetes, €10,970.83 per life year gained for cardiovascular disease, and €663.46 per 1% PASI decrease for psoriasis; approach A]. WTP was converted to MCID thresholds: diabetes: €16,907.04; cardiovascular drugs: no MCID existent to convert; and psoriasis: €33,173.00. WTP remained constant over time for diabetes and cardiovascular drugs but increased for psoriasis drugs.

CONCLUSION

This paper is one of the first to estimate the implicit WTP for prescription pharmaceuticals post-AMNOG and suggests that the WTP may vary between different therapeutic areas. Additionally, making different assumptions (approach A versus approach B) with regard to the assumed effectiveness in indication areas that had been declared as having no additional benefit by the FJC may explain the different perspectives of decision-makers and of the pharmaceutical industry on the value of a pharmaceutical.

Study protocol of an economic evaluation embedded in the Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) trial

BACKGROUND

Tobacco smoking during pregnancy is the most important preventable risk factor for pregnancy complications and adverse birth outcomes and can have lifelong consequences for infants. Smoking during pregnancy is associated with higher healthcare costs related to birth complications and during childhood. Psychosocial interventions to support pregnant women to quit are effective, yet provision of smoking cessation support has been inconsistent. The Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) intervention provides systems change, and leadership and clinician elements, to support clinicians to help women stop smoking in pregnancy. There have been few long-term analyses conducted of the cost-effectiveness of smoking cessation interventions for pregnant women that target healthcare providers. This protocol describes the economic evaluation of the MOHMQuit trial, a pragmatic stepped-wedge cluster-randomised controlled implementation trial in nine public maternity services in New South Wales (NSW), Australia, to ascertain whether MOHMQuit is cost-effective in supporting clinicians to help women quit smoking in pregnancy compared to usual care.

METHODS

Two primary analyses will be carried out comparing MOHMQuit with usual care from an Australian health care system perspective: i) a within-trial cost-effectiveness analysis with results presented as the incremental cost per additional quitter; and ii) a lifetime cost-utility analysis using a published probabilistic decision analytic Markov model with results presented as incremental cost per quality-adjusted life-year (QALY) gained for mother and child. Patient-level data on resource use and outcomes will be used in the within-trial analysis and extrapolated and supplemented with national population statistics and published data from the literature for the lifetime analysis.

DISCUSSION

There is increasing demand for information on the cost-effectiveness of implementing healthcare interventions to provide policy makers with critical information for the best value for money within finite budgets. Economic evaluation of the MOHMQuit trial will provide essential, policy-relevant information for decision makers on the value of evidence-based implementation of support for healthcare providers delivering services for pregnant women.

TRIAL REGISTRATIONS

ACTRN12622000167763, registered 2 February 2022.

Cost-effectiveness of opportunistic QCT-based osteoporosis screening for the prediction of incident vertebral fractures

Objectives

Opportunistic quantitative computed tomography (oQCT) derived from non-dedicated routine CT has demonstrated high accuracy in diagnosing osteoporosis and predicting incident vertebral fractures (VFs). We aimed to investigate the cost-effectiveness of oQCT screening compared to dual-energy X-ray absorptiometry (DXA) as the standard of care for osteoporosis screening.

Methods

Three screening strategies ("no osteoporosis screening", "oQCT screening", and "DXA screening") after routine CT were simulated in a state-transition model for hypothetical cohorts of 1,000 patients (women and men aged 65 years) over a follow-up period of 5 years (base case). The primary outcomes were the cumulative costs and the quality-adjusted life years (QALYs) estimated from a U.S. health care perspective for the year 2022. Cost-effectiveness was assessed based on a willingness-to-pay (WTP) threshold of $70,249 per QALY. The secondary outcome was the number of prevented VFs. Deterministic and probabilistic sensitivity analyses were conducted to test the models' robustness.

Results

Compared to DXA screening, oQCT screening increased QALYs in both sexes (additional 2.40 per 1,000 women and 1.44 per 1,000 men) and resulted in total costs of $3,199,016 and $950,359 vs. $3,262,934 and $933,077 for women and men, respectively. As a secondary outcome, oQCT screening prevented 2.6 and 2.0 additional VFs per 1,000 women and men, respectively. In the probabilistic sensitivity analysis, oQCT screening remained cost-effective in 88.3% (women) and 90.0% (men) of iterations.

