Cost-effectiveness analyses alongside randomised clinical trials

Conducting Trial-Based Economic Evaluations Using R: A Tutorial

Trial-based economic evaluations are increasingly being conducted to support healthcare decision-making. When analysing trial-based economic evaluation data, different methodological challenges may be encountered, including (i) missing data, (ii) correlated costs and effects, (iii) baseline imbalances and (iv) skewness of costs and/or effects. Despite the broad range of methods available to account for these methodological challenges in effectiveness studies, they may not always be directly applicable in trial-based economic evaluations where costs and effects are analysed jointly, and more than one methodological challenge typically needs to be addressed simultaneously. The use of inappropriate methods can bias results and conclusions regarding the cost-effectiveness of healthcare interventions. Eventually, such low-quality evidence can hamper healthcare decision-making, which may in turn result in a waste of already scarce healthcare resources. Therefore, this tutorial aims to provide step-by-step guidance on how to combine appropriate statistical methods for handling the abovementioned methodological challenges using a ready-to-use R script. The theoretical background of the described methods is provided, and their application is illustrated using a simulated trial-based economic evaluation.

Decentralised clinical trials in multiple sclerosis research

Randomised controlled trials (RCTs) play an important role in multiple sclerosis (MS) research, ensuring that new interventions are safe and efficacious before their introduction into clinical practice. Trials have been evolving to improve the robustness of their designs and the efficiency of their conduct. Advances in digital and mobile technologies in recent years have facilitated this process and the first RCTs with decentralised elements became possible. Decentralised clinical trials (DCTs) are conducted remotely, enabling participation of a more heterogeneous population who can participate in research activities from different locations and at their convenience. DCTs also rely on digital and mobile technologies which allows for more flexible and frequent assessments. While hospitals quickly adapted to e-health and telehealth assessments during the COVID-19 pandemic, the conduct of conventional RCTs was profoundly disrupted. In this paper, we review the existing evidence and gaps in knowledge in the design and conduct of DCTs in MS.

Cost-effectiveness analysis of a GP- and parent-directed intervention to reduce antibiotic prescribing for children with respiratory tract infections in primary care

OBJECTIVES

We evaluated costs and effects of the RAAK (RAtional Antibiotic use Kids) intervention (GP online training and information booklets for parents), aiming to reduce antibiotic prescribing for children with respiratory tract infection (RTI).

METHODS

We conducted a trial-based cost-effectiveness analysis from a societal perspective. We included children consulting the GP with RTI for whom parents kept a 2 week (cost) diary. The antibiotic prescribing rate was the percentage of children receiving an antibiotic prescription at the index consultation and during the 2 weeks of follow-up. The cost difference between the intervention and usual care groups per percentage decrease in antibiotic prescribing was calculated. Bootstrapping was used to assess uncertainty surrounding the outcomes.

RESULTS

Costs and effects of 153 children in the intervention group and 107 children in the usual care group were available for analysis. Antibiotic prescribing was 12% lower in the intervention group and costs were €10.27 higher in the intervention group compared with the usual care group. This resulted in an incremental cost-effectiveness ratio of €0.85 per percentage decrease in antibiotic prescribing. The probability that the intervention was more effective, but more expensive, was 53%, whereas the probability that the intervention was more effective and less expensive compared with usual care was 41%.

CONCLUSIONS

The online training for GPs and the information booklet for parents resulted in a decrease in antibiotic prescribing in children with RTI, at very low cost, and should therefore be considered for implementation in primary care.

Mini-Implants for Mandibular Overdentures: Cost-Effectiveness Analysis alongside a Randomized Trial

Mandibular overdentures retained by 2 conventional implants have been considered the standard of care for complete edentulism, according to the McGill and York consensuses. However, many patients refuse this treatment modality due to the associated costs and postsurgical discomfort. Mini-implants have the chance to overcome these limitations due to their potentially lower costs and a relatively uncomplicated surgical technique. This study compared treatment costs and incremental cost-effectiveness following the insertion of mini-implants (2 or 4) or 2 standard-size implants for the retention of mandibular overdentures, by means of a randomized clinical trial. In total, 120 edentulous participants (mean age 59.5 ± 8.5 y) were randomly allocated into 3 groups according to treatment received: 4 mini-implants (group 1), 2 mini-implants (group 2), or 2 standard implants (group 3). Treatment costs and outcomes (Oral Health Impact Profile for Edentulous [OHIP-EDENT] and satisfaction with the dentures) were evaluated after 6 mo. Incremental cost-effectiveness ratios (ICERs) were calculated for each intervention in terms of cost per 1-point change in patient outcomes. A 1-way sensitivity analysis was performed considering a 95% confidence interval variation in cost and outcome parameters, represented in tornado diagrams. Overall treatment cost was the lowest for group 2 (average cost: US$318.08), followed by group 1 (US$510.75) and group 3 (US$566.13). Groups did not differ in terms of the length of unscheduled appointments and time spent by participants. In summary, our findings indicate that mandibular overdentures retained by 2 or 4 mini-implants are less costly compared to 2-implant overdentures. Despite the lower costs of overdentures retained by 2 mini-implants, those retained by 4 mini-implants showed further improvement in patient-reported outcomes and reduced costs compared to standard implants ( ClinicalTrials.gov NCT01411683).

Knowledge Transfer Statement: This report shows that mini-implant retained overdentures are less costly than overdenture treatment on 2 standard-sized implants. Treatment with 2 mini-implants is an effective procedure to substantially save resources, whereas treatment with 4 mini-implants provides better results from a patient perspective combined with slightly reduced costs compared to the treatment with 2 standard implants. Therefore, mini-implant overdentures may be effective and more accessible than overdentures on 2 standard-size implants for those with limited incomes.

