Incorporating productivity loss in health economic evaluations: a review of guidelines and practices worldwide for research agenda in China

A Systematic Review of Methods for Estimating Productivity Losses due to Illness or Caregiving in Low- and Middle-Income Countries

BACKGROUND

Productivity losses are often included in costing studies and economic evaluations to provide a comprehensive understanding of the economic burden of disease. Global guidance on estimating productivity losses is sparse, especially for low-and middle-income countries (LMICs) where informal and unpaid work remains dominant. This study aims to describe current practices for valuing productivity losses in LMICs.

METHODS

We performed a systematic review of studies published before April 2022 using three databases, including PubMed, Cochrane Library and Web of Science Core Collection. We included any costing or economic evaluation study conducted in a LMIC that provided methodological details on how the monetary value for productivity losses was estimated. Two reviewers independently screened articles for inclusion, extracted data and assessed the quality of the studies.

RESULTS

A total of 281 articles were included. While most studies did not specify the overall approach used to measure and value productivity losses (58%), the human capital approach was the most frequently used approach to measure productivity losses when this was clearly stated (39%). The most common methods to estimate a monetary value for productivity losses were market wages (51%), self-reported wages (28%) and macroeconomic measures (15%).

CONCLUSION

Reporting standards for productivity losses in LMIC settings have room for improvement. While market wages were the most frequently used method to estimate the monetary value of productivity losses, this relies on context-specific data availability. Until a consensus is reached on if, when and how to include productivity losses in costing and economic evaluation studies, future studies could include a sensitivity analysis to explore the impact of different methods for estimating the monetary value of productivity losses.

The Value of Flexible Vaccine Manufacturing Capacity: Value Drivers, Estimation Methods, and Approaches to Value Recognition in Health Technology Assessment

Expanding flexible vaccine manufacturing capacity (FVMC) for routine vaccines could facilitate more timely access to novel vaccines during future pandemics. Vaccine manufacturing capacity is 'flexible' if it is built on a technology platform that allows rapid adaption to new infectious agents. The added value of routine vaccines produced using a flexible platform for pandemic preparedness is not currently recognised in conventional health technology assessment (HTA) methods. We start by examining the current state of play of incentives for FVMC and exploring the relation between flexible and spare capacity. We then establish the key factors for estimating FVMC and draw from established frameworks to identify relevant value drivers. The role of FVMC as a countermeasure against pandemic risks is deemed an additional value attribute that should be recognised. Next, we address the gap in the vaccine-valuation literature between the conceptual understanding of the value of additional FVMC and the availability of accurate and reliable tools for its estimation to facilitate integration into HTA. Three practical approaches for estimating the value of additional FVMC are discussed: stated and revealed preference studies, macroeconomic modelling, and benefit-cost analysis. Lastly, we review how value recognition of additional FVMC can be realised within the HTA process for routine vaccines manufactured on flexible platforms. We argue that, while the value of additional FVMC is uncertain and further research is needed to help to better estimate it, the value of increased pandemic preparedness is likely to be too large to be ignored.

Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective

OBJECTIVES

Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke.

METHODS

Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients.

RESULTS

1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point.

CONCLUSIONS

The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.

The return on investment for the prevention and treatment of childhood and adolescent overweight and obesity in China: a modelling study

Background

The rapid increase in child and adolescent overweight and obesity (OAO) in China has a significant health and economic impact. This study undertook an investment case analysis to evaluate the health and economic impacts of child and adolescent OAO in China and the potential health and economic returns from implementing specific policies and interventions.

Methods

The analysis estimates the reduction in mortality and morbidity from implementing a set of evidence-based interventions across China between 2025 and 2092 using a deterministic Markov cohort model. Modelled interventions were identified by literature review and expert recommendation and include fiscal and regulatory policies, eHealth breastfeeding promotion, school-based interventions, and nutritional counselling by physicians. The study applies a societal costing perspective to model the economic impact on healthcare cost savings, wages, and productivity during adulthood. By projecting and comparing the costs between a status quo scenario and an intervention scenario, the study estimates the return on investment (ROI) for interventions separately and in combination.

Findings

Without intervention China will experience 3.3 billion disability-adjusted life years (DALYs) due its current levels of child and adolescent OAO and a lifetime economic impact of CNY 218 trillion (USD 31.6 trillion), or a lifetime CNY 2.5 million loss per affected child or adolescent (USD 350 thousand). National implementation of all five interventions would avert 179.4 million DALYs and result in CNY 13.1 trillion of benefits over the model cohort's lifetime. Implementing fiscal and regulatory policies had the strongest ROI, with benefits accruing at least 10 years after implementation. Scaling up China's current school-based interventions offers China significant health and economic gains, however, the ROI is lower than other modelled interventions.