Conclusion

oQCT screening is a cost-effective ancillary approach for osteoporosis screening and has the potential to prevent a substantial number of VFs if considered in daily clinical practice.

Clinical and Economic Value of Reducing Antimicrobial Resistance in the Management of Hospital-Acquired Infections with Limited Treatment Options in Greece

INTRODUCTION

Antimicrobial resistance (AMR) is a major public health threat worldwide. Greece has the highest burden of infections due to antibiotic-resistant bacteria among European Union/European Economic Area (EU/EEA) countries. One of the most serious AMR threats in Greece is hospital-acquired infections (HAIs) with limited treatment options (LTO) caused by resistant gram-negative pathogens. Thus, this study sought to estimate the current AMR burden in Greece and the value of reducing AMR to gram-negative pathogens for the Greek healthcare system.

METHODS

The current model was adapted from a previously published and validated model of AMR to investigate the overall and AMR-specific burden of treating the most common HAIs with LTO in Greece and scenarios to demonstrate the benefits associated with reducing AMR levels from a third-party payer perspective. Clinical and economic outcomes were estimated over a 10-year time horizon; life years (LYs) and quality-adjusted life years (QALYs) were calculated over a lifetime (based on the annual number of infections over 10 years) at a willingness-to-pay of €30,000 per QALY gained and a 3.5% discount rate.

RESULTS

In Greece, the current AMR levels in HAIs with LTO caused by four gram-negative pathogens account for > 316,000 hospital bed days, €73 million in hospitalisation costs, and > 580,000 LYs and 450,000 QALYs lost over 10 years. The monetary burden is estimated at €13.9 billion. A reduction in current AMR levels by 10-50% results in clinical and economic benefit; 29,264-151,699 bed days may be saved, leading to decreased hospitalisation costs (€6.8 million-€35.3 million) and a gain in LYs (85,328-366,162) and QALYs (67,421-289,331), associated with a monetary benefit of between €2.0 billion and €8.7 billion.

CONCLUSION

This study shows the substantial clinical and economic burden AMR represents to the Greek healthcare system and the value that can be achieved by effectively reducing AMR levels.

Implementing a Managed Entry Agreement Framework in Cyprus

INTRODUCTION

The aim of this study is to explore the current practice in Cyprus regarding the introduction and reimbursement of innovative pharmaceuticals through Managed Entry Agreements (MEA), assess its operational context, and suggest approaches toward spanning the knowledge gap consequential to these efforts, especially the barriers of a small country context.

AREAS COVERED

The recent introduction of a National Health System (NHS), brought about fundamental reforms in Cyprus' Healthcare sector. Among such reforms, of particular interest, has been the introduction of a Managed Entry Agreements (MEA) mechanism. The first preliminary results indicate that despite being a small and unattractive market, Cyprus can apply a substantial MEA program. Concomitantly, it annotates the need to design an operational framework which should include, the definition of important technical parameters, clear demarcation of the scope, cooperation principles ensuring the effective operation of scientific committees, and clear delineation of what 'value' is. Moreover, in the context of the unified healthcare market, budget transfers should be considered, which could alleviate the inordinate budget impact of new products, which nevertheless will cut down on hospital expenditures. Narrative synthesis and health policy analysis-related resources were used.

EXPERT OPINION

The implementation of MEA in Cyprus provides an ideal testing ground for innovative reimbursement approaches. This will streamline the country's efforts toward reimbursement of innovation, while concomitantly add to the collective MEA experience.

Daring discourse: economics of neuromodulation for the treatment of persistent spinal pain syndrome and complex regional pain syndrome

The treatment options for patients with chronic pain conditions are impacted by recent research, patient needs, and insurance coverage. Although various factors affect the cost of healthcare, the economic burden on the patient and the healthcare system must be considered when choosing the appropriate treatments for each patient. This Daring Discourse aims to review and further clarify existing economic evaluations and thus examine cost-effectiveness with regards to neuromodulation for the treatment of persistent spinal pain syndrome and complex regional pain syndrome. Specific consideration is given to spinal cord stimulation, as it is a widely studied and implemented neuromodulation modality for the treatment of these debilitating conditions.

