Cost-effectiveness analysis of tofacitinib for the treatment of moderate to severe rheumatoid arthritis: a systematic review and meta-analysis

BACKGROUND

As rheumatoid arthritis (RA) is a chronic and progressive disease that requires lifelong therapeutic intervention, it represents a considerable economic burden on those affected. This study investigated whether tofacitinib is a cost-effective therapeutic alternative to other DMARDs for treating moderate-to-severe RA.

RESEARCH DESIGN AND METHODS

All economic evaluation studies of tofacitinib compared to other DMARDs were identified. Using random-effects meta-analysis, we pooled incremental net benefit (INB) in (purchasing power parity) adjusted US$ with 95% confidence intervals. The modified economic evaluation bias checklist and Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument for quality appraisal were used. The subgroup analysis was done based on the comparator regimen.

RESULTS

Of the selected 11 studies, the number of studies from high-, upper-middle- and lower-middle-income countries was 7, 3, and 1, respectively. The subgroup analysis showed that tofacitinib with an INB of 19,180 US$ [95% CI, -34520 to -3840; p-value = 0.01] was not statistically cost-effective compared with cDMARDs (p-value > 0.0001). Compared to other DMARDs, the estimated pooled INB of tofacitinib was US$ 7260 [95% CI, 3030 to 11,480; p-value < 0.001], but there was substantial heterogeneity among the included studies, and the observed publication bias.

CONCLUSION

While tofacitinib shows potential as a cost-effective treatment, tailored economic evaluations are needed to account for the diverse and evolving contexts of RA treatment.

REGISTRATION

PROSPERO: CRD42023405970.

Incremental net monetary benefit of using varenicline for smoking cessation: A systematic review and meta-analysis of economic evaluation studies

AIMS

To conduct a systematic review and meta-analysis and pool the incremental net benefits (INBs) of varenicline compared with behaviour support with bupropion or nicotine replacement therapy (NRT), behaviour support alone and unaided cessation in adult smokers making a first-time attempt to quit.

METHODS

A search for economic evaluation studies was conducted from inception to 30 September 2022, on PubMed, Embase, Cost-Effectiveness Analysis (CEA) Registry by Tufts Medical Centre, EconLit and the NHS Economic Evaluation Database (NHS EED). Eligible studies were included if they were (1) conducted among adults ages 18 years old and older who were smokers attempting to quit for the first time; (2) compared varenicline to behaviour support with bupropion or NRT, behaviour support alone and unaided cessation; and (3) performed a CEA or cost-utility analysis. The INBs were calculated and pooled across studies stratified by country income level and study perspective using the random-effects model. Statistical heterogeneity between studies was assessed using the I2 statistic and Cochrane Q statistic.

RESULTS

Of the 1433 identified studies, 18 studies were included in our review. Our findings from healthcare system/payer perspective suggested that the use of varenicline is statistically significantly cost-effective compared with bupropion (pooled INB, $830.75 [95% confidence interval, $208.23, $1453.28]), NRTs ($636.16 [$192.48, $1079.84]) and unaided cessation ($4212.35 [$1755.79, $6668.92]) in high-income countries. Similarly, varenicline is also found to be cost-effective compared to bupropion ($2706.27 [$1284.44, $4128.11]), NRTs ($3310.01 [$1781.53, $4838.50]) and behavioural support alone ($5438.22 [$4105.99, $6770.46]) in low- and middle-income countries.

CONCLUSION

Varenicline is cost-effective as a smoking cessation aid when compared with behavioural support with bupropion or nicotine replacement therapies and behavioural support alone in both high-income countries and low- and middle-income countries, from the healthcare system/payer perspective in adult smokers who attempt to quit for the first time.

Cost Effectiveness of Deep Brain Stimulation for Parkinson's Disease: A Systematic Review

BACKGROUND AND OBJECTIVE

Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD) in patients with advanced motor symptoms with an inadequate response to pharmacotherapies. Despite its effectiveness, the cost effectiveness of DBS remains a subject of debate. This systematic review aims to update and synthesize evidence on the cost effectiveness of DBS for PD.

METHODS

To identify full economic evaluations that compared the cost effectiveness of DBS with other best medical treatments, a comprehensive search was conducted of the PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry databases. The selected papers were systematically reviewed, and the results were summarized. For the quality appraisal, we used the modified economic evaluations bias checklist. The review protocol was a priori registered with PROSPERO, CRD42022345508.

RESULTS

Sixteen identified cost-utility analyses that reported 19 comparisons on the use of DBS for PD were systematically reviewed. The studies were primarily conducted in high-income countries and employed Markov models. The costs considered were direct costs: surgical expenses, calibration, pulse generator replacement, and annual drug expenses. The majority of studies used country-specific thresholds. Fourteen comparisons from 12 studies reported on the cost effectiveness of DBS compared to best medical treatments. Eleven comparisons reported DBS as cost effective based on incremental cost-utility ratio results.

CONCLUSIONS

The cost effectiveness of DBS for PD varies by time horizon, costs considered, threshold utilized, and stage of PD progression. Standardizing approaches and comparing DBS with other treatments are needed for future research on effective PD management.

Economic evaluation of second measles containing vaccine (MCV) dose: a systematic review of available evidence

INTRODUCTION

The global measles incidence has decreased from 145 to 49 cases per 1 million population from 2000 to 2018, but evaluating the economic benefits of a second measles-containing vaccine (MCV2) is crucial. This study reviewed the evidence and quality of economic evaluation studies to guide MCV2 introduction.

METHODS

The systematic review of model-based economic evaluation studies was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search yielded 2231 articles, with 876 duplicates removed and 1355 articles screened, with nine studies included for final analysis.

RESULTS

Six studies reported a positive benefit-cost ratio with one resulting in net savings of $11.6 billion, and two studies estimated a 2-dose MMR vaccination program would save $119.24 to prevent one measles case, and a second dose could prevent 9,200 cases at 18 months, saving $548.19 per case. The most sensitive variables were the discount rate and vaccination administration cost.

CONCLUSIONS

Two MCV doses or a second opportunity with an additional dose of MCV were highly cost-beneficial and resulted in substantial cost savings compared to a single routine vaccine. But further research using high-quality model-based health economic evaluation studies of MCV2 should be made available to decision-makers.

PROSPERO REGISTRATION

CRD42020200669.

Mapping the value for money of precision medicine: a systematic literature review and meta-analysis

Objective

This study aimed to quantify heterogeneity in the value for money of precision medicine (PM) by application types across contexts and conditions and to quantify sources of heterogeneity to areas of particular promises or concerns as the field of PM moves forward.

Methods

A systemic search was performed in Embase, Medline, EconLit, and CRD databases for studies published between 2011 and 2021 on cost-effectiveness analysis (CEA) of PM interventions. Based on a willingness-to-pay threshold of one-time GDP per capita of each study country, the net monetary benefit (NMB) of PM was pooled using random-effects meta-analyses. Sources of heterogeneity and study biases were examined using random-effects meta-regressions, jackknife sensitivity analysis, and the biases in economic studies checklist.

Results

Among the 275 unique CEAs of PM, publicly sponsored studies found neither genetic testing nor gene therapy cost-effective in general, which was contradictory to studies funded by commercial entities and early stage evaluations. Evidence of PM being cost-effective was concentrated in a genetic test for screening, diagnosis, or as companion diagnostics (pooled NMBs, $48,152, $8,869, $5,693, p < 0.001), in the form of multigene panel testing (pooled NMBs = $31,026, p < 0.001), which only applied to a few disease areas such as cancer and high-income countries. Incremental effectiveness was an essential value driver for varied genetic tests but not gene therapy.

Conclusion

Precision medicine's value for money across application types and contexts was difficult to conclude from published studies, which might be subject to systematic bias. The conducting and reporting of CEA of PM should be locally based and standardized for meaningful comparisons.

Is Using Sodium-Glucose Cotransporter-2 Inhibitors to Treat Adults with Chronic Heart Failure Cost-Effective? A Systematic Review of Cost-Effectiveness Studies

OBJECTIVE

This systematic review aimed to summarise the outcomes of economic evaluations that evaluated sodium-glucose cotransporter-2 inhibitors (SGLT2i) in combination with standard of care compared to standard of care alone for patients with chronic heart failure.

METHODS

This systematic review searched MEDLINE, CINAHL+, Econlit, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database and the Cost-Effectiveness Analysis Registry from inception to 31 December, 2022, for relevant economic evaluations, which were critically appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and Bias in Economic Evaluation (ECOBIAS) criteria. The costs, quality-adjusted life-years, incremental cost-effectiveness ratios and cost-effectiveness thresholds were qualitatively analysed. Net monetary benefits at different decision thresholds were also computed. Subgroup analyses addressing the heterogeneity of economic outcomes were conducted. All costs were adjusted to 2023 international dollar (US$) values using the CCEMG-EPPI-Centre cost converter.

RESULTS

Thirty-nine economic evaluations that evaluated dapagliflozin and empagliflozin in patients with heart failure were found: 32 for the left ventricular ejection fraction (LVEF) ≤ 40% and seven for LVEF > 40%. Sodium-glucose cotransporter-2 inhibitors were cost-effective in all but two economic evaluations for LVEF > 40%. Economic outcomes varied widely, but favoured SGLT2i use in LVEF ≤ 40% over LVEF > 40% and upper-middle income over high-income countries. At a threshold of US$30,000/quality-adjusted life-year, ~ 90% of high to upper-middle income countries would consider SGLT2i cost-effective for heart failure treatment. The generalisability of study findings to low- and low-middle income countries is limited because of insufficient evidence.