Interpretation

Effective prevention and treatment of child and adolescent OAO is critical to China's health and economic development. Multiple interventions offer a comprehensive approach to address the various factors that increase risk of child and adolescent OAO. Nonetheless, fiscal and regulatory policies offer the strongest health and economic gains.

Funding

Funding was provided by UNICEF China.

Cost-effectiveness analysis of 20-valent pneumococcal conjugate vaccine for routine pediatric vaccination programs in Japan

BACKGROUND

The Japanese National Immunization Program currently includes the pediatric 13 valent pneumococcal conjugate vaccine (PCV13) to prevent pneumococcal infections. We aimed to evaluate the cost-effectiveness of 20-valent PCV (PCV20) as a pediatric vaccine versus PCV13.

METHODS

A decision-analytic Markov model was used to estimate expected costs, quality-adjusted life-years (QALYs), and prevented cases and deaths caused by invasive pneumococcal disease, pneumonia, and acute otitis media over a ten-year time horizon from the societal and healthcare payer perspectives.

RESULTS

PCV20 was dominant, i.e. less costly and more effective, over PCV13 (gained 294,599 QALYs and reduced Japanese yen [JPY] 352.6 billion [2.6 billion United States dollars, USD] from the societal perspective and JPY 178.9 billion [USD 1.4 billion] from the payer perspective). Sensitivity and scenario analyses validated the robustness of the base scenario results. When comparing PCV20 with PCV13, the threshold analysis revealed an incremental cost-effectiveness ratio that was within the threshold value (JPY 5 million/QALY) at a maximum acquisition cost of JPY 74,033 [USD 563] (societal perspective) and JPY 67,758 [USD 515] (payer perspective).

CONCLUSIONS

As a pediatric vaccine, PCV20 was dominant over PCV13 regardless of the study perspective.

Prophylactic Interventions for Hereditary Breast and Ovarian Cancer Risks and Mortality in BRCA1/2 Carriers

BACKGROUND

Hereditary breast and ovarian cancers (HBOCs) pose significant health risks worldwide and are mitigated by prophylactic interventions. However, a meta-analysis of their efficacy and the impact of different genetic variants on their effectiveness is lacking.

METHODS

A systematic review and meta-analysis were conducted, adhering to Cochrane guidelines. The review encompassed studies that involved prophylactic interventions for healthy women with BRCA variants, focusing on cancer incidence and mortality outcomes. The Newcastle-Ottawa Scale was used for risk of bias assessment. We pooled the extracted outcomes using random effects models and conducted subgroup analyses stratified by intervention, variant, and cancer types.

RESULTS

A total of 21 studies met the inclusion criteria. The meta-analysis revealed that prophylactic interventions significantly reduced cancer risk and mortality. The subgroup analysis showed a greater protective effect for BRCA2 than BRCA1 variant carriers. Risk-reducing surgeries (RRS) were more effective than chemoprevention, with RRS notably reducing cancer risk by 56% compared to 39% for chemoprevention. Prophylactic oophorectomy significantly reduced HBOC risks, while the effect of prophylactic mastectomy and chemoprevention on mortality was less conclusive.

CONCLUSIONS

Prophylactic interventions significantly reduce the risk of HBOC and associated mortality. This comprehensive analysis provides insights for future economic evaluations and clinical decision-making in HBOC interventions.

Associating Health-Related Quality-of-Life Score with Time Uses to Inform Productivity Measures in Cost-Effectiveness Analysis

BACKGROUND

The Second Panel on Cost Effectiveness in Health and Medicine recommended that cost-effectiveness analyses (CEA) explicitly incorporate the valuation of productive time from a societal perspective. We developed a new approach to capture productivity impacts in CEA without direct evidence on these impacts by associating varying levels of health-related quality-of-life (HrQoL) score with different time uses in the United States.

METHODS

We conceptualized a framework that estimates the association between HrQoL score with productivity through time uses. We used the American Time-Use Survey (ATUS) from year 2012-2013, when data on a Well-Being Module (WBM) was additionally collected alongside ATUS. The WBM measured the quality of life (QoL) score using a visual analog scale. To operationalize our conceptual framework, we employed an econometric approach that addressed three technical issues in the observed data: (i) distinction between overall QoL and HrQoL, (ii) correlation across different categories of time use and the share structure of time-use data, and (iii) reverse causality between time uses and HrQoL score in a cross-sectional setting. Furthermore, we developed a metamodel-based algorithm to summarize the numerous estimates from the primary econometric model efficiently. Finally, we illustrated the use of our algorithm to calculate productivity and time spent seeking care costs in an empirical CEA of a prostate cancer treatment.