Culture-expanded mesenchymal stromal cell therapy: does it work in knee osteoarthritis? A pathway to clinical success

Osteoarthritis (OA) is a degenerative multifactorial disease with concomitant structural, inflammatory, and metabolic changes that fluctuate in a temporal and patient-specific manner. This complexity has contributed to refractory responses to various treatments. MSCs have shown promise as multimodal therapeutics in mitigating OA symptoms and disease progression. Here, we evaluated 15 randomized controlled clinical trials (RCTs) and 11 nonrandomized RCTs using culture-expanded MSCs in the treatment of knee OA, and we found net positive effects of MSCs on mitigating pain and symptoms (improving function in 12/15 RCTs relative to baseline and in 11/15 RCTs relative to control groups at study endpoints) and on cartilage protection and/or repair (18/21 clinical studies). We examined MSC dose, tissue of origin, and autologous vs. allogeneic origins as well as patient clinical phenotype, endotype, age, sex and level of OA severity as key parameters in parsing MSC clinical effectiveness. The relatively small sample size of 610 patients limited the drawing of definitive conclusions. Nonetheless, we noted trends toward moderate to higher doses of MSCs in select OA patient clinical phenotypes mitigating pain and leading to structural improvements or cartilage preservation. Evidence from preclinical studies is supportive of MSC anti-inflammatory and immunomodulatory effects, but additional investigations on immunomodulatory, chondroprotective and other clinical mechanisms of action are needed. We hypothesize that MSC basal immunomodulatory "fitness" correlates with OA treatment efficacy, but this hypothesis needs to be validated in future studies. We conclude with a roadmap articulating the need to match an OA patient subset defined by molecular endotype and clinical phenotype with basally immunomodulatory "fit" or engineered-to-be-fit-for-OA MSCs in well-designed, data-intensive clinical trials to advance the field.

Cost-Effectiveness of Cerebrolysin after Ischemic Stroke: Secondary Analysis of the CARS Study

The cost-effectiveness of Cerebrolysin as an add-on therapy for moderate-severe acute ischemic stroke is a topic that remains understudied. This study aims to address this gap by performing a comprehensive cost-utility analysis using both deterministic and probabilistic methods from a payer perspective and within the Romanian inpatient care setting. Quality-adjusted life years (QALYs) were calculated using partial individual patient data from the 2016 Cerebrolysin and Recovery After Stroke (CARS) trial, utilizing three different health state valuation models. Cost data was extracted from actual acute care costs reported by Romanian public hospitals for reimbursement purposes for patients included in the CARS study. Incremental cost-effectiveness ratios were calculated for each treatment arm for the duration of the clinical trial. Deterministic analysis based on sample mean values indicates Cerebrolysin would be cost-effective at a threshold between roughly 18.8 and 29.9 thousand EUR, depending on valuation techniques. Probabilistic sensitivity analysis results indicate an 80% chance probability of cost-effectiveness of Cerebrolysin as an add-on therapy for acute ischemic stroke, considering a willingness-to-pay threshold of 50,000 EUR in a 90-day timeframe after stroke. Further economic evaluations of Cerebrolysin are needed to strengthen these findings, covering a timeframe of at least 12 months after the acute incident, which would account for treatment effects spanning beyond the first 90 days after ischemic stroke. These should be conducted to determine its cost-effectiveness under various care settings and patient pathways. Most importantly, modelling techniques are needed to answer important questions such as the estimates of population gain in QALYs after acute administration of Cerebrolysin and the potential offsetting of direct medical costs as a result of administering the intervention.

Cost-effectiveness of Increasing Buprenorphine Treatment Initiation, Duration, and Capacity Among Individuals Who Use Opioids

Importance

Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity.

Objective

To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity.

Design and Setting

This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US.

Interventions

Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination.

Main Outcomes and Measures

Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective.

Results

Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously.

Conclusion and Relevance

This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.

Cost-Effectiveness of Thrombopoietin Mimetics in Patients with Thrombocytopenia: A Systematic Review

OBJECTIVES

Thrombopoietin (TPO) mimetics are a potential alternative to platelet transfusion to minimize blood loss in patients with thrombocytopenia. This systematic review aimed to evaluate the cost-effectiveness of TPO mimetics, compared with not using TPO mimetics, in adult patients with thrombocytopenia.