CONCLUSIONS

Using SGLT2i to treat heart failure is cost-effective, with more certainty in LVEF ≤ 40% compared to LVEF > 40%. Policymakers in jurisdictions where economic evaluations are not available could potentially use this study's findings to make informed decisions about treatment adoption.

SYSTEMATIC REVIEW PROTOCOL REGISTRATION

This study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42023388701).

Economic Evaluations of Imaging Biomarker-Driven Companion Diagnostics for Cancer: A Systematic Review

INTRODUCTION

There is a boom in imaging biomarker-driven companion and complementary diagnostics (CDx) for cancer, which brings opportunity for personalized medicine. Whether adoption of these technologies is likely to be cost-effective is a relevant question, and studies on this topic are emerging. Despite the growing number of economic evaluations, no review of the methods used, quality of reporting, and potential risk of bias has been done. We report a systematic review to identify, summarize, and critique the cost-effectiveness evidence for the use of biomarker-driven and imaging-based CDx to inform cancer treatments.

METHODS

The Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Systematic literature searches until 30 December 2022 were performed in PubMed, Web of Science, Medline, Embase, and Scopus for economic evaluations of imaging biomarker-based CDx for cancer. The inclusion and exclusion of studies were determined by pre-specified eligibility criteria informed by the 'Patient, Intervention, Comparison, Outcome' (PICO) framework. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) was used to assess the quality of reporting, and the Bias in Economic Evaluation (ECOBIAS) was used to examine the potential risk of bias of included studies.

RESULTS

A total of 12 papers were included, with eight model-based and four trial-based studies. Implementing biomarker-driven, imaging-based CDx was reported to be cost-effective, cost saving, or dominant (cost saving and more effective) in ten papers. Inconsistent methods were found in the studies, and the quality of reporting was lacking against the CHEERS reporting guideline. Several potential sources of 'risk of bias' were identified. These should be acknowledged and carefully considered by researchers planning future health economic evaluations.

CONCLUSION

Despite favorable results towards the implementation of imaging biomarker-based CDx for cancer, there is room for improvement regarding the quantity and quality of economic evaluations, and that is expected as the awareness of current study limitations increases and more clinical data become available in the future.

Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality

BACKGROUND

The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations.

METHODS

We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively.

RESULTS

In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common.

CONCLUSIONS

While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.

Transforming global approaches to chronic disease prevention and management across the lifespan: integrating genomics, behavior change, and digital health solutions

Chronic illnesses are a major threat to global population health through the lifespan into older age. Despite world-wide public health goals, there has been a steady increase in chronic and non-communicable diseases (e.g., cancer, cardiovascular and metabolic disorders) and strong growth in mental health disorders. In 2010, 67% of deaths worldwide were due to chronic diseases and this increased to 74% in 2019, with accelerated growth in the COVID-19 era and its aftermath. Aging and wellbeing across the lifespan are positively impacted by the presence of effective prevention and management of chronic illness that can enhance population health. This paper provides a short overview of the journey to this current situation followed by discussion of how we may better address what the World Health Organization has termed the "tsunami of chronic diseases." In this paper we advocate for the development, validation, and subsequent deployment of integrated: 1. Polygenic and multifactorial risk prediction tools to screen for those at future risk of chronic disease and those with undiagnosed chronic disease. 2. Advanced preventive, behavior change and chronic disease management to maximize population health and wellbeing. 3. Digital health systems to support greater efficiencies in population-scale health prevention and intervention programs. It is argued that each of these actions individually has an emerging evidence base. However, there has been limited research to date concerning the combined population-level health effects of their integration. We outline the conceptual framework within which we are planning and currently conducting studies to investigate the effects of their integration.

Economic Evaluations of Guideline-Directed Medical Therapies for Heart Failure With Reduced Ejection Fraction: A Systematic Review

OBJECTIVES

Decision-analytic models (DAMs) with varying structures and assumptions have been applied in economic evaluations (EEs) to assist decision making for heart failure with reduced ejection fraction (HFrEF) therapeutics. This systematic review aimed to summarize and critically appraise the EEs of guideline-directed medical therapies (GDMTs) for HFrEF.

METHODS

A systematic search of English articles and gray literature, published from January 2010, was performed on databases including MEDLINE, Embase, Scopus, NHSEED, health technology assessment, Cochrane Library, etc. The included studies were EEs with DAMs that compared the costs and outcomes of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin-receptor neprilysin inhibitors, beta-blockers, mineralocorticoid-receptor agonists, and sodium-glucose cotransporter-2 inhibitors. The study quality was evaluated using the Bias in Economic Evaluation (ECOBIAS) 2015 checklist and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklists.

RESULTS

A total of 59 EEs were included. Markov model, with a lifetime horizon and a monthly cycle length, was most commonly used in evaluating GDMTs for HFrEF. Most EEs conducted in the high-income countries demonstrated that novel GDMTs for HFrEF were cost-effective compared with the standard of care, with the standardized median incremental cost-effectiveness ratio (ICER) of $21 361/quality-adjusted life-year. The key factors influencing ICERs and study conclusions included model structures, input parameters, clinical heterogeneity, and country-specific willingness-to-pay threshold.

CONCLUSIONS

Novel GDMTs were cost-effective compared with the standard of care. Given the heterogeneity of the DAMs and ICERs, alongside variations in willingness-to-pay thresholds across countries, there is a need to conduct country-specific EEs, particularly in low- and middle-income countries, using model structures that are coherent with the local decision context.

Evaluating the Value for Money of Precision Medicine from Early Cycle to Market Access: A Comprehensive Review of Approaches and Challenges

OBJECTIVES

This study aimed to perform a comprehensive review of modeling approaches and methodological and policy challenges in the economic evaluation (EE) of precision medicine (PM) across clinical stages.

METHODS

First, a systematic review was performed to assess the approaches of EEs in the past 10 years. Next, a targeted review of methodological articles was conducted for methodological and policy challenges in performing EEs of PM. All findings were synthesized into a structured framework that focused on patient population, Intervention, Comparator, Outcome, Time, Equity and ethics, Adaptability and Modeling aspects, named the "PICOTEAM" framework. Finally, a stakeholder consultation was conducted to understand the major determinants of decision making in PM investment.

RESULTS

In 39 methodological articles, we identified major challenges to the EE of PM. These challenges include that PM applications involve complex and evolving clinical decision space, that clinical evidence is sparse because of small subgroups and complex pathways in PM settings, a one-time PM application may have lifetime or intergenerational impacts but long-term evidence is often unavailable, and that equity and ethics concerns are exceptional. In 275 EEs of PM, current approaches did not sufficiently capture the value of PM compared with targeted therapies, nor did they differentiate Early EEs from Conventional EEs. Finally, policy makers perceived the budget impact, cost savings, and cost-effectiveness of PM as the most important determinants in decision making.

CONCLUSIONS

There is an urgent need to modify existing guidelines or develop a new reference case that fits into the new healthcare paradigm of PM to guide decision making in research and development and market access.

Economic evaluations of artificial intelligence-based healthcare interventions: a systematic literature review of best practices in their conduct and reporting

Objectives: Health economic evaluations (HEEs) help healthcare decision makers understand the value of new technologies. Artificial intelligence (AI) is increasingly being used in healthcare interventions. We sought to review the conduct and reporting of published HEEs for AI-based health interventions. Methods: We conducted a systematic literature review with a 15-month search window (April 2021 to June 2022) on 17th June 2022 to identify HEEs of AI health interventions and update a previous review. Records were identified from 3 databases (Medline, Embase, and Cochrane Central). Two reviewers screened papers against predefined study selection criteria. Data were extracted from included studies using prespecified data extraction tables. Included studies were quality assessed using the National Institute for Health and Care Excellence (NICE) checklist. Results were synthesized narratively. Results: A total of 21 studies were included. The most common type of AI intervention was automated image analysis (9/21, 43%) mainly used for screening or diagnosis in general medicine and oncology. Nearly all were cost-utility (10/21, 48%) or cost-effectiveness analyses (8/21, 38%) that took a healthcare system or payer perspective. Decision-analytic models were used in 16/21 (76%) studies, mostly Markov models and decision trees. Three (3/16, 19%) used a short-term decision tree followed by a longer-term Markov component. Thirteen studies (13/21, 62%) reported the AI intervention to be cost effective or dominant. Limitations tended to result from the input data, authorship conflicts of interest, and a lack of transparent reporting, especially regarding the AI nature of the intervention. Conclusion: Published HEEs of AI-based health interventions are rapidly increasing in number. Despite the potentially innovative nature of AI, most have used traditional methods like Markov models or decision trees. Most attempted to assess the impact on quality of life to present the cost per QALY gained. However, studies have not been comprehensively reported. Specific reporting standards for the economic evaluation of AI interventions would help improve transparency and promote their usefulness for decision making. This is fundamental for reimbursement decisions, which in turn will generate the necessary data to develop flexible models better suited to capturing the potentially dynamic nature of AI interventions.

Economic Evaluation Associated With Clinical-Grade Mobile App-Based Digital Therapeutic Interventions: Systematic Review

BACKGROUND

Digital therapeutics (DTx), a class of software-based clinical interventions, are promising new technologies that can potentially prevent, manage, or treat a spectrum of medical disorders and diseases as well as deliver unprecedented portability for patients and scalability for health care providers. Their adoption and implementation were accelerated by the need for remote care during the COVID-19 pandemic, and awareness about their utility has rapidly grown among providers, payers, and regulators. Despite this, relatively little is known about the capacity of DTx to provide economic value in care.

OBJECTIVE

This study aimed to systematically review and summarize the published evidence regarding the cost-effectiveness of clinical-grade mobile app-based DTx and explore the factors affecting such evaluations.