RESULTS

We provide the estimates of the metamodel algorithm. Incorporating these estimates into the empirical CEA reduced the incremental cost-effectiveness ratio by 27%.

CONCLUSION

Our estimates can facilitate the inclusion of productivity and time spent seeking care in CEA as recommended by the Second Panel.

Population-level health and economic impacts of introducing Vaccae vaccination in China: a modelling study

INTRODUCTION

Given the ageing epidemic of tuberculosis (TB), China is facing an unprecedented opportunity provided by the first clinically approved next-generation TB vaccine Vaccae, which demonstrated 54.7% efficacy for preventing reactivation from latent infection in a phase III trial. We aim to assess the population-level health and economic impacts of introducing Vaccae vaccination to inform policy-makers.

METHODS

We evaluated a potential national Vaccae vaccination programme in China initiated in 2024, assuming 20 years of protection, 90% coverage and US$30/dose government contract price. An age-structured compartmental model was adapted to simulate three strategies: (1) no Vaccae; (2) mass vaccination among people aged 15-74 years and (3) targeted vaccination among older adults (60 years). Cost analyses were conducted from the healthcare sector perspective, discounted at 3%.

RESULTS

Considering postinfection efficacy, targeted vaccination modestly reduced TB burden (~20%), preventing cumulative 8.01 (95% CI 5.82 to 11.8) million TB cases and 0.20 (0.17 to 0.26) million deaths over 2024-2050, at incremental cost-effectiveness ratio of US$4387 (2218 to 10 085) per disability adjusted life year averted. The implementation would require a total budget of US$22.5 (17.6 to 43.4) billion. In contrast, mass vaccination had a larger bigger impact on the TB epidemic, but the overall costs remained high. Although both preinfection and postinfection vaccine efficacy type might have a maximum impact (>40% incidence rate reduction in 2050), it is important that the vaccine price does not exceed US$5/dose.

CONCLUSION

Vaccae represents a robust and cost-effective choice for TB epidemic control in China. This study may facilitate the practice of evidence-based strategy plans for TB vaccination and reimbursement decision making.

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.

Patient Preferences in Targeted Pharmacotherapy for Cancers: A Systematic Review of Discrete Choice Experiments

BACKGROUND

Targeted pharmacotherapy has been increasingly applied in cancer treatment due to its breakthroughs. However, the unmet needs of cancer patients are still significant, highlighting the urgency to investigate patient preferences. It is unclear how patients deliberate their choices between different aspects of targeted therapy, including cost, efficacy, and adverse events. Since discrete choice experiments (DCEs) have been widely applied to patient preference elicitation, we reviewed DCEs on targeted therapy for different cancers. We also synthesized evidence on the factors influencing patients' choices and their willingness-to-pay (WTP) for survival when treated by targeted therapy.

METHODS

We searched databases, including PubMed, EMBASE and MEDLINE, up to August 16, 2022, supplemented by a reference screening. The attributes from the selected studies were categorized into three groups: outcomes, costs, and process. We also calculated the relative importance of attributes and WTP for survival whenever possible. The purpose, respondents, explanation, findings, significance (PREFS) checklist was used to evaluate the quality of the included DCE studies.

RESULTS

The review identified 34 eligible studies from 13 countries covering 14 cancers, such as breast, ovarian, kidney, prostate, and skin cancers. It also reveals a rising trend of DCEs on this topic, as most studies were published after 2018. We found that patients placed higher weights on the outcome (e.g., overall survival) and cost attributes than on process attributes. On average, patients were willing to pay $561 (95% confidence interval [CI]: $415-$758) and $716 (95% CI $524-$958) out-of-pocket for a 1-month increase in progression-free survival and overall survival, respectively. PREFS scores of the 34 studies ranged from 2 to 4, with a mean of 3.38 (SD: 0.65), suggesting a reasonable quality based on the checklist. However, most studies (n = 32, 94%) did not assess the impact of non-responses on the results.

CONCLUSIONS

This is the first systematic review focusing on patient preferences for targeted cancer therapy. We showcased novel approaches for evidence synthesis of DCE results, especially the attribute relative importance and WTP. The results may inform stakeholders about patient preferences toward targeted therapy and their WTP estimates. More studies with improved study design and quality are warranted to generate more robust evidence to assist decision making.