METHODS

Eight databases and registries were searched for full economic evaluations (EEs) and randomized controlled trials (RCTs). Incremental cost-effectiveness ratios (ICERs) were synthesized as cost per quality-adjusted life year gained (QALY) or as cost per health outcome (e.g. bleeding event avoided). Included studies were critically appraised using the Philips reporting checklist.

RESULTS

Eighteen evaluations from nine different countries were included, evaluating the cost-effectiveness of TPO mimetics compared with no TPO, watch-and-rescue therapy, the standard of care, rituximab, splenectomy or platelet transfusion. ICERs varied from a dominant strategy (i.e. cost-saving and more effective), to an incremental cost per QALY/health outcome of EUR 25,000-50,000, EUR 75,000-750,000 and EUR > 1 million, to a dominated strategy (cost-increasing and less effective). Few evaluations (n = 2, 10%) addressed the four principal types of uncertainty (methodological, structural, heterogeneity and parameter). Parameter uncertainty was most frequently reported (80%), followed by heterogeneity (45%), structural uncertainty (43%) and methodological uncertainty (28%).

CONCLUSIONS

Cost-effectiveness of TPO mimetics in adult patients with thrombocytopenia ranged from a dominant strategy to a significant incremental cost per QALY/health outcome or a strategy that is clinically inferior and has increased costs. Future validation and tackling the uncertainty of these models with country-specific cost data and up-to-date efficacy and safety data are needed to increase the generalizability.

Comparisons in the Health and Economic Assessments of Using Quadrivalent Versus Trivalent Influenza Vaccines: A Systematic Literature Review

OBJECTIVES

Seasonal influenza vaccines protect against 3 (trivalent influenza vaccine [IIV3]) or 4 (quadrivalent influenza vaccine [IIV4]) viruses. IIV4 costs more than IIV3, and there is a trade-off between incremental cost and protection. This is especially the case in low- and middle-income countries (LMICs) with limited budgets; previous reviews have not identified studies of IIV4-IIV3 comparisons in LMICs. We summarized the literature that compared health and economic outcomes of IIV4 and IIV3, focused on LMICs.

METHODS

We systematically searched 5 databases for articles published before October 6, 2021, that modeled health or economic effects of IIV4 versus IIV3. We abstracted data and compared findings among countries and models.

RESULTS

Thirty-eight studies fit our selection criteria; 10 included LMICs. Most studies (N = 31) reported that IIV4 was cost-saving or cost-effective compared with IIV3; we observed no difference in health or economic outcomes between LMICs and other countries. Based on cost differences of influenza vaccines, only one study compared coverage of IIV3 with IIV4 and reported that the maximum IIV4 price that would still yield greater public health impact than IIV3 was 13% to 22% higher than IIV3.

CONCLUSIONS

When vaccination coverage with IIV4 and IIV3 is the same, IIV4 tends to be not only more effective but more cost-effective than IIV3, even with relatively high price differences between vaccine types. Alternatively, where funding is limited as in most LMICs, higher vaccine coverage can be achieved with IIV3 than IIV4, which could result in more favorable health and economic outcomes.

Use of Decision-Analytic Modelling to Assess the Cost-Effectiveness of Diagnostic Imaging of the Spine, Shoulder, and Knee: A Scoping Review

BACKGROUND

Limited evidence is available on the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. Decision analytic modelling may be an appropriate method to synthesise evidence from multiple sources, and overcomes issues with trial-based economic evaluations.

OBJECTIVE

The aim was to describe the reporting of methods and objectives utilised in existing decision analytic modelling studies that assess the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints.

METHODS

Decision analytic modelling studies investigating the use of any imaging modality for people of any age with back, neck, knee, or shoulder complaints were included. No restrictions on comparators were applied, and included studies were required to estimate both costs and benefits. A systematic search (5 January 2023) of four databases was conducted with no date limits imposed. Methodological and knowledge gaps were identified through a narrative summary.

RESULTS

Eighteen studies were included. Methodological issues were identified relating to the poor reporting of methods, and measures of effectiveness did not incorporate changes in quantity and/or quality of life (cost-utility analysis in only ten of 18 studies). Included studies, particularly those investigating back or neck complaints, focused on conditions that were of low prevalence but have a serious impact on health (i.e. cervical spine trauma, cancer-related back pain).

CONCLUSIONS

Future models should pay particular attention to the identified methodological and knowledge gaps. Investment in the health technology assessment of these commonly utilised diagnostic imaging services is needed to justify the current level of utilisation and ensure that these services represent value for money.

