Comparing the cost-per-QALYs gained and cost-per-DALYs averted literatures

Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique

BACKGROUND

Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity.

METHODS

We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.

RESULTS

In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures.

CONCLUSION

Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

Development of the Indian Reference Case for undertaking economic evaluation for health technology assessment

Background

Health technology assessment (HTA) is globally recognised as an important tool to guide evidence-based decision-making. However, heterogeneity in methods limits the use of any such evidence. The current research was undertaken to develop a set of standards for conduct of economic evaluations for HTA in India, referred to as the Indian Reference Case.

Methods

Development of the reference case comprised of a four-step process: (i) review of existing international HTA guidelines; (ii) systematic review of economic evaluations for three countries to assess adherence with pre-existing country-specific HTA guidelines; (iii) empirical analysis to assess the impact of alternate assumptions for key principles of economic evaluation on the results of cost-effectiveness analysis; (iv) stakeholder consultations to assess appropriateness of the recommendations. Based on the inferences drawn from the first three processes, a preliminary draft of the reference case was developed, which was finalised based on stakeholder consultations.

Findings

The Indian Reference Case provides twelve recommendations on eleven key principles of economic evaluation: decision problem, comparator, perspective, source of effectiveness evidence, measure of costs, health outcomes, time-horizon, discounting, heterogeneity, uncertainty analysis and equity analysis, and for presentation of results. The recommendations are user-friendly and have scope to allow for context-specific flexibility.

Interpretation

The Indian Reference Case is expected to provide guidance in planning, conducting, and reporting of economic evaluations. It is anticipated that adherence to the Reference Case would increase the quality and policy utilisation of future evaluations. However, with advancement in the field of health economics efforts aimed at refining the Indian Reference Case would be needed.

Funding

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. The research was undertaken as part of doctoral thesis of Sharma D, who received scholarship from the Indian Council of Medical Research (ICMR), New Delhi, India.

Informing a cost-effectiveness threshold for Saudi Arabia

BACKGROUND

Saudi Arabia's Vision 2030 aims to reform health care across the Kingdom, with health technology assessment being adopted as one tool promising to improve the efficiency with which resources are used. An understanding of the opportunity costs of reimbursement decisions is key to fulfilling this promise and can be used to inform a cost-effectiveness threshold. This paper is the first to provide a range of estimates of this using existing evidence extrapolated to the context of Saudi Arabia.

METHODS AND MATERIALS

We use four approaches to estimate the marginal cost per unit of health produced by the healthcare system; drawing from existing evidence provided by a cross-country analysis, two alternative estimates from the UK context, and based on extrapolating a UK estimate using evidence on the income elasticity of the value of health. Consequences of estimation error are explored.

RESULTS

Based on the four approaches, we find a range of SAR 42,046 per QALY gained (48% of GDP per capita) to SAR 215,120 per QALY gained (246% of GDP per capita). Calculated potential central estimates from the average of estimated health gains based on each source gives a range of SAR 50,000-75,000. The results are in line with estimates from the emerging literature from across the world.

CONCLUSION

A cost-effectiveness threshold reflecting health opportunity costs can aid decision-making. Applying a cost-effectiveness threshold based on the range SAR 50,000 to 75,000 per QALY gained would ensure that resource allocation decisions in healthcare can in be informed in a way that accounts for health opportunity costs.

LIMITATIONS

A limitation is that it is not based on a within-country study for Saudi Arabia, which represents a promising line of future work.

Does the Choice of Health Metric, DALY or QALY, Influence Conclusions of Health Economic Evaluation? A Case Study of Rotavirus Vaccine in Burundi

BACKGROUND

Two metrics, quality-adjusted life-year (QALY) and disability-adjusted life-year (DALY), have been commonly used to measure health benefits associated with health interventions. This study aimed to explore the effect of the choice of health metric (DALY or QALY) on economic evaluation conclusion.

METHODS

A previous published model for a cost-utility analysis (CUA) of rotavirus vaccine was adapted to estimate the QALYs gained and DALYs averted from four rotavirus vaccines: Rotarix, RotaTeq, Rotavac, and Rotasiil. The study was conducted in both Burundi provider and societal perspectives over a five-year time horizon. Disability weights (DW) were derived from the Global Burden of Disease (GBD) study. Scenario analysis was performed to evaluate the impact of age weights and source of utility weight.

RESULTS

In base-case analysis, the QALYs gained ranged from 46 to 78% of the DALYs averted. The incremental cost-effectiveness ratios (ICER) per QALY gained were higher than ICER per DALY averted by 28 to 113%, leading to less favorable cost effectiveness. The QALYs gained from using 1-DW as utility weight were slightly higher than those using EQ-5D utility weight obtained from previous literature, yet less likely to alter CUA conclusions. When age-weighting was incorporated in the DALY calculation, the ICERs per DALY averted were reduced leading to more favorable cost effectiveness.