METHODS

A systematic review of economic evaluations of clinical-grade mobile app-based DTx was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Major electronic databases, including PubMed, Cochrane Library, and Web of Science, were searched for eligible studies published from inception to October 28, 2022. Two independent reviewers evaluated the eligibility of all the retrieved articles for inclusion in the review. Methodological quality and risk of bias were assessed for each included study.

RESULTS

A total of 18 studies were included in this review. Of the 18 studies, 7 (39%) were nonrandomized study-based economic evaluations, 6 (33%) were model-based evaluations, and 5 (28%) were randomized clinical trial-based evaluations. The DTx intervention subject to assessment was found to be cost-effective in 12 (67%) studies, cost saving in 5 (28%) studies, and cost-effective in 1 (6%) study in only 1 of the 3 countries where it was being deployed in the final study. Qualitative deficiencies in methodology and substantial potential for bias, including risks of performance bias and selection bias in participant recruitment, were identified in several included studies.

CONCLUSIONS

This systematic review supports the thesis that DTx interventions offer potential economic benefits. However, DTx economic analyses conducted to date exhibit important methodological shortcomings that must be addressed in future evaluations to reduce the uncertainty surrounding the widespread adoption of DTx interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022358616; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022358616.

Cost-effectiveness of tumor necrosis factor-alpha inhibitors: a systematic review and meta-analysis of cost-utility studies

OBJECTIVE

To systematically review the cost-utility evidence of TNF-a-i treatment for rheumatoid arthritis (RA) and to estimate the pooled incremental net benefit (INBp).

METHODS

We selected economic evaluation studies reporting the cost-utility of TNF-a-i compared to other disease-modifying anti-rheumatic drugs (DMARDs) after a systematic search in PubMed, Embase, Scopus, and Tufts Medical Centers' cost-effective analysis registry. The results were reported as pooled INB in purchasing power parity-adjusted US dollars, along with 95% confidence intervals. We used GRADE quality assessment to present summaries of evidence and random-effects meta-analysis to synthesize cost-utility of TNF-a-i.

RESULTS

We included 86 studies for systematic review, of which 27 for meta-analysis. TNF-a-i is not cost-effective [$ -4,129(-6,789 to -1,469)] compared to other DMARDs but with high heterogeneity. There was no evidence of publication bias (p = 0.447). On separate analysis, TNF-a-i is not cost-effective [$ -4,805(-7,882 to -1,728)] compared to conventional synthetic DMARDs for RA treatment. GRADE assessment indicated very low confidence in pooled cost-utility results and likely presence of risk of bias on the overall ECOBIAS checklist in studies.

CONCLUSION

Based on the available evidence during the study period, TNF-a-i is not a cost-effective option for treating RA compared to other DMARDs. However, high heterogeneity and low confidence in GRADE quality assessment preclude the results from being generalizable.

Comprehensive Review of Methods to Assess Uncertainty in Health Economic Evaluations

Uncertainty assessment is a cornerstone in model-based health economic evaluations (HEEs) that inform reimbursement decisions. No comprehensive overview of available uncertainty assessment methods currently exists. We aimed to review methods for uncertainty assessment for use in model-based HEEs, by conducting a snowballing review. We categorised all methods according to their stage of use relating to uncertainty assessment (identification, analysis, communication). Additionally, we classified identification methods according to sources of uncertainty, and subdivided analysis and communication methods according to their purpose. The review identified a total of 80 uncertainty methods: 30 identification, 28 analysis, and 22 communication methods. Uncertainty identification methods exist to address uncertainty from different sources. Most identification methods were developed with the objective to assess related concepts such as validity, model quality, and relevance. Almost all uncertainty analysis and communication methods required uncertainty to be quantified and inclusion of uncertainties in probabilistic analysis. Our review can help analysts and decision makers in selecting uncertainty assessment methods according to their aim and purpose of the assessment. We noted a need for further clarification of terminology and guidance on the use of (combinations of) methods to identify uncertainty and related concepts such as validity and quality. A key finding is that uncertainty assessment relies heavily on quantification, which may necessitate increased use of expert elicitation and/or the development of methods to assess unquantified uncertainty.

Cost-Utility of Ranolazine for Chronic Stable Angina Pectoris: Systematic Review and Meta-Analysis

PURPOSE

Ranolazine is used to treat stable angina pectoris, the most common symptom of ischemic heart disease. Appropriate management of chronic stable angina pectoris is essential from both a clinical and an economic view point.

METHODS

This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included cost-utility analyses, which compared ranolazine with other standard treatments for treating stable angina pectoris. The search was conducted in PubMed, EMBASE, and Scopus databases. A random-effects model based on the DerSimonian and Laird method was used to pool the incremental net benefit reported in purchasing power parity adjusted US dollars. The modified economic evaluation checklist was used to assess the risk of bias.

FINDINGS

The pooled results from 7 selected studies with a time horizon of 1 year show that add-on ranolazine was significantly cost-effective compared with standard treatment, with a pooled incremental net benefit of US$1335 (95% CI, 500 to 2169) but with substantial heterogeneity (I² = 79.46%). On subgroup analysis, ranolazine was cost-effective from the payers' perspective (US$1975; 95% CI, 1042 to 2908; I² = 69.23) but not from a societal perspective (US$297; 95% CI, -241 to 715; I² = 0%)]. There was limited evidence from lower economies.

IMPLICATIONS

Pooled evidence suggests that add-on ranolazine therapy is cost-effective for chronic stable angina pectoris up to a 1-year time horizon. There is a lacuna of evidence from low- and middle-income countries and on long-term cost-effectiveness. The current evidence synthesis may provide a macroeconomic point of view for policy makers regarding the direction of ranolazine's cost-effectiveness for evidence-informed policy-making. PROSPERO identifier: CRD42022332454.

Pneumococcal Vaccination in Children: A Systematic Review and Meta-Analysis of Cost-Effectiveness Studies

OBJECTIVES

Pneumococcal conjugate vaccines (PCVs) have significantly reduced disease burden caused by Streptococcus pneumoniae, a leading cause of childhood morbidity and mortality globally. This systematic review and meta-analysis aimed to assess the incremental net benefit (INB) of the 13-valent PCV (PCV13) and 10-valent PCV (PCV10) in children.

METHODS

We performed a comprehensive search in several databases published before May 2022. Studies were included if they were cost-effectiveness or cost-utility analyses of PCV13 or PCV10 compared with no vaccination or with each other in children. Various monetary units were converted to purchasing power parity, adjusted to 2021 US dollars. The INBs were calculated and then pooled across studies stratified by country income level, perspective, and consideration of herd effects, using a random-effect model.

RESULTS

Seventy studies were included. When herd effects were considered, PCV13 was cost-effective compared with PCV10 from the payer perspective in both high-income countries (HICs) (INB, $103.94; 95% confidence interval, $75.28-$132.60) and low- and middle-income countries (LMICs) (INB, $53.49; 95% confidence interval, $30.42-$76.55) with statistical significance. These findings were robust across a series of sensitivity analyses. PCV13 was cost-effective compared with no vaccination across perspectives and consideration of herd effects in both HICs and LMICs, whereas findings were less consistent for PCV10.

CONCLUSION

PCVs were generally cost-effective compared with no vaccination in HICs and LMICs. Our study found that PCV13 was cost-effective compared with PCV10 when herd effects were considered from the payer perspective in both HICs and LMICs. The results are sensitive to the consideration of herd effects.

Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis: systematic review of cost-effectiveness analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a less invasive and costly treatment for patients with severe aortic stenosis (AS). This study aimed to systematically review the published literature focusing on economic evaluation of TAVI compared with other alternative treatments in AS populations.

METHODS

A systematic review was conducted from inception until May 2021 using PubMed, Scopus, Web of science and Embase databases. The qualities of included studies were evaluated using Consolidated Health Economic Evaluation Reporting Standard (CHEERS) criteria. Data of costs, outcomes, incremental cost-effectiveness ratio (ICER) and willingness to pay were extracted. To compare results, ICERs were converted to the 2020 United States dollar (USD) rate.

RESULTS

Of the 29 included cost-effectiveness studies, TAVI was cost-effective in all studies in the low-risk group (3/3), 77% of studies (7/9) in the intermediate-risk group, half of the studies (6/12) in the high-risk group, and 83% of studies (10/12) in the inoperable group. When adjusted to USD 2020, ICERs ranged from USD 2741 to 1027,674 USD per quality-adjusted life-year gained. The overall quality of the studies ranged from moderate to high.

CONCLUSIONS

TAVI is potentially a cost-effective alternative to surgical aortic valve replacement (SAVR) for patients with operable AS with low, intermediate or high risk compared with medical management (MM) for patients with inoperable AS. TAVI was associated with a significant gain in quality-adjusted life-years in almost all studies compared to either SAVR or MM. TAVI is a costly procedure; therefore, justifying its cost-effectiveness depends on the acceptable threshold in each country.

Incremental net monetary benefit of biologic therapies in moderate to severe asthma: a systematic review and meta-analysis of economic evaluation studies

OBJECTIVES

This meta-analysis was conducted to quantitatively pool the incremental net benefit (INB) of using biologic therapies as an add-on treatment to standard therapy in patients with moderate to severe asthma.

METHODS

We performed a comprehensive search in several databases published until April 2022. Studies were included if they were cost-effectiveness analyses reporting cost per quality-adjusted life-year or life-year on any biologic therapies as an add-on treatment for moderate to severe asthma in patients of all ages. Various monetary units were converted to purchasing power parity, adjusted to 2021 US dollars. The INBs were pooled across studies using a random-effects model, stratified by country income level (high-income countries (HICs) and low- and middle-income countries (LMICs)) and perspectives (health care or payer perspective (HCPP) and societal perspective (SP)) and age group (>12 years and 6-11 years). Heterogeneity was assessed using the I² statistic.