Endovascular thrombectomy is cost-effective in acute basilar artery occlusion stroke

Objective

Endovascular thrombectomy is a long-established therapy for acute basilar artery occlusion (aBAO). Unlike for anterior circulation stroke, cost-effectiveness of endovascular treatment has not been evaluated and is urgently needed to calculate expected health benefits and financial rewards. The aim of this study was therefore to simulate patient-level costs, analyze the economic potential of endovascular thrombectomy in patients with acute basilar artery occlusion (aBAO), and identify major determinants of cost-effectiveness.

Methods

A Markov model was developed to compare outcome and cost parameters between patients treated by endovascular thrombectomy and patients treated by best medical care, based on four recent prospective clinical trials (ATTENTION, BAOCHE, BASICS, and BEST). Treatment outcomes were derived from the most recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. Willingness to pay per QALY thresholds were set at 1x gross domestic product per capita, as recommended by the World Health Organization.

Results

Endovascular treatment of acute aBAO stroke yielded an incremental gain of 1.71 quality-adjusted life-years per procedure with an incremental cost-effectiveness ratio of $7,596 per QALY. This was substantially lower than the Willingness to pay of $63,593 per QALY. Lifetime costs were most sensitive to costs of the endovascular procedure.

Conclusion

Endovascular treatment is cost-effective in patients with aBAO stroke.

Breast Cancer Screening Should Embrace Precision Medicine: Evidence by Reviewing Economic Evaluations in China

The cost-effectiveness of conventional population-based breast cancer screening strategies (e.g. mammography) has been found controversial, while evidence shows that genetic testing for early detection of pathogenic variants is cost-effective. We aimed to review the economic evaluations of breast cancer screening in China to provide an information summary for future research on this topic. We searched the literature to identify the economic evaluations that examined breast cancer screening and testing in China, supplemented by hand-searching the reference lists of the included studies. We finally included five studies satisfying our inclusion criteria. Four articles examined mammography while the rest investigated multigene testing. The existing breast cancer screening programmes were found to be cost-effective among urban Chinese women, but one study concluded that they might cause harm to women in rural areas. Contextual factors, such as data absence, urban-rural disparity, willingness-to-pay threshold, and model design, imposed barriers to cost-effectiveness analysis. Multigene testing was found to be cost-effective and has a promising population impact among all women with breast cancer in China. Future research should investigate the cost-effectiveness of screening and identifying breast cancer through precision medicine technologies, including genetic testing, genome sequencing, cascade testing, and the return of secondary findings.

Cost-effectiveness of the MitraClip device in German heart failure patients with secondary mitral regurgitation

AIM

To evaluate the cost-effectiveness of the MitraClip device (MitraClip) in addition to optimal medical therapy (OMT) in patients with heart failure and secondary mitral regurgitation in Germany.

METHODS AND RESULTS

A model-based economic evaluation was performed to estimate the incremental cost per quality-adjusted life-years (QALYs) for patients with a moderate-to-severe or severe secondary mitral regurgitation receiving MitraClip plus OMT compared with OMT alone from the statutory health insurance (SHI) perspective. Transition probabilities, data on survival rates, and hospitalization rates were obtained from the COAPT trial, a randomized-controlled multicenter trial. Data on health utility and costs were taken from published evidence. To assess parameter uncertainty, several deterministic and probabilistic sensitivity analyses were performed. The incremental costs per QALY gained were € 59,728 (costs/incremental life years gained: € 42,360). The results were most sensitive to the transition probabilities and the hospitalization rates. The probabilistic sensitivity analysis showed that the MitraClip strategy was cost-effective with a probability of 80% at a willingness-to-pay threshold of € 67,000/QALY.

CONCLUSIONS

Depending on the willingness-to-pay threshold, for patients with heart failure and a moderate-to-severe or severe secondary mitral regurgitation the MitraClip can be cost-effective from the perspective of the German SHI.

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability

PURPOSE

The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6.

METHODS

A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval.

RESULTS

Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER.

CONCLUSION

From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

Willingness to pay for cancer prevention, screening, diagnosis, and treatment: a systematic review

INTRODUCTION

Willingness to pay (WTP) studies examine the maximum amount of money an individual is willing to pay for a specified health intervention, and can be used to inform coverage and reimbursement decisions. Our objectives were to assess how people value cancer-related interventions, identify differences in the methodologies used, and review the trends in studies' publication.

