The economic perspective

A systematic review of economic analyses of home-based telerehabilitation

PURPOSE

Telerehabilitation, or the delivery of rehabilitation using information and communication technologies, may improve timely and equitable access to rehabilitation services at home. A systematic literature review was conducted of studies that formally documented the costs and effects of home-based telerehabilitation versus in-person rehabilitation across all health conditions.

MATERIALS AND METHODS

Six electronic databases were searched from inception to 13 July 2021 (APA, PsycInfo, CINAHL, Embase, EmCare, Medline (Ovid), and PubMed) using a protocol developed by a medical librarian. A quality appraisal of full economic evaluation studies was conducted using the Drummond 10-point quality checklist.

RESULTS

Thirty-five studies were included in this review covering various rehabilitation types and diverse populations. The majority were published in the last six years. Available evidence suggests that telerehabilitation may result in similar or lower costs as compared to in-person rehabilitation for the health care system and for patients. However, the impact of telerehabilitation on long-term clinical outcomes and health-related quality of life remains unclear.

CONCLUSIONS

More high quality and robust economic evaluations exploring the short- and long-term costs and other impacts of telerehabilitation on patients, caregivers, and health care systems across all types of patient populations are still required.Implications for rehabilitationHome-based telerehabilitation may reduce barriers in access to care for individuals living in the community.Economic analyses can inform health care system decision-making by evaluating the costs and effects associated with telerehabilitation.This study found that telerehabilitation may result in similar or lower costs as in-person rehabilitation; however, its impact on health-related quality of life is unclear.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

Measuring health utility in varying pregnancy contexts among a diverse cohort of pregnant women

OBJECTIVE

To contribute to decision analysis by estimating utility, defined as an individual's valuation of specific health states, for different pregnancy contexts.

STUDY DESIGN

Cross-sectional analysis of data from pregnant women recruited at pregnancy testing clinics during June 2014-June 2015. Utility was measured using the visual analog scale (VAS), PROMIS GSF-derived utility, standard gamble (SG), and time-trade-off (TTO) approaches. Six dimensions of pregnancy context were assessed including: intention, desirability, planning, timing, wantedness, and happiness. Multivariable regression modeling was used to examine the associations between pregnancy context and utility while controlling for women's sociodemographic and health characteristics.

RESULTS

Among 123 participants with diverse characteristics, aged 27±6 years, with mean gestation of 7.5±3 weeks, few reported optimal pregnancy contexts. Mean utility of the pregnancy state varied across contexts, whether measured with VAS (0.28-0.91), PROMIS GSF-derived utility (0.66-0.75), SG (0.985-1.00) or TTO (0.9990-0.99999). The VAS-derived mean utility score for unintended pregnancy was 0.68 (95% CI 0.59, 0.77). Multivariable regression analysis demonstrated significant disutility of unintended pregnancy, as well as all other unfavorable pregnancy contexts, when measured by VAS. In contrast, PROMIS GSF-derived utility only detected a significant reduction in utility among ambivalent compared to wanted pregnancy, while SG and TTO did not show meaningful differences in utility across pregnancy contexts.

CONCLUSIONS

Unintended pregnancy is associated with significant patient-reported disutility, as is pregnancy occurring in other unfavorable contexts. VAS-based measurements provide the most nuanced measures of the utility for pregnancy in varying contexts.

IMPLICATIONS

Decision analyses, including assessments of the cost-effectiveness of pregnancy related interventions, should incorporate measures of the utility of pregnancy in various contexts.

Introducing the non-invasive prenatal test for trisomy 21 in Belgium: a cost-consequences analysis

BACKGROUND

The first- and second-trimester screening for trisomy 21 (T21) are reimbursed for all pregnant women in Belgium. Using a cut-off risk of 1:300 for T21, about 5% of all pregnant women are referred for definitive prenatal diagnosis using an invasive test, at a sensitivity of (only) 72.5%. The sensitivity and specificity of the non-invasive prenatal test (NIPT) are over 99% but come at a cost of €460 (£373) per test. The objective is to estimate the consequences of introducing NIPT for the detection of T21.