RESULTS

A total of 32 comparisons from 25 studies were included. Pooled INB indicated that the use of omalizumab as an add-on treatment to standard therapy in those aged >12 years was not cost-effective in HICs from the HCPP (n = 8, INB, -6,341 (95% CI, -$25,000 to $12,210), I²=86.18%) and SP (n = 5, -$14,000 (-$170,000 to $140,000), I²=75.64%). A similar finding was observed in those aged 6-11 years from the HCPP in LMICs (n = 2, -$45,000 (-$73,000 to $17,000), I²=00.00%). Subgroup analyses provided no explanations of the potential sources of heterogeneity.

CONCLUSION

The use of biologic therapies in moderate to severe asthma is not cost-effective compared to standard treatment alone.

Systematic Literature Review of Economic Evaluations of Treatment Alternatives in Chronic Lymphocytic Leukemia

BACKGROUND

Economic evaluations are widely used to predict the economic impact of new treatment alternatives. Comprehensive economic reviews in the field of chronic lymphocytic leukemia (CLL) are warranted to supplement the existing analyses focused on specific therapeutic areas.

METHODS

A systematic literature review was conducted based on literature searches in Medline and EMBASE to summarize the published health economics models related to all types of CLL therapies. Narrative synthesis of relevant studies was performed focusing on compared treatments, patient populations, modelling approaches and key findings.

RESULTS

We included 29 studies, the majority of which were published between 2016 and 2018, when data from large clinical trials in CLL became available. Treatment regimens were compared in 25 cases, while the remaining four studies considered treatment strategies with more complex patient pathways. Based on the review results, Markov modelling with a simple structure of three health states (progression-free, progressed, death) can be considered as the traditional basis to simulate cost effectiveness. However, more recent studies added further complexity, including additional health states for different therapies (e.g. best supportive care or stem cell transplantation), for progression-free state (e.g. by differentiating between with or without treatment), or for response status (i.e. partial response and complete response).

CONCLUSIONS

As personalized medicine is increasingly gaining recognition, we expect that future economic evaluations will also incorporate new solutions, which are necessary to capture a larger number of genetic and molecular markers and more complex patient pathways with individual patient-level allocation of treatment options and thus economic assessments.

The Cost-Effectiveness of Adjunctive Lifestyle Interventions for the Management of Cancer: A Systematic Review

OBJECTIVE

There is a paucity of papers synthesizing the cost-effectiveness (CE) of lifestyle interventions to support cancer patients, and the synthesis papers available have used analytic methods that do not permit easy comparison between studies. We therefore evaluated the CE of adjunctive lifestyle interventions compared with usual care.

METHODS

A systematic literature search of Scopus, MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library databases was conducted from database inception until June 2021. Eligible studies were economic evaluations from randomised controlled trials or modelled economic evaluations that recruited subjects with a confirmed diagnosis of cancer and were allocated to a lifestyle intervention as an adjunct or supportive treatment, or usual care. Studies were excluded if there was no cost-effectiveness analysis or if costs were identified but not related back to measures of effectiveness. CE of the included interventions was recalculated, adjusting for key differences (with respect to absolute resource costs and timing) between the broad range of study settings and a common 'target' setting. All CE data were converted into incremental net monetary benefit using a common cost-effectiveness threshold to facilitate comparison. The quality of the studies was evaluated for risk of bias using the ECOBIAS check list.

RESULTS

Nine studies were included in our review. Seven studies investigated the benefits of physical exercise in combination with cancer treatment and two studies investigated the combination of exercise and psychosocial counselling alongside cancer treatment. Six studies with an exercise intervention reported larger quality-adjusted life year (QALY) gains compared with usual care and when cost per QALY gained was considered, three of the interventions were cost effective. One of the two interventions combining exercise with psychosocial counselling was cost effective. All studies were considered of good quality but all had some limitations.

CONCLUSIONS

The evidence to support the cost effectiveness of lifestyle interventions in patients with cancer is mixed with four of the nine interventions found to be cost effective and two remaining cost effective when uncertainty was taken into account. Sensitivity analysis showed the influence of the CE threshold on the results, highlighting the importance of selecting a CE threshold that is appropriate to the setting.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number: CRD42020185376.

Cost Effectiveness of Rituximab Therapy for Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Cost-Utility Studies

BACKGROUND AND OBJECTIVES

Depletion of B cells is shown to be clinically effective for rheumatoid arthritis (RA) treatment. Although B-cell depletion therapy with rituximab is indicated for RA patients who have failed to other disease-modifying anti-rheumatic drugs (DMARDs), primary cost-effectiveness evidence is inconsistent. We aimed to provide synthesised cost-effectiveness evidence of rituximab in the treatment of RA compared to other DMARDs, since the published cost-effectiveness evidence is mixed.

METHODS

We identified economic evaluation studies reporting cost-utility of rituximab compared to other DMARDs by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled incremental net benefit (INB) in (purchasing power parity) adjusted US$ with 95% confidence intervals. We used the modified economic evaluations bias checklist and Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument for quality appraisal. The study protocol was pre-registered with PROSPERO, CRD 42021222541.

RESULTS

Of the selected 18 studies, the majority were from high-income countries (n = 14) followed by upper middle-income countries (n = 3) and lower middle-income countries (n = 1), with minimal risk of bias. Rituximab is significantly cost effective with a pooled INB (95% CI) of $8767 (720 to 16,814). On subgroup analysis, rituximab is significantly cost effective from a health system perspective [$12,832 (3392 to 22,272)], for studies using 3.5% discount rate [$15,468 (5973 to 24,963)] and a for a time horizon of less than 5 years [$8496 (1547 to 15,445)]. In a separate analysis, rituximab as third-line therapy (for conventional synthetic DMARDs followed by any other biologic DMARD failed patients) was not cost effective compared to DMARDs [$5314 (-2278 to 12,905)]. Further, the GRADE assessment indicated very-low confidence in the pooled results.

CONCLUSION

Rituximab is cost effective compared to other DMARDs but not if used as third-line therapy after failure of biologics. There is a need to generate context-specific evidence for the lower income settings.

Economic evaluation: a reader's guide to studies of cost-effectiveness

BACKGROUND

Understanding what an economic evaluation is, how to interpret it, and what it means for making choices in a health delivery context is necessary to contribute to decisions about healthcare resource allocation. The aim of this paper to demystify the working parts of a health economic evaluation, and explain to clinicians and clinical researchers how to read and interpret cost-effectiveness research.

MAIN BODY

This primer distils key content and constructs of economic evaluation studies, and explains health economic evaluation in plain language. We use the PICOT (participant, intervention, comparison, outcome, timeframe) clinical trial framework familiar to clinicians, clinical decision-makers, and clinical researchers, who may be unfamiliar with economics, as an aide to reading and interpreting cost-effectiveness research. We provide examples, primarily of physiotherapy interventions for osteoarthritis.

CONCLUSIONS

Economic evaluation studies are essential to improve decisions about allocating resources, whether those resources be your time, the capacity of your service, or the available funding across the entire healthcare system. The PICOT framework can be used to understand and interpret cost-effectiveness research.

Cost-effectiveness of janus kinase inhibitors for rheumatoid arthritis: A systematic review and meta-analysis of cost-utility studies

Introduction: Janus kinase inhibitors (JAK-i), a class of targeted synthetic disease-modifying antirheumatic drugs (tDMARDs), are suggested as second or third-line therapies in rheumatoid arthritis (RA). Synthesized cost-effective evidence would aid in informed decision-making given the similar clinical effectiveness of JAKi, but incongruent cost-effectiveness reports. Methods: Literature search was conducted in PubMed, Embase, Scopus, and Tufts Medical Centers' cost-effective analysis registry. We pooled the incremental net benefit (INB) with 95% confidence interval (CI) using random-effects model and the heterogeneity was assessed using Cochrane-Q test and I2 statistic. Modified economic evaluation bias checklist was used to assess the quality of selected studies. Publication bias was assessed using a funnel plot and Egger's test. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) assessment was performed to assess the certainty of outcomes presented. Results: We included seventeen relevant studies for systematic review, of which fifteen were eligible for meta-analysis. The meta-analysis results showed that JAK-i is cost-effective compared to csDMARDS/bDMARDs with a pooled INB (INBp) of $19,886 (95% CI, 1,635 to 38,137) but with considerable heterogeneity (I2 = 99.14). As a second-line treatment for csDMARD failed RA, JAK-i is cost-effective than csDMARD/bDMARD with a pooled INB of $23,144 (74.1-46,214) and high heterogeneity (I2 = 99.67). But on a separate analysis JAK-i as second-line treatment is not cost-effective than TNF-a-i (INBp = $25,813, -5,714 to 57,340). However, leave-one-out analysis found that omitting a single outlier makes JAK-i cost-effective. Further, JAK-i is not cost-effective as a third-line treatment for csDMARD-TNF-a-I failed RA, compared to csDMARDs/bDMARDs with INBp $26,157 (-7,284 to 59,598). Conclusion: Meta-analysis suggests that JAK-i is cost-effective when used after csDMARD failure but not cost-effective when used after csDMARD-TNF-a-i failure with low certainty of evidence. Clinical Trial Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021222541, identifier CRD42021222541.