Do Economic Evaluations in Primary Care Prevention and the Management of Hypertension Conform to Good Practice Guidelines? A Systematic Review

Background: Results of previous research have identified the need for further investigation into the compliance with good practice guidelines for current decision-analytic modeling (DAM). Objective: To identify the extent to which recent model-based economic evaluations of interventions focused on lowering the blood pressure (BP) of patients with hypertension conform to published guidelines for DAM in health care using a five-dimension framework developed to assess compliance to DAM guidelines. Methods: A systematic review of English language articles was undertaken to identify published model-based economic evaluations that examined interventions aimed at lowering BP. The review covered the period January 2000 to March 2015 and included the following electronic bibliographic databases: EMBASE and Medline via Ovid interface and the Centre for Reviews and Dissemination’s (CRD) NHS-EED. Data were extracted based on different components of good practice across five dimensions utilizing a framework to assess compliance to DAM guidelines. Results: Thirteen articles were included in this review. The review found limited compliance to good practice DAM guidelines, which was most frequently justified by the lack of data. Conclusions: The assessment of structural uncertainty cannot yet be considered common practice in primary prevention and management of hypertension, and researchers seem to face difficulties with identifying sources of structural uncertainty and then handling them correctly. Additional guidelines are needed to aid researchers in identifying and managing sources of potential structural uncertainty. Adherence to guidelines is not always possible and it does pose challenges, in particular when there are limitations due to data availability that restrict, for example, a validation process.

End point selection in acute decompensated heart failure clinical trials: economic end points

The selection of economic end points in acute decompensated heart failure (ADHF) clinical trials requires prospectively planned evaluations that are developed in tandem with clinical end points. Integrating economic end points with concrete clinical outcomes postdischarge will provide meaningful data to evaluate a treatment's incremental value in the setting of ADHF.

Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial)

Background

Health outcomes and costs are both important when deciding whether general (GA) or local (LA) anaesthesia should be used during carotid endarterectomy. The aim of this study was to assess the cost-effectiveness of carotid endarterectomy under LA or GA in patients with symptomatic or asymptomatic carotid stenosis for whom surgery was advised.

Methods

Using patient-level data from a large, multinational, randomized controlled trial (GALA Trial) time free from stroke, myocardial infarction or death, and costs incurred were evaluated. The cost-effectiveness outcome was incremental cost per day free from an event, within a time horizon of 30 days.

Results

A patient undergoing carotid endarterectomy under LA incurred fewer costs (mean difference £178) and had a slightly longer event-free survival (difference 0·16 days, but the 95 per cent confidence limits around this estimate were wide) compared with a patient who had GA. Existing uncertainty did not have a significant impact on the decision to adopt LA, over a wide range of willingness-to-pay values.

Conclusion

If cost-effectiveness was considered in the decision to adopt GA or LA for carotid endarterectomy, given the evidence provided by this study, LA is likely to be the favoured treatment for patients for whom either anaesthetic approach is clinically appropriate.

Uncertainty and validation of health economic decision models

Health economic decision models are based on specific assumptions relating to model structure and parameter estimation. Validation of these models is recommended as an indicator of reliability, but is not commonly reported. Furthermore, models derived from different data and employing different assumptions may produce a variety of results.A Markov model for evaluating the long-term cost-effectiveness of screening for abdominal aortic aneurysm is described. Internal, prospective and external validations are carried out using individual participant data from two randomised trials. Validation is assessed in terms of total numbers and timings of key events, and total costs and life-years. Since the initial model validates well only internally, two further models are developed that better fit the prospective and external validation data. All three models are then extrapolated to a life-time horizon, producing cost-effectiveness estimates ranging from pound1600 to pound4200 per life-year gained.Parameter uncertainty is now commonly addressed in health economic decision modelling. However, the derivation of models from different data sources adds another level of uncertainty. This extra uncertainty should be recognised in practical decision-making and, where possible, specifically investigated through independent model validation.

Beware: the misuse of technology and the law of unintended consequences

Electronic monitoring of the fetal heart rate during labor (EFM), originally designed to assess fetal stress and allow the early detection of the compromised fetus, has instead led to increasing maternal morbidity without decreasing fetal morbidity. The unintended consequences of this technologic advance have led to the creation of a pseudodisease and unwarranted intervention in response to its detection. Is it ethical to introduce a new technology without adequate assessment of its possible consequences? Are we about to repeat this (error resulting from the introduction of EFM?) There is increasing interest in monitoring the function of the newborn brain, to enable the early detection of subclinical seizures. The monitor may also be used for assessing brain function in older children and adults who are comatose or paralyzed and cannot appropriately respond to stimuli. Use of this amplitude-integrated electroencephalography (aEEG) in the newborn for detection of seizures and other brain abnormalities is not dissimilar to the use of electronic fetal heart rate monitoring. Whether seizures or subclinical seizures themselves cause harm to the developing nervous system is unclear. The effectiveness of medications for treatment of seizures in the newborn has not been established. Therefore, the consequences of introducing automated EEG for the detection of subclinical neonatal seizures are likely to be similar to the results of the introduction of EFM: creation of another pseudodisease, followed by unwarranted intervention, and increased legal liability. What are the ethics of continued approval and introduction of unevaluated technology? What is the wisdom of its use? Beware of the unintended consequences.