CONCLUSION

In case of rotavirus diarrhea, in which mortality burden is considered larger than morbidity due to short duration of disease, although the use of DALY consistently led to more favorable cost-effective result than the use of QALY such effects were considered small and less likely to affect the EE conclusion under current CET of 1 GDP per capita.

Herd Immunity Effects in Cost-Effectiveness Analyses among Low- and Middle-Income Countries

BACKGROUND

Herd immunity (HI) is a key benefit of vaccination programs, but the effects are not routinely included in cost-effectiveness analyses (CEAs).

OBJECTIVE

This study investigated how the inclusion of HI in CEAs may influence the reported value of immunizations in low- and middle-income countries (LMICs) and illustrated the implications for COVID-19 immunization.

METHODS

We reviewed immunization CEAs published from 2000 to 2018 focusing on LMICs using data from the Tufts Medical Center CEA Registries. We investigated the proportion of studies that included HI, the methods used, and the incremental cost-effectiveness ratios (ICERs) reported. When possible, we evaluated how ICERs would change with and without HI.

RESULTS

Among the 243 immunization CEAs meeting inclusion criteria, 44 studies (18%) included HI. Of those studies, 11 (25%) used dynamic transmission models, whereas the remainder used static models. Sixteen studies allowed for ICER calculations with and without HI (n = 48 ratios). The inclusion of HI always resulted in more favorable ratios. In 20 cases (42%), adding HI decreased the ICERs enough to cross at least one or more common cost-effectiveness benchmarks for LMICs. Among pneumococcal vaccination studies, including HI in the analyses decreased seven of 24 ICERs enough to cross at least one cost-effectiveness benchmark.

CONCLUSION

The full value of immunization may be underestimated without considering a scenario in which HI is achieved. Given the evidence in pneumococcal CEAs, COVID-19 vaccine value assessments should aim to show ICERs with and without HI to inform decision-making in LMICs.

An intensive model of care for hepatitis C virus screening and treatment with direct-acting antivirals in people who inject drugs in Nairobi, Kenya: a model-based cost-effectiveness analysis

BACKGROUND AND AIMS

Hepatitis C virus (HCV) treatment is essential for eliminating HCV in people who inject drugs (PWID), but has limited coverage in resource-limited settings. We measured the cost-effectiveness of a pilot HCV screening and treatment intervention using directly observed therapy among PWID attending harm reduction services in Nairobi, Kenya.

DESIGN

We utilized an existing model of HIV and HCV transmission among current and former PWID in Nairobi to estimate the cost-effectiveness of screening and treatment for HCV, including prevention benefits versus no screening and treatment. The cure rate of treatment and costs for screening and treatment were estimated from intervention data, while other model parameters were derived from literature. Cost-effectiveness was evaluated over a life-time horizon from the health-care provider's perspective. One-way and probabilistic sensitivity analyses were performed.

SETTING

Nairobi, Kenya.

POPULATION

PWID.

MEASUREMENTS

Treatment costs, incremental cost-effectiveness ratio (cost per disability-adjusted life year averted).

FINDINGS

The cost per disability-adjusted life-year averted for the intervention was $975, with 92.1% of the probabilistic sensitivity analyses simulations falling below the per capita gross domestic product for Kenya ($1509; commonly used as a suitable threshold for determining whether an intervention is cost-effective). However, the intervention was not cost-effective at the opportunity cost-based cost-effectiveness threshold of $647 per disability-adjusted life-year averted. Sensitivity analyses showed that the intervention could provide more value for money by including modelled estimates for HCV disease care costs, assuming lower drug prices ($75 instead of $728 per course) and excluding directly-observed therapy costs.

CONCLUSIONS

The current strategy of screening and treatment for hepatitis C virus (HCV) among people who inject drugs in Nairobi is likely to be highly cost-effective with currently available cheaper drug prices, if directly-observed therapy is not used and HCV disease care costs are accounted for.

An Introduction to the Main Types of Economic Evaluations Used for Informing Priority Setting and Resource Allocation in Healthcare: Key Features, Uses, and Limitations

Economic evidence is increasingly being used for informing health policies. However, the underlining principles of health economic analyses are not always fully understood by non-health economists, and inappropriate types of analyses, as well as inconsistent methodologies, may be being used for informing health policy decisions. In addition, there is a lack of open access information and methodological guidance targeted to public health professionals, particularly those based in low- and middle-income country (LMIC) settings. The objective of this review is to provide a comprehensive and accessible introduction to economic evaluations for public health professionals with a focus on LMIC settings. We cover the main principles underlining the most common types of full economic evaluations used in healthcare decision making in the context of priority setting (namely cost-effectiveness/cost-utility analyses, cost-benefit analyses), and outline their key features, strengths and weaknesses. It is envisioned that this will help those conducting such analyses, as well as stakeholders that need to interpret their output, gain a greater understanding of these methods and help them select/distinguish between the different approaches. In particular, we highlight the need for greater awareness of the methods used to place a monetary value on the health benefits of interventions, and the potential for such estimates to be misinterpreted. Specifically, the economic benefits reported are typically an approximation, summarising the health benefits experienced by a population monetarily in terms of individual preferences or potential productivity gains, rather than actual realisable or fiscal monetary benefits to payers or society.