METHODS

A cost-consequences analysis was performed presenting the impact on benefits, harms and costs. Context-specific real-world information was available to set up a model reflecting the current screening situation in Belgium. This model was used to construct the second and first line NIPT screening scenarios applying information from the literature on NIPT's test accuracy.

RESULTS

Introducing NIPT in the first or second line reduces harm by decreasing the number of procedure-related miscarriages after invasive testing. In contrast with NIPT in the second line, offering NIPT in the first line additionally will miss fewer cases of T21 due to less false-negative test results. The introduction of NIPT in the second line results in cost savings, which is not true for NIPT at the current price in the first line. If NIPT is offered to all pregnant women, the price should be lowered to about €150 to keep the screening cost per T21 diagnosis constant.

CONCLUSIONS

In Belgium, the introduction and reimbursement of NIPT as a second line triage test significantly reduces procedure-related miscarriages without increasing the short-term screening costs. Offering and reimbursing NIPT in the first line to all pregnant women is preferred in the long term, as it would, in addition, miss fewer cases of T21. However, taking into account the government's limited resources for universal reimbursement, the price of NIPT should first be lowered substantially before this can be realised.

The impact of rotavirus vaccination on discounted net tax revenue in Egypt: a government perspective analysis

BACKGROUND

We evaluated national rotavirus (RV) immunization programme costs to estimate how resulting changes in morbidity and mortality will influence government fiscal accounts over time. The assumption was that increased childhood survival in vaccinated cohorts leads to increased numbers of children consuming government resource, and an increased number of future tax payers.

OBJECTIVE

Our objective was to evaluate the difference in lifetime discounted net tax revenue generated by RV vaccinated and unvaccinated cohorts from the Egyptian government perspective.

METHODS

The model framework adopts the Egyptian government perspective for RV immunization costs (year 2009 values) and all government transfers (e.g. education costs, health costs, pensions). To reflect the government tax revenue, we applied a fixed income tax burden to earnings over the lifetime of vaccinated and unvaccinated cohorts. At each year of the model, we derive net taxes (gross taxes less transfers) discounted to the immunization year to reflect the present value of RV vaccination investment costs.

RESULTS

Projected incremental net present values of the vaccinated cohort versus the unvaccinated cohort are $US6.1 million, $US58.1 million and $US55.7 million at 25-, 50- and 72-year time horizons, respectively. The internal rate of return for the government based on RV vaccination at years 25, 50 and 72 was 10.8%, 15.1% and 14.9, respectively. Within the first 5 years of vaccination, 76% of vaccine acquisition costs were offset due to direct and indirect cost savings attributed to a reduction in RV-related disease burden. Investments in RV vaccination in a single year are entirely offset when the vaccinated cohort of newborns reach 22 years of age.

CONCLUSION

The government perspective is useful for evaluating investments in RV vaccination because of ongoing government transfers and tax receipts attributed to changes in RV-attributed morbidity and mortality. The analysis described here illustrates that investing in RV offers tangible long-term fiscal benefits for government over many generations that would not ordinarily be captured in economic evaluations typically applied to healthcare interventions.

Cost-effectiveness of colorectal cancer screening

PURPOSE

To determine the most cost-effective colorectal cancer screening strategy costing less than $100,000 per life-year saved and to determine how available strategies compare with each other.

MATERIALS AND METHODS

Standardized methods were used to calculate incremental cost-effectiveness ratios (ICERs) from published estimates of cost and effectiveness of colorectal cancer screening strategies, and the direction and magnitude of any effect on the ratio from parameter estimate adjustments based on literature values were estimated.

RESULTS

Strategies in which double-contrast barium enema examination was performed emerged as optimal from all studies included. In average-risk individuals, screening with double-contrast barium enema examination every 3 years, or every 5 years with annual fecal occult blood testing, had an ICER of less than $55,600 per life-year saved. However, double-contrast barium enema examination screening every 3 years plus annual fecal occult blood testing had an ICER of more than $100,000 per life-year saved. Colonoscopic screening had an ICER of more than $100,000 per life-year saved, was dominated by other screening strategies, and offered less benefit than did double-contrast barium enema examination screening.

CONCLUSION

Double-contrast barium enema examination can be a cost-effective component of colorectal cancer screening, but further modeling efforts are necessary.