AREAS COVERED

We extracted PubMed and EconLit articles published in 1997-2020 that reported WTP for cancer-related interventions, characterized the methodological differences and summarized each intervention's mean and median WTP values. We reviewed 1,331 abstracts and identified 103 relevant WTP studies, of which 37 (36%) focused on treatment followed by screening (26), prevention (21), diagnosis (7) and other interventions (12). The methods used to determine WTP values were primarily discrete-choice questions (n = 54, 52%), bidding games (15), payment cards (12) and open-ended questions (12). We found a wide variation in WTP reported values ranged from below $100 to over $20,000.

EXPERT OPINION

The WTP literature on oncology interventions has grown rapidly. There is considerable heterogeneity with respect to the type of interventions and diseases assessed, the respondents' characteristics, and the study methodologies. This points to the need to establish international guidelines for best practices in this field.

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up.

SUMMARY OF BACKGROUND DATA

Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness.

MATERIALS AND METHODS

A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility.

CONCLUSION

Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

Willingness to pay for medications among patients with Rome IV Irritable Bowel Syndrome

BACKGROUND

Little is known about willingness to pay for medications among individuals with irritable bowel syndrome (IBS).

METHODS

We collected demographic, gastrointestinal symptom, psychological health, quality of life, and healthcare usage data from 752 adults with Rome IV-defined IBS. We examined willingness to pay for a hypothetical medication in return for improvement in IBS symptoms using a contingent valuation method, according to these variables.

RESULTS

The median amount of money individuals was willing to pay was £1-£50 (IQR £0-£100) per month for a medication with a 100% chance of improving IBS symptoms. Women, compared with men, (92.7% willing to pay "£0," 89.8% "£1-£50," 87.3% "£51-£100," 78.9% "£101-£200," and 78.5% "more than £200," p = 0.008) were less likely to be willing to pay for a pill with a 100% chance of improving IBS symptoms whilst those with an annual income of £30,000 or more (12.2% willing to pay "£0," 25.2% "£1-£50," 33.5% "£51-£100," 40.2% "£101-£200," and 35.1% "more than £200," p = 0.002) were more likely. We observed a higher willingness to pay among those with lower IBS-related quality of life (p = 0.002 for trend). Of all 752 individuals, 92.7%, 74.5%, and 58.0% would be willing to pay for a medication that would give them a 100%, 50%, or 30% chance of improving IBS symptoms, respectively.

CONCLUSION

Patients with IBS are willing to pay for medications which improve IBS symptoms. Future studies should investigate the relative importance of medication pricing, efficacy, and side effect profile among individuals with IBS.

Economic evaluation of COVID-19 vaccination: A systematic review

Background

Safe and effective vaccination is considered to be the most critical strategy to fight coronavirus disease 2019 (COVID-19), leading to individual and herd immunity protection. We aimed to systematically review the economic evaluation of COVID-19 vaccination globally.

Methods

We performed a systematic search to identify relevant studies in two major databases (MEDLINE/PubMed and EBSCO) published until September 8, 2022. After deduplication, two researchers independently screened the study titles and abstracts according to pre-determined inclusion and exclusion criteria. The remaining full-text studies were assessed for eligibility. We assessed their quality of reporting using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist and summarized and narratively presented the results.

Results

We identified 25 studies that assessed the economic evaluation of COVID-19 vaccination worldwide by considering several input parameters, including vaccine cost, vaccine efficacy, utility value, and the size of the targeted population. All studies suggested that COVID-19 vaccination was a cost-effective or cost-saving intervention for mitigating coronavirus transmission and its effect in many countries within certain conditions. Most studies reported vaccine efficacy values ranging from 65% to 75%.

Conclusions

Given the favorable cost-effectiveness profile of COVID-19 vaccines and disparities in affordability across countries, considering prioritization has become paramount. This review provides comprehensive insights into the economic evaluation of COVID-19 vaccination that will be useful to policymakers, particularly in highlighting preventive measures and preparedness plans for the next possible pandemic.

Consumers' Willingness to Pay for Pharmacist Counselling Services and the Factors Affecting It in Community Pharmacies

Background

Community pharmacists play an important role in improving outcome by providing advice and counselling services to patients.