Bridging the gap: aligning economic research with disease burden

Introduction

Cost-effectiveness analysis (CEA) is critical for identifying high-value interventions that address significant unmet need. This study examines whether CEA study volume is proportionate to the burden associated with 21 major disease categories.

Methods

We searched the Tufts Medical Center CEA and Global Health CEA Registries for studies published between 2010 and 2019 that measured cost per quality-adjusted life-year or cost per disability-adjusted life-year (DALY). Stratified by geographical region and country income level, the relationship between literature volume and disease burden (as measured by 2019 Global Burden of Disease estimates of population DALYs) was analysed using ordinary least squares linear regression. Additionally, the number of CEAs per intervention deemed ‘essential’ for universal health coverage by the Disease Control Priorities Network was assessed to evaluate how many interventions are supported by cost-effectiveness evidence.

Results

The results located below the regression line but with relatively high burden suggested disease areas that were ‘understudied’ compared with expected study volume. Understudied disease areas varied by region. Higher-income and upper-middle-income country (HUMIC) CEA volume for non-communicable diseases (eg, mental/behavioural disorders) was 100-fold higher than that in low-income and lower-middle-income countries (LLMICs). LLMIC study volume remained concentrated in HIV/AIDS as well as other communicable and neglected tropical diseases. Across 60 essential interventions, only 33 had any supporting CEA evidence, and only 21 had a decision context involving a low-income or middle-income country. With the exception of one intervention, available CEA evidence revealed the 21 interventions to be cost-effective, with base-case findings less than three times the GDP per capita.

Conclusion

Our analysis highlights disease areas that require significant policy attention. Research gaps for highly prevalent, lethal or disabling diseases, as well as essential interventions may be stifling potential efficiency gains. Large research disparities between HUMICs and LLMICs suggest funding opportunities for improving allocative efficiency in LLMIC health systems.

Economic evaluation studies in the field of HIV/AIDS: bibliometric analysis on research development and scopes (GAPRESEARCH)

Background

The rapid decrease in international funding for HIV/AIDS has been challenging for many nations to effectively mobilize and allocate their limited resources for HIV/AIDS programs. Economic evaluations can help inform decisions and strategic planning. This study aims to examine the trends and patterns in economic evaluation studies in the field of HIV/AIDS and determine their research landscapes.

Methods

Using the Web of Science databases, we synthesized the number of papers and citations on HIV/AIDS and economic evaluation from 1990 to 2017. Collaborations between authors and countries, networks of keywords and research topics were visualized using frequency of co-occurrence and Jaccards’ similarity index. A Latent Dirichlet Allocation (LDA) analysis to categorize papers into different topics/themes.

Results

A total of 372 economic evaluation papers were selected, including 351 cost-effectiveness analyses (CEA), 11 cost-utility analyses (CUA), 12 cost-benefit analyses (CBA). The growth of publications, their citations and usages have increased remarkably over the years. Major research topics in economic evaluation studies consisted of antiretroviral therapy (ART) initiation and treatment; drug use prevention interventions and prevention of mother-to-child transmission interventions. Moreover, lack of contextualized evidence was found in specific settings with high burden HIV epidemics, as well as emerging most-at-risk populations such as trans-genders or migrants.

Conclusion

This study highlights the knowledge and geographical discrepancies in HIV/AIDS economic evaluation literature. Future research directions are also informed for advancing economic evaluation in HIV/AIDS research.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

Cost effectiveness and affordability of trastuzumab in sub-Saharan Africa for early stage HER2-positive breast cancer

Background

Breast cancer is the second most common cancer worldwide, the most common among women, and the most frequent cause of death among women in less developed regions. Trastuzumab is a humanized monoclonal antibody that downregulates the extracellular domain of the HER2 protein. Using trastuzumab to treat women with localized HER2-positive breast cancer has been shown to improve survival. The objective of this study is to explore the cost-effectiveness of adjuvant trastuzumab, from a societal perspective, in 11 African countries. In addition, we aimed to establish value-based prices for trastuzumab based on the gross domestic product per capita in each country.

Methods

We developed a Markov model in order to assess the costs and benefits associated with trastuzumab treatment over a lifetime horizon. A probabilistic sensitivity analysis was performed in order to estimate the impact of uncertainty of parameter-values on the results. Efficacy inputs were derived using clinical trial data from non-African countries.

Results

In the base case analysis, trastuzumab yielded a gain ranging from 0.92 LYs in Nigeria to 1.07 LYs in South Africa, and 0.9 QALYs in Nigeria to 1.02 QALYs in South Africa. The incremental cost ranged from 19,561 USD in Nigeria to 19,997 USD in Congo, and an incremental cost-effectiveness ratio ranging from 19,534 USD/QALY in South Africa to 21,697 USD/QALY in Nigeria. Using willingness to pay estimates based on World Health Organization recommendations, trastuzumab appear to not be cost-effective in all countries analyzed. Cost-effectiveness estimates were most sensitive to the discount rate, trastuzumab cost, and the hazard ratio.

Conclusions

Trastuzumab does not appear to be cost effective in the African countries analyzed. In order for trastuzumab to be cost-effective, the costs of treatment would require significant discounts.

Electronic supplementary material

The online version of this article (10.1186/s12962-019-0174-7) contains supplementary material, which is available to authorized users.

Evidence-Based Medicine in Otolaryngology Part 9: Valuing Health Outcomes

Decisions about resource allocation are increasingly based on value trade-offs between health outcomes and cost. This process relies on comprehensive and standardized definitions of health status that accurately measure the physical, mental, and social well-being of patients across disease states. These metrics, assessed through clinical trials, observational studies, and health surveys, can facilitate the integration of patient preferences into clinical practice. This ninth installment in the Evidence-Based Medicine in Otolaryngology Series is a practical overview of health outcome valuation, as well as the integration of both quality and quantity of life into standardized metrics for health research, program planning, and resource allocation. Tools for measuring preference-based health states, measures of effectiveness, and the application of metrics in economic evaluations are discussed.

Comparing the cost-per-QALYs gained and cost-per-DALYs averted literatures

Background: We examined the similarities and differences between studies using two common metrics used in cost-effectiveness analyses (CEAs): cost per quality-adjusted life year (QALY) gained and cost per disability-adjusted life year (DALY) averted. Methods: We used the Tufts Medical Center CEA Registry, which contains English-language cost-per-QALY gained studies, and the Global Cost-Effectiveness Analysis (GHCEA) Registry, which contains cost-per-DALY averted studies. We examined study characteristics, including intervention type, sponsor, country, and primary disease, and also compared the number of published CEAs to disease burden for major diseases and conditions across geographic regions. Results: We identified 6,438 cost-per-QALY and 543 cost-per-DALY studies published through 2016 and observed rapid growth for both literatures. Cost-per-QALY studies most often examined pharmaceuticals and interventions in high-income countries. Cost-per-DALY studies predominantly focused on infectious disease interventions and interventions in low and lower-middle income countries. We found that while diseases imposing a larger burden tend to receive more attention in the cost-effectiveness analysis literature, the number of publications for some diseases and conditions deviates from this pattern, suggesting "under-studied" conditions (e.g., neonatal disorders) and "over-studied" conditions (e.g., HIV and TB). Conclusions: The CEA literature has grown rapidly, with applications to diverse interventions and diseases.  The publication of fewer studies than expected for some diseases given their imposed burden suggests funding opportunities for future cost-effectiveness research.

Comparing the cost-per-QALYs gained and cost-per-DALYs averted literatures

Background: We examined the similarities and differences between studies using two common metrics used in cost-effectiveness analyses (CEAs): cost per quality-adjusted life year (QALY) gained and cost per disability-adjusted life year (DALY) averted. Methods: We used the Tufts Medical Center CEA Registry, which contains English-language cost-per-QALY gained studies, and the Global Cost-Effectiveness Analysis (GHCEA) Registry, which contains cost-per-DALY averted studies. We examined study characteristics, including intervention type, sponsor, country, and primary disease, and also compared the number of published CEAs to disease burden for major diseases and conditions across geographic regions. Results: We identified 6,438 cost-per-QALY and 543 cost-per-DALY studies published through 2016 and observed rapid growth for both literatures. Cost-per-QALY studies most often examined pharmaceuticals and interventions in high-income countries. Cost-per-DALY studies predominantly focused on infectious disease interventions and interventions in low and lower-middle income countries. We found that while diseases imposing a larger burden tend to receive more attention in the cost-effectiveness analysis literature, the number of publications for some diseases and conditions deviates from this pattern, suggesting "under-studied" conditions (e.g., neonatal disorders) and "over-studied" conditions (e.g., HIV and TB). Conclusions: The CEA literature has grown rapidly, with applications to diverse interventions and diseases.  The publication of fewer studies than expected for some diseases given their imposed burden suggests funding opportunities for future cost-effectiveness research.