Decrementally cost-effective health technologies in non-inferiority studies: A systematic review

Background: HTA guidance has generally been driven by situations where innovative and usually more expensive technologies are compared to the prevailing standards of care. Cheaper and less efficacious interventions have received scarce attention, although strategies with minimal individual efficacy losses might produce collective health gains when savings are redistributed. Purpose: This systematic review of health economic evaluations identified interventions that are both cost and outcome reducing to procure a list of candidate decrementally cost-effective technologies. Data Sources: English language searches were performed in PubMed, EMBASE and ClinicalTrials.gov covering 2005 to September 2021. Study Selection: Full economic evaluations reporting in English decrementally cost-effective health technologies based on RCT data, modelling or mixed methods. Data Synthesis: After filtering 4,975 studies found through the systematic database search, 107 decrementally cost-effective health technologies (HTs) were identified. Nearly a third were services (n = 29) and similarly for drugs (n = 31). For over half of the studies (n = 54) health outcomes were measured in QALYs and the cost-utility ratios varied from €140 to €5 million saved per QALY lost, albeit with time horizons varying from 4 days of follow-up to lifetime extrapolations. Less than a quarter of the studies were carried out from the societal perspective. Limitations: Despite including ClinicalTrials.gov as data source, unpublished studies may have been missed. Conclusions: Our results show a growth in recent years in the number of economic publications demonstrating decrementally cost-effective HTs. Economic tools are needed to facilitate the adoption of such HTs by policy-makers at the national level to maximise health outcomes at the population level. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=95504, identifier CRD42018095504.

A systematic review of cost-utility analyses of screening methods in latent tuberculosis infection in high-risk populations

Background

The World Health Organisation (WHO) recommends that testing and treatment for latent tuberculosis infection (LTBI) should be undertaken in high-risk groups using either interferon gamma release assays (IGRAs) or a tuberculin skin test (TST). As IGRAs are more expensive than TST, an assessment of the cost-effectiveness of IGRAs can guide decision makers on the most appropriate choice of test for different high-risk populations. This current review aimed to provide the most up to date evidence on the cost-effectiveness evidence on LTBI testing in high-risk groups—specifically evidence reporting the costs per QALY of different testing strategies.

Methods

A comprehensive search of databases including MEDLINE, EMBASE and NHS-EED was undertaken from 2011 up to March 2021. Studies were screened and extracted by two independent reviewers. The study quality was assessed using the Bias in Economic Evaluation Checklist (ECOBIAS). A narrative synthesis of the included studies was undertaken.

Results

Thirty-two studies reported in thirty-three documents were included in this review. Quality of included studies was generally high, although there was a weakness across all studies referencing sources correctly and/or justifying choices of parameter values chosen or assumptions where parameter values were not available. Inclusions of IGRAs in testing strategies was consistently found across studies to be cost-effective but this result was sensitive to underlying LTBI prevalence rates.

Conclusion

While some concerns remain about uncertainty in parameter values used across included studies, the evidence base since 2010 has grown with modelling approaches addressing the weakness pointed out in previous reviews but still reaching the same conclusion that IGRAs are likely to be cost-effective in high-income countries for high-risk populations. Evidence is also required on the cost-effectiveness of different strategies in low to middle income countries and countries with high TB burden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02149-x.

Economic evaluation of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation: a systematic review and meta-analysis

OBJECTIVES

To assess cost-effectiveness of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF) by pooling incremental net benefits (INBs).

DESIGN

Systematic review and meta-analysis.

SETTING

We searched PubMed, Scopus and Centre for Evaluation of Value and Risks in Health Registry from inception to December 2019.

PARTICIPANTS

Patients with AF.

MAIN OUTCOME MEASURES

The INB was defined as a difference of incremental effectiveness multiplied by willing to pay threshold minus the incremental cost; a positive INB indicated favour treatment. These INBs were pooled (stratified by level of country income, perspective, time-horizon, model types) with a random-effects model if heterogeneity existed, otherwise a fixed effects model was applied. Heterogeneity was assessed using Q test and I² statistic. Risk of bias was assessed using the economic evaluations bias (ECOBIAS) checklist.

RESULTS

A total of 100 eligible economic evaluation studies (224 comparisons) were included. For high-income countries (HICs) from a third-party payer (TPP) perspective, the pooled INBs for DOAC versus VKA pairs were significantly cost-effective with INBs (95% CI) of $6632 ($2961.67 to $10 303.72; I²=59.9%), $6353.24 ($4076.03 to $8630.45; I²=0%), $7664.58 ($2979.79 to $12 349.37; I²=0%) and $8573.07 ($1877.05 to $15 269.09; I²=0%) for dabigatran, apixaban, rivaroxaban and edoxaban relative to VKA, respectively but only dabigatran was significantly cost-effective from societal perspective (SP) with an INB of $11 746.96 ($2429.34 to $21 064.59; I²=52.4%). The pooled INBs of all comparisons for upper-middle income countries (UMICs) were not significantly cost-effective. The ECOBIAS checklist indicated that risk of bias was mostly low for most items with the exception of five items which should be less influenced on pooling INBs.

CONCLUSIONS

Our meta-analysis provides comprehensive economic evidence that allows policy makers to generalise cost-effectiveness data to their local context. All DOACs may be cost-effective compared with VKA in HICs with TPP perspective. The pooling results produced moderate to high heterogeneity particularly in UMICs. Further studies are required to inform UMICs with SP.

PROSPERO REGISTERATION NUMBER

CRD 42019146610.

Incremental net monetary benefit of direct oral anticoagulants for the prevention of venous thromboembolism after total knee or hip replacement: A systematic review and meta-analysis

INTRODUCTION

This meta-analysis was conducted to quantitatively pool the incremental net benefit (INB) of using direct oral anticoagulants (DOACs) for the prevention of venous thromboembolism (VTE) in patients undergoing total knee or hip replacements (TKR or THR).

MATERIALS AND METHODS

We performed a comprehensive search in several databases published before June 2021. Studies were included if they were cost-effectiveness analyses reporting cost per quality-adjusted life-year or life-year of DOACs compared to low molecular-weight heparins (LMWHs) or other anticoagulant agents for the prevention of VTE after TKR or THR. Risk of bias was also assessed using the biases in economic studies (ECOBIAS) checklist. Various monetary units were converted to purchasing power parity, adjusted to 2020 US dollars. The INBs were pooled across studies using a random-effects model, stratified by high-income countries (HICs) and low- and middle-income countries (LMICs). Heterogeneity was assessed using the I² statistic.

RESULTS

A total of 49 comparisons (TKR = 25 and THR = 24) from 16 studies was included. In HICs, DOACs were cost-effective compared to LMWHs from the health care system/payer perspective for the prevention of VTE after both TKR and THR with corresponding INBs (95 % CI; I²) of $231.91 ($178.71, $285.11; 0 %) and $254.99 ($159.20, $350.77; 27.79 %), respectively. In LMICs, DOACs were not cost-effective compared to LMWHs for both TKR and THR with the INBs of $94.13 (-$40.21, $228.47; 97.04 %) and $80.55 (-$157.37, $318.47; 99.78 %), respectively. No evidence of small-study effects was identified in any analyses. The cost-effectiveness of using DOACs for TKR and THR in HICs was robust across a series of sensitivity analyses.

CONCLUSIONS

DOACs were cost-effective as compared to LMWHs for VTE prophylaxis following TKR and THR surgeries in HICs. Further studies from LMICs are warranted.

Cost-effectiveness of Ezetimibe plus statin lipid-lowering therapy: A systematic review and meta-analysis of cost-utility studies

In addition to statin therapy, Ezetimibe, a non-statin lipid-modifying agent, is increasingly used to reduce low-density lipoprotein cholesterol and atherosclerotic cardiovascular disease risk. Literature suggests the clinical effectiveness of Ezetimibe plus statin (EPS) therapy; however, primary evidence on its economic effectiveness is inconsistent. Hence, we pooled incremental net benefit to synthesise the cost-effectiveness of EPS therapy. We identified economic evaluation studies reporting outcomes of EPS therapy compared with other lipid-lowering therapeutic agents or placebo by searching PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry. Using random-effects meta-analysis, we pooled Incremental Net Benefit (INB) in the US $ with a 95% confidence interval (CI). We used the modified economic evaluations bias checklist and GRADE quality assessment for quality appraisal. The pooled INB from twenty-one eligible studies showed that EPS therapy was significantly cost-effective compared to other lipid-lowering therapeutic agents or placebo. The pooled INB (95% CI) was $4,274 (621 to 7,927), but there was considerable heterogeneity (I² = 84.21). On subgroup analysis EPS therapy is significantly cost-effective in high-income countries [$4,356 (621 to 8,092)], for primary prevention [$4,814 (2,523 to 7,106)], and for payers’ perspective [$3,255 (571 to 5,939)], and from lifetime horizon [$4,571 (746 to 8,395)]. EPS therapy is cost-effective compared to other lipid-lowering therapeutic agents or placebo in high-income countries and for primary prevention. However, there is a dearth of evidence from lower-middle-income countries and the societal perspective.

Economic evaluation of seasonal influenza vaccination in elderly and health workers: A systematic review and meta-analysis

BACKGROUND

A number of cost-effectiveness analysis of influenza vaccination have been conducted to estimate value of influenza vaccines in elderly and health workers (HWs). This study aims to summarize cost-effectiveness evidence by pooling the incremental net monetary benefit (INMB) of influenza vaccination.

METHODS

A systematic review was performed in electronic databases from their inceptions to February 2022. Cost-effectiveness studies reporting quality-adjusted life year (QALY), or life year (LY) of influenza vaccination were included. Stratified meta-analyses by population, perspective, country income-level, and herd-effect were performed to pool INMB across studies. The protocol was registered at PROSPERO (CRD42021246746).

FINDINGS

A total of 21 studies were included. Eighteen studies were conducted in elderly, two studies were conducted in HWs, and one study was conducted in both elderly and HWs. According to pre-specified analyses, studies for elderly in high-income economies (countries) (HIEs) and upper-middle income economies (UMIEs) without herd effect could be pooled. For HIEs under a societal perspective, the perspective which identify all relevant costs occurred in the society including direct medical cost, direct non-medical cost and indirect cost, pooled INMB was $217·38 (206·23, 228·53, I² =28.2%), while that for healthcare provider/payer perspective was $0·20 (-11,908·67, 11,909·07, I² = 0.0%). For societal perspective in UMIEs, pooled INMB was $28·39 (-190·65, 133·87, I² = 92.8%). The findings were robust across a series of sensitivity analyses for HIEs. Studies in HWs indicated that influenza vaccination was cost-effective compared to no vaccination or current practice.

INTERPRETATION

Influenza vaccination might be cost-effective for HWs and elderly in HIEs under a societal perspective with relatively small variations among included studies, while there remains limited evidence for healthcare provider/payer perspective or other level of incomes. Further evidence is warranted.

FUNDING

This study was funded by a grant of Immunization, Vaccine and Biologicals department of the World Health Organization. The authors would like to acknowledge the contributions of the US CDC which provided financial support to the development and publication of this report. Grant number US CDC, WHO IVR (U50CK000431).

Assessing the cost-effectiveness of precision medicine: protocol for a systematic review and meta-analysis

INTRODUCTION

Precision medicine (PM) involves gene testing to identify disease risk, enable early diagnosis or guide therapeutic choice, and targeted gene therapy. We aim to perform a systematic review and meta-analysis to quantify the cost-effectiveness profile of PM stratified by intervention type, identify sources of heterogeneity in the value-for-money of PM.

METHODS AND ANALYSIS

We will perform a systematic search in Embase, MEDLINE, EconLit and CRD databases for studies published in English language or with translation in English between 1 January 2011 and 8 July 2021 on the topic of cost-effectiveness analysis of PM interventions. The focus will be on studies that reported health and economic outcomes. Study quality will be assessed using the Biases in Economic Studies checklist. The incremental net benefit of PM screening, diagnostic, treatment-targeting and therapeutic interventions over conventional strategies will be respectively pooled across studies using a random-effect model if heterogeneity is present, otherwise a fixed-effect model. Subgroup analyses will be performed based on disease area, WHO region and World Bank country-income level. Additionally, we will identify the potential sources of heterogeneity with random-effect meta-regressions. Finally, biases will be detected using jackknife sensitivity analysis, funnel plot assessment and Egger's tests.

ETHICS AND DISSEMINATION

For this type of study ethics approval or formal consent is not required. The results will be disseminated at various presentations and feedback sessions, in conference abstracts and manuscripts that will be submitted to peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021272956.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

Introduction

Cholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease.

Methods

We systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger’s test.

Results

We have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis.

Conclusion

ELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies.

PROSPERO registration number

CRD42020194052.

Methodological Approaches to Cost-Effectiveness Analysis in Saudi Arabia: What Can We Learn? A Systematic Review

OBJECTIVE

The recent establishment of the health technology assessment (HTA) entity in the Kingdom of Saudi Arabia (KSA) has resulted in increased interest in economic evaluation. The aim of this study is to evaluate the technical approaches used in published economic evaluations and the limitations reported by the authors of the respective studies that could affect the ability to perform economic evaluations in the KSA.

METHODS

We conducted a systematic literature review of published economic evaluations performed for the KSA over the past 10 years. An electronic literature search of the PubMed, EMBASE, and Cochrane databases was performed. A CHEERS checklist was used to assess the quality of reporting. Reported limitations were classified into domains including the definition of perspectives, identification of comparators, estimation of costs and resources, and use of the incremental cost-effectiveness ratio threshold.

RESULTS

Twelve evaluations were identified; most involved cost-effectiveness analysis (92%). Missing and unclear data were found within the CHEERS criteria. Regardless of the perspective used, most described the perspective as an "institutional" perspective (70%) and almost half were reclassified by the current reviewer (42%). Most did not clearly state the comparator (83%), and published model comparators were commonly used (50%). Resource estimation was mostly performed by the authors of the respective studies (67%), and costs were mostly obtained from hospital institutional data (75%). The lack of an established threshold for the country-specific willingness to pay was observed in 50% of the analyses.

CONCLUSIONS

Economic evaluations from the KSA are limited. Capacity building and country-specific HTA guidelines could improve the quality of evaluations to better inform decision making.

HIGHLIGHTS

Economic analysis of health technology should follow standard guidelines. Unfortunately, these guides are often underutilized, and our findings identify considerable missing, not clearly stated, or incomplete data within the analyses, which can weaken the impact of the recommendations.The limitations reported by the authors of the respective studies emphasize the suboptimal quality of the reporting. A lack of data was frequently identified and resulted in using "institutional" practice as a major source of data input for the analyses.In light of the call for the establishment of an HTA entity in the KSA, framing a standard analytic approach when conducting economic evaluations will support HTA in informing resource allocation decisions. We hope that our findings highlight the need for country-specific guidance to improve practice and enhance future research.

Incremental net monetary benefit of herpes zoster vaccination: a systematic review and meta-analysis of cost-effectiveness evidence

OBJECTIVES

To perform a systematic review and meta-analysis to pool the incremental net benefit (INB) of each herpes zoster vaccine [i.e. Zoster Vaccine Live (ZVL) and Recombinant Zoster Vaccine (RZV)].

METHODS

We initially identified individual studies by hand-searching reference lists of the relevant systematic review articles. An updated comprehensive search was performed in Medline, Scopus, and Embase until June 2020 for additional studies. Studies were eligible if they assessed the cost-effectiveness/utility of any pair among ZVL and RZV, and no vaccine and reported economic outcomes. Details of the study characteristics, economic model inputs, costs, and outcomes were extracted. INB was calculated with monetary units adjusting for purchasing power parity for 2019 US dollars and pooled by meta-analysis.

RESULTS

A total of 37 studies were pooled for meta-analysis stratified by perspectives [i.e. societal (SP) and third-party payer (TPP)] and vaccine types. In SP, ZVL was cost-effective compared to no vaccine when vaccinated at ages of 50-59 and 70-79 years with INBs (95% CI) of $0.61 (0.37, 0.85) and $9.67 (5.20, 14.14), respectively. RZV was cost-effective for those aged 60-69 and 70-79 years with INBs of $75.61 (17.98, 133.23) and $85.01 (30.02, 140.01), respectively. In TPP, ZVL was cost-effective compared to no vaccine when vaccinated at age 70-79 years with INB of $7.57 (0.27, 14.86) and RZV was cost-effective at 60-69 years with INB $220.87 (47.80, 393.93). The cost-effectiveness of RZV was robust across a series of sensitivity analyses, but ZVL differs on different vaccination ages.

CONCLUSIONS

RZV may be cost-effective for vaccination in ages of 60-79 years for both SP and TPP perspectives, while ZVL might be cost-effective in some age groups, but results are not robust.

Systematic Review of Cost-Effectiveness Models in Prostate Cancer: Exploring New Developments in Testing and Diagnosis

OBJECTIVES

Recent innovations in prostate cancer diagnosis include new biomarkers and more accurate biopsy methods. This study assesses the evidence base on cost-effectiveness of these developments (eg, Prostate Health Index and magnetic resonance imaging [MRI]-guided biopsy) and identifies areas of improvement for future cost-effectiveness models.

METHODS

A systematic review using the National Health Service Economic Evaluation Database, MEDLINE, Embase, Health Technology Assessment databases, National Institute for Health and Care Excellence guidelines, and United Kingdom National Screening Committee guidance was performed, between 2009 and 2021. Relevant data were extracted on study type, model inputs, modeling methods and cost-effectiveness conclusions, and results narratively synthesized.

RESULTS

A total of 22 model-based economic evaluations were included. A total of 11 compared the cost-effectiveness of new biomarkers to prostate-specific antigen testing alone and all found biomarkers to be cost saving. A total of 8 compared MRI-guided biopsy methods to transrectal ultrasound-guided methods and found MRI-guided methods to be most cost-effective. Newer detection methods showed a reduction in unnecessary biopsies and overtreatment. The most cost-effective follow-up strategy in men with a negative initial biopsy was uncertain. Many studies did not model for stage or grade of cancer, cancer progression, or the entire testing and treatment pathway. Few fully accounted for uncertainty.

CONCLUSIONS

This review brings together the cost-effectiveness literature for novel diagnostic methods in prostate cancer, showing that most studies have found new methods to be more cost-effective than standard of care. Several limitations of the models were identified, however, limiting the reliability of the results. Areas for further development include accurately modeling the impact of early diagnostic tests on long-term outcomes of prostate cancer and fully accounting for uncertainty.

Indirect costs associated with skin infectious disease in children: a systematic review

BACKGROUND

There are limited data in the literature on the indirect costs associated with skin and soft tissue infections (SSTIs) in the pediatric population. This study aimed to conduct a systematic review of the indirect costs associated with SSTIs in children.

METHODS

The search was conducted in PubMed, SCOPUS, and Web of Science up to January 2020. Thirteen search strategies were designed combining MeSH terms and free terms. SSTIs were defined as bacterial or viral infections, dermatomycoses, and parasitic infestations. Only primary studies were included. All analyzed costs were converted to 2020 Euros.

RESULTS

Thirteen of the identified publications presented indirect costs of SSTIs in children and were conducted in Argentina, Australia, Brazil, Hungary, New Zealand, Poland, Spain, Taiwan, and the USA. Nine studies described indirect costs associated with infection of Varicella-zoster virus: lost workdays by outpatient caregivers ranged from 0.27 to 7.8, and up to 6.14 if caring for inpatients; total productivity losses ranged from €1.16 to €257.46 per patient. Three studies reported indirect costs associated with acute bacterial SSTIs (community-associated methicillin-resistant Staphylococcus aureus) in children: total productivity losses ranged from €1,814.39 to €8,224.06 per patient, based on impetigo, cellulitis, and folliculitis. One study of parasitic infestations (Pediculus humanus capitis) reported total indirect costs per patient of €68.57 (formal care) plus €21.41 due to time lost by parents in purchasing treatment.

CONCLUSIONS

The economic burden of SSTIs is highly relevant but underestimated due to the lack of studies reporting indirect costs. Further cost studies will allow a better understanding of the magnitude of the financial burden of the disease.

Cost effectiveness of breast cancer screening and prevention: a systematic review with a focus on risk-adapted strategies

OBJECTIVES

Benefit and cost effectiveness of breast cancer screening are still matters of controversy. Risk-adapted strategies are proposed to improve its benefit-harm and cost-benefit relations. Our objective was to perform a systematic review on economic breast cancer models evaluating primary and secondary prevention strategies in the European health care setting, with specific focus on model results, model characteristics, and risk-adapted strategies.

METHODS

Literature databases were systematically searched for economic breast cancer models evaluating the cost effectiveness of breast cancer screening and prevention strategies in the European health care context. Characteristics, methodological details and results of the identified studies are reported in evidence tables. Economic model outputs are standardized to achieve comparable cost-effectiveness ratios.

RESULTS

Thirty-two economic evaluations of breast cancer screening and seven evaluations of primary breast cancer prevention were included. Five screening studies and none of the prevention studies considered risk-adapted strategies. Studies differed in methodologic features. Only about half of the screening studies modeled overdiagnosis-related harms, most often indirectly and without reporting their magnitude. All models predict gains in life expectancy and/or quality-adjusted life expectancy at acceptable costs. However, risk-adapted screening was shown to be more effective and efficient than conventional screening.

CONCLUSIONS

Economic models suggest that breast cancer screening and prevention are cost effective in the European setting. All screening models predict gains in life expectancy, which has not yet been confirmed by trials. European models evaluating risk-adapted screening strategies are rare, but suggest that risk-adapted screening is more effective and efficient than conventional screening.

Incremental net benefit of lipid-lowering therapy with PCSK9 inhibitors: a systematic review and meta-analysis of cost-utility studies

INTRODUCTION

Proprotein convertase subtilisin/kexin 9 inhibitors (PCSK9i) are monoclonal antibodies that lower lipid levels. Although several cardiovascular outcome trials reported the effectiveness of PCSK9i, the evidence on cost-effectiveness is mixed. We systematically reviewed the evidence and synthesized incremental net benefit (INB) to quantify pooled cost-effectiveness.

METHODS

We systematically searched for full economic evaluation studies reporting outcomes of PCSK9i compared with other lipid-lowering pharmacotherapies. We searched PubMed, Embase, Scopus, and Tufts Registry for eligible studies up to August 2021, adhering to preferred reporting items for systematic reviews and meta-analyses guidelines. We pooled INB in US$ with a 95% confidence interval using a random-effects model. We assessed heterogeneity using the Cochran Q test and I² statistics. We used the modified economic evaluations bias (ECOBIAS) checklist to evaluate the quality of selected studies.

RESULTS

Twenty-three studies were eligible, mainly from high-income countries (HIC). The pooled INB (INBp) of PCSK9i versus other lipid-lowering pharmacotherapies were estimated from n = 24 comparisons, with high heterogeneity (I² = 99.99). The INBp (95% CI) was $ - 78,207 (- 120,422; - 35,993) or € - 52,526 (- 80,879; - 24,174) (conversion factor 1 US$ = 0.67€) which shows that PCSK9i was not significantly cost-effective when compared to other standard therapies. On subgroup analysis PCSK9i was significantly not cost-effective [$ - 23,672 (- 24,061; - 23,282)] compared to other lipid-lowering pharmacotherapies in HICs, upper-middle-income countries [$ - 158,412 (- 241,738; - 75,086)] or when the target population was CVD [$ - 109,343 (- 158,968; - 59,717)]; and for treatment subgroup: against placebo or no treatment [$ - 79,018 (- 79,649; - 78,388 PCSK9)] and standard statin therapies [$ - 131,833 (- 173,449; - 90,216)]. The sensitivity analysis revealed that the findings are not robust for HICs and the treatment subgroups.

CONCLUSION

PCSK9 inhibitors are not cost-effective compared to other lipid-lowering pharmacotherapies in HICs. Further, current pieces of evidence are predominantly from HICs with largely lacking evidence from other economies.

PROSPERO REGISTRATION

ID CRD42020206043.

Economic evaluations and costing studies of lung transplantation: A scoping review

BACKGROUND

Evaluation of the joint clinical and economic impacts of lung transplant and associated technologies is crucial for evidence-informed decision-making and wise allocation of scarce healthcare resources. We performed a scoping review to summarize and categorize the available evidence of the costs and cost-effectiveness of lung transplantation.

METHODS

A systematic search of MEDLINE, EMBASE, NHS EED, and EconLit was performed to identify studies involving lung transplantation for adults that measured costs, cost-effectiveness, or which described themselves as economic evaluations. A scoping review was performed in adherence to the framework described by Arksey & O'Malley. Risk of bias was assessed in included studies using the ECOBIAS and CHEC-list tools.

RESULTS

In total, 324 studies were identified, of which 28 met inclusion criteria. Cost-utility estimates of lung transplant versus waitlist, from the healthcare payer perspective and a time-horizon of at least 10-years ranged between $42,459 and $154,051 per quality-adjusted life year. Common topics of study included lung transplant versus waitlist care, immunosuppression, organ retrieval and allocation, and mechanical life support.

CONCLUSIONS

Sources of variation in costs-assessments and economic evaluations included differences in the type of study performed, payer perspective adopted, study time horizon, and variation in clinical practice. The best available cost-utility estimates for lung transplant versus waitlist may represent cost-effectiveness under some circumstances, but high-quality evidence is lacking. Further cost-utility analyses, with sufficient methodologic rigour, are required to overcome the observed variation in results and confirm cost-effectiveness of the current standard of care in lung transplantation.

Evaluation of the cost-utility of phosphate binders as a treatment option for hyperphosphatemia in chronic kidney disease patients: a systematic review and meta-analysis of the economic evaluations

BACKGROUND

Uncontrolled hyperphosphatemia in chronic kidney disease (CKD) patients commonly results in vascular calcification leading to increased risk of cardiovascular disease. Phosphate binders (PBs) are used for hyperphosphatemia and can be calcium-based (CBPBs) or non-calcium-based (NCBPBs), the latter being more expensive than CBPBs. In this study, we used meta-analysis approaches to assess the cost-utility of PBs for hyperphosphatemia in CKD patients.

METHODS

Relevant studies published prior to June 2019 were identified from PubMed, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Studies were eligible if they included CKD patients with hyperphosphatemia, compared any PBs and reported economic outcomes. Meta-analysis was applied to pool incremental net benefit (INB) across studies stratified by country income.

RESULTS

A total of 25 studies encompassing 32 comparisons were eligible. Lanthanum carbonate, a NCBPB, was a more cost-effective option than CBPBs in high-income countries (HICs), with a pooled INB of $3984.4 (599.5-7369.4), especially in pre-dialysis patients and used as a second-line option with INBs of $4860.2 (641.5-9078.8), $4011.0 (533.7-7488.3), respectively. Sevelamer, also a NCBPB, was not more cost-effective as a first-line option compared to CBPBs with a pooled INB of $6045.8 (- 23,453.0 to 35,522.6) and $34,168.9 (- 638.0 to 68,975.7) in HICs and upper middle-income countries, respectively.

CONCLUSIONS

Lanthanum carbonate was significantly more cost-effective than CBPBs as a second-line option for hyperphosphatemia in pre-dialysis patients in HICs. However, the use of sevelamer is not more cost-effective as a first-line option compared to CBPBs.

Incremental Net Monetary Benefit of Bariatric Surgery: Systematic Review and Meta-Analysis of Cost-Effectiveness Evidences

This systematic review aimed to comprehensively synthesize cost-effectiveness evidences of bariatric surgery by pooling incremental net monetary benefits (INB). Twenty-eight full economic evaluation studies comparing bariatric surgery with usual care were identified from five databases. In high-income countries (HICs), bariatric surgery was cost-effective among mixed obesity group (i.e., obesity with/without diabetes) over a 10-year time horizon (pooled INB = $53,063.69; 95% CI $42,647.96, $63,479.43) and lifetime horizon (pooled INB = $101,897.96; 95% CI $79,390.93, $124,404.99). All studies conducted among obese with diabetes reported that bariatric surgery was cost-effective. Also, the pooled INB for obesity with diabetes group over lifetime horizon in HICs was $80,826.28 (95% CI $32,500.75, $129,151.81). Nevertheless, no evidence is available in low- and middle-income countries.

Informing policy makers on the efficiency of population level tobacco control interventions in Asia: A systematic review of model-based economic evaluations

BACKGROUND

Economic evaluations of tobacco control interventions support decisions regarding resource allocation in public health policy. Our systematic review was aimed at identifying potential bias in decision models used to estimate the long-term costs and effects of population-based tobacco control interventions in Asia.

METHODS

We included studies conducted in Asian countries and using a modelling technique to evaluate the economic impacts of one or more population-based tobacco interventions in line with the Framework Convention on Tobacco Control (FCTC). We assessed the structure, input parameters, and risk of bias for each model, and performed a narrative synthesis of the included studies.

RESULTS

Nine model-based economic evaluation studies of population-based tobacco interventions were identified. About 60% of the criteria for reporting quality were met in all studies, indicating that reporting generally lacked transparency. The studies were highly heterogeneous in terms of the scope, types, and structures of their models and the quality of input parameters. One-third of the models applied in the studies scored a high risk of bias, with problems mostly falling into the following categories: model type, time horizons, and smoking transition probabilities.

CONCLUSIONS

More data are needed to provide high-quality evidence regarding the cost-effectiveness of tobacco control policies in Asia. Strong evidence at the country level hinges on the availability of accurate estimates of the effects of the interventions, the relative risks of smoking, and the price elasticity of the demand for tobacco. Simple transfers of models built in Western populations do not suffice.

PROTOCOL REGISTRATION

PROSPERO CRD 42019141679.

Quality of health economic evaluations submitted to the Italian Medicines Agency: current state and future actions

Objectives

The purpose of this study was to evaluate the current state of health economic evaluations (HEEs) submitted by pharmaceutical companies to the Italian Medicines Agency (AIFA) as part of their pricing and reimbursement (P&R) dossiers, and to explore potential future actions in order to enhance their quality.

Methods

All company dossiers submitted from October 2016 to December 2018 were reviewed to select those containing pharmacoeconomic studies. The general characteristics of HEEs were described and their quality assessed based on a checklist adapted from Philips et al. (Review of guidelines for good practice in decision-analytic modelling in health technology assessment. Health Technol Assess. 2004;8: 1–158).

Results

Of the 299 dossiers submitted to AIFA, 105 included one or more pharmacoeconomic studies, of which fifty-three were cost-effectiveness analyses. Overall, the compliance of the HEEs with the quality checklist was highly variable: some studies reached high methodological standards whereas others had serious flaws (mean 59.22 percent, range 19.35–90.32 percent). The main weaknesses were the unjustified exclusion of relevant alternatives, poor description and justification of model data and assumptions, and insufficient exploration of uncertainty and study validity. Non-homogeneity across studies was found in study perspectives, discount rates, methods for costing, estimating quality-adjusted life-years and conducting sensitivity analyses.

Conclusions

Based on the results of this study, the recommended actions for increasing the quality of HEEs within reimbursement submissions in Italy are twofold: first, to set methodological standards for conducting and reporting HEEs; second, to strengthen the internal assessment process, also through the acquisition of companies' models and re-evaluation of results. These actions will hopefully provide greater contribution to the evidence-based P&R decision making.

Cost-effectiveness of Interventional therapies for management of Treatment-resistant hypertension: systematic review of pharmacoeconomic studies

Background

Treatment resistant hypertension (TRH) is defined as uncontrolled blood pressure (&gt;140/90 mm Hg) after treatment with the intensified dose of three standard antihypertensive drugs. Management of TRH involves addition of fourth line drugs on standard care or interventional therapies (Renal denervation, Baroreceptor activation, Central venous anastomosis). However, evidence concerning cost-effectiveness of interventional therapies is inconclusive. Objective: This systematic review was conducted to extract the level of evidence on cost-effectiveness of interventional therapies for TRH.

Method

We systematically searched articles written in English language since January 2000 to January 2020 from the following databases: PubMed/Medline, Ovid/Medline, Embase, Scopus, Web of Science, Google scholar and other relevant sources.

Key findings

Twelve pharmacoeconomic studies were included in this systematic review. Renal denervation (RDN) is the most commonly studied intervention therapy for treatment of TRH. Participants included in the study vary from age 18-99 years. The incremental cost-effectiveness ratio (ICER) of RDN ranged from $1,709.84 per QALY gained in Netherlands to 66,380.3 per QALY gained in Australia. RDN was cost-effective in high-risk patients in UK, Australia, Canada, Netherlands, USA, Germany, Russia and Korea. The cost-effectiveness was influenced by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN nonresponders, and the procedure costs of RDN and assumption of long-term time horizon. However, the ICER of RDN in Mexico was above MXN$ 139,000 GDP/capita of the country. The ICER of implantable carotid body stimulator was $64,400 per QALYs gained. The cost-effectiveness of baroreceptor activation didn’t improve with age.

Conclusion

Overall cost-effectiveness of interventional therapies for treatment of TRH was inconclusive based on the current available evidence. Therefore, strong clinical trials and pharmacoeconomic evaluations from different perspectives in various candidate populations are needed to generate adequate clinical and cost-effectiveness evidence for using interventional therapies in treatment of treatment resistant hypertension.

Glucagon-like peptide 1 agonists for treatment of patients with type 2 diabetes who fail metformin monotherapy: systematic review and meta-analysis of economic evaluation studies

OBJECTIVES

To conduct a systematic review and meta-analysis and to pool the incremental net benefits (INBs) of glucagon-like peptide 1 (GLP1) compared with other therapies in type 2 diabetes mellitus (T2DM) after metformin monotherapy failure.

RESEARCH DESIGN AND METHODS

The study design is a systematic review and meta-analysis. We searched MEDLINE (via PubMed), Scopus and Tufts Registry for eligible cost-utility studies up to June 2018, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We conducted a systematic review and pooled the INBs of GLP1s compared with other therapies in T2DM after metformin monotherapy failure. Various monetary units were converted to purchasing power parity, adjusted to 2017 US$. The INBs were calculated and then pooled across studies, stratified by level of country income; a random-effects model was used if heterogeneity was present, and a fixed-effects model if it was absent. Heterogeneity was assessed using Q test and I² statistic.

RESULTS

A total of 56 studies were eligible, mainly from high-income countries (HICs). The pooled INBs of GLP1s compared with dipeptidyl peptidase-4 inhibitor (DPP4i) (n=10), sulfonylureas (n=6), thiazolidinedione (TZD) (n=3), and insulin (n=23) from HICs were US$4012.21 (95% CI US$-571.43 to US$8595.84, I²=0%), US$3857.34 (95% CI US$-7293.93 to US$15 008.61, I²=45.9%), US$37 577.74 (95% CI US$-649.02 to US$75 804.50, I²=92.4%) and US$14 062.42 (95% CI US$8168.69 to US$19 956.15, I²=86.4%), respectively. GLP1s were statistically significantly cost-effective compared with insulins, but not compared with DPP4i, sulfonylureas, and TZDs. Among GLP1s, liraglutide was more cost-effective compared with lixisenatide, but not compared with exenatide, with corresponding pooled INBs of US$4555.09 (95% CI US$3992.60 to US$5117.59, I²=0) and US$728.46 (95% CI US$-1436.14 to US$2893.07, I²=0), respectively.

CONCLUSION

GLP1 agonists are a cost-effective choice compared with insulins, but not compared with DPP4i, sulfonylureas and TZDs.

PROSPERO REGISTRATION NUMBER

CRD42018105193.

Systematic Literature Review of Economic Evaluations of Biological Treatment Sequences for Patients with Moderate to Severe Rheumatoid Arthritis Previously Treated with Disease-Modifying Anti-rheumatic Drugs

OBJECTIVE

This systematic literature review (SLR) had two objectives: to analyse published economic evaluations of biological disease-modifying anti-rheumatic drugs (bDMARDs) for patients with moderate to severe rheumatoid arthritis (RA) previously treated with DMARDs and to assess the quality of those that included sequences of treatments.

METHODS

We performed an SLR on PubMed, Central, Cochrane, and French databases from January 2000 to December 2018. The search focused on cost-effectiveness/utility/benefit analyses. We extracted data on treatment sequences, outcomes (e.g. quality-adjusted life year) and choices of economic evaluation methods (e.g. model type, type of analysis, and method of utility estimation). We analysed the improvement of methods by comparing two sub-periods (2000-2009 and 2010-2018). The quality of reporting and the quality of the methods were assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and a set of eight key aspects for a reference case for economic evaluation of bDMARDs based on the Outcome Measures in Rheumatology (OMERACT) and Drummond checklists. Data extraction and study assessment were performed independently by two health economists.

RESULTS

From the 824 records identified in the initial search, 51 publications were selected. Of these, 31 included sequences. Individual models such as discrete-event simulations were used in over two-fifths (22/51, 43%) of the selected studies. Few studies (7/51, 14%) used utility scores based on generic instruments (e.g. EQ-5D). Estimation of hospitalization costs was described in only approximately one-third of studies (19/51). Loss of quality of life (QoL) related to adverse events such as tuberculosis and pneumonia was included in one-tenth (5/51, 10%) of the studies. It was difficult to compare the results of the economic evaluations (i.e. incremental cost-effectiveness ratios) due to the high heterogeneity of studies in terms of disease stage, data sources, inputs, and methods of health outcome assessment used. For identified studies including sequences, the CHEERS assessment of reporting quality showed insufficient reporting of uncertainty analyses and utility weights in more than a third of the studies (11/31, 35%; 9/25, 36%). An in-depth assessment of the quality of the studies revealed that only seven, mostly conducted during the sub-period 2010-2018, addressed the majority of methodological quality assessment issues such as the simulation of patient sequence pathways, the use of systematic reviews and meta-analyses of comparative effectiveness, the choice of treatment sequence, and rules for switching.

CONCLUSION

Our SLR identified a lack of high-quality evaluations assessing bDMARD sequences, although some improvements were made in the reporting and modelling of patients' pathways in studies published after 2010. In order to improve economic evaluations of RA, clear health technology