Objectives

The aim of this study was to measure the willingness to pay (WTP) for pharmacist counselling services in community pharmacies and identify determinant factors on consumers' WTP.

Methods

A self-administered questionnaire-based survey was conducted in community pharmacies in Tehran (capital of Iran) from January 1, 2020 to February 20, 2021. Contingent valuation method was applied to evaluate respondents' maximum WTP using three hypothetical scenarios illustrating different levels of counselling services. Logistic regression was used to analyze the association between different variables and WTP for pharmacy services.

Results

Total number of participants who completed the questionnaire were 332 and 60% of the participants were male. In the first scenario 70.2% of participants were willing to pay for oral counselling pharmacy services. In the second and third scenario, percentage of people willing to pay increased to 79.5%. and 86.1%, respectively. In the first scenario, monthly income (OR = 0.041, P value = 0.04), the duration of underlying illness (OR = 0.04, P value = 0.04) and the using internet (OR = 2.59, P value = 2.59) had a statistically significant relationship with willingness to pay. In the third scenario, the willingness to pay increased as the age decreased. The possibility of using the internet (OR = 3.32, P value = 0.00) and the need for a community pharmacist (OR = 2.19, P value = 0.03) increased the chance of willingness to pay.

Conclusions

More consumers are willing to pay for more pharmacist counselling services. Therefore, improving the quality of counselling services could have positive economic effects on community pharmacies.

Estimating the Clinical and Economic Impact of Introducing a New Antibacterial into Greek Clinical Practice for the Management of Hospital-Acquired Infections with Limited Treatment Options

INTRODUCTION

Hospital-acquired infections (HAIs) and growing antimicrobial resistance (AMR) represent a significant healthcare burden globally. Especially in Greece, HAIs with limited treatment options (LTO) pose a serious threat due to increased morbidity and mortality. This study aimed to estimate the clinical and economic value of introducing a new antibacterial for HAIs with LTO in Greece.

METHODS

A previously published and validated dynamic model of AMR was adapted to the Greek setting. The model estimated the clinical and economic outcomes of introducing a new antibacterial for the treatment of HAIs with LTO in Greece. The current treatment pathway was compared with introducing a new antibacterial to the treatment sequence. Outcomes were assessed from a third-party payer perspective, over a 10-year transmission period, with quality-adjusted life years (QALYs) and life years (LYs) gained considered over a lifetime horizon.

RESULTS

Over the next 10 years, HAIs with LTO in Greece account for approximately 1.4 million hospital bed days, hospitalisation costs of more than €320 million and a loss of approximately 403,000 LYs (319,000 QALYs). Introduction of the new antibacterial as first-line treatment provided the largest clinical and economic benefit, with savings of up to 93,000 bed days, approximately €21 million in hospitalisation costs and an additional 286,000 LYs (226,000 QALYs) in comparison to the current treatment strategy. The introduction of a new antibacterial was linked to a monetary benefit of €6.8 billion at a willingness to pay threshold of €30,000 over 10 years.

CONCLUSION

This study highlights the considerable clinical and economic benefit of introducing a new antibacterial for HAIs with LTO in Greece. This analysis shows the additional benefit when a new antibacterial is introduced to treatment sequences. These findings can be used to inform decision makers to implement policies to ensure timely access to new antibacterial treatments in Greece.

Lifetime economic potential of mobile stroke units in acute stroke care: A model-based analysis of the drivers of cost-effectiveness

BACKGROUND AND PURPOSE

To simulate patient-level costs, analyze the economic potential of telemedicine-based mobile stroke units for acute prehospital stroke care, and identify major determinants of cost-effectiveness, based on two recent prospective trials from the United States and Germany.

METHODS

A Markov decision model was developed to simulate lifetime costs and outcomes of mobile stroke unit. The model compares diagnostic and therapeutic pathways of ischemic stroke, hemorrhagic stroke, and stroke mimic patients by conventional care or by mobile stroke units. The treatment outcomes were derived from the B_PROUD and the BEST-mobile stroke unit trials and further input parameters were derived from recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. A lifetime horizon based on the US healthcare system was adopted to evaluate different cost thresholds for mobile stroke unit and the resulting cost-effectiveness. Willingness-to-pay thresholds were set at 1x and 3x gross domestic product per capita, as recommended by the World Health Organization.

RESULTS

In the base case scenario, mobile stroke unit care yielded an incremental gain of 0.591 quality-adjusted life years per dispatch. Mobile stroke unit was highly cost-effective up to a maximum average cost of 43,067 US dollars per patient. Sensitivity analyses revealed that MSU cost-effectiveness is mainly affected by reduction of long-term disability costs. Also, among other parameters, the rate of stroke mimics patients diagnosed by MSU plays an important role.

CONCLUSION

This study demonstrated that mobile stroke unit can possibly be operated on an excellent level of cost-effectiveness in urban areas in North America with number of stroke mimic patients and long-term stroke survivor costs as major determinants of lifetime cost-effectiveness.

Determinants of willingness to pay for health services: a systematic review of contingent valuation studies

INTRODUCTION

Stated preference studies are a valuable tool to elicit respondents' willingness to pay (WTP) for goods or services, especially in situations where no market valuation exists. Contingent valuation (CV) is a widely used approach among stated-preference techniques for eliciting WTP if prices do not exist or do not reflect actual costs, for example, when services are covered by insurance. This review aimed to provide an overview of relevant factors determining WTP for health services to support variable selection.

METHODS

A comprehensive systematic literature search and review of CV studies assessing determinants of WTP for health services was conducted, including 11 electronic databases. Two of the authors made independent decisions on the eligibility of studies. We extracted all determinants used and related p values for the effect sizes (e.g. reported in regression models with WTP for a health service as outcome variable). Determinants were summarised in systematic evidence tables and structured by thematic domains.

RESULTS

We identified 2082 publications, of which 202 full texts were checked for eligibility. We included 62 publications on 61 studies in the review. Across all studies, we identified 22 WTP determinants and other factors from 5 thematic domains: sociodemographic characteristics, perceived threat, perceived benefit, perceived barriers, and other information.

CONCLUSION

Our review provides evidence on 22 relevant determinants of WTP for health services, which may be used for variable selection and as guidance for planning CV surveys. Endogeneity should be carefully considered before interpreting these determinants as causal factors and potential intervention targets.

Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems

In view of the staggering disease and economic burden of mental disorders, internet and mobile-based interventions (IMIs) targeting mental disorders have often been touted to be cost-effective; however, available evidence is inconclusive and outdated. This review aimed to provide an overview of the cost-effectiveness of IMIs for mental disorders and symptoms. A systematic search was conducted for trial-based economic evaluations published before 10th May 2021. Electronic databases (including MEDLINE, PsycINFO, CENTRAL, PSYNDEX, and NHS Economic Evaluations Database) were searched for randomized controlled trials examining IMIs targeting mental disorders and symptoms and conducting a full health economic evaluation. Methodological quality and risk of bias were assessed. Cost-effectiveness was assumed at or below £30,000 per quality-adjusted life year gained. Of the 4044 studies, 36 economic evaluations were reviewed. Guided IMIs were likely to be cost-effective in depression and anxiety. The quality of most evaluations was good, albeit with some risks of bias. Heterogeneity across studies was high because of factors such as different costing methods, design, comparison groups, and outcomes used. IMIs for anxiety and depression have potential to be cost-effective. However, more research is needed into unguided (preventive) IMIs with active control conditions (e.g., treatment as usual) and longer time horizon across a wider range of disorders.Trial registration: PROSPERO Registration No. CRD42018093808.

A general framework for optimising cost-effectiveness of pandemic response under partial intervention measures

The COVID-19 pandemic created enormous public health and socioeconomic challenges. The health effects of vaccination and non-pharmaceutical interventions (NPIs) were often contrasted with significant social and economic costs. We describe a general framework aimed to derive adaptive cost-effective interventions, adequate for both recent and emerging pandemic threats. We also quantify the net health benefits and propose a reinforcement learning approach to optimise adaptive NPIs. The approach utilises an agent-based model simulating pandemic responses in Australia, and accounts for a heterogeneous population with variable levels of compliance fluctuating over time and across individuals. Our analysis shows that a significant net health benefit may be attained by adaptive NPIs formed by partial social distancing measures, coupled with moderate levels of the society's willingness to pay for health gains (health losses averted). We demonstrate that a socially acceptable balance between health effects and incurred economic costs is achievable over a long term, despite possible early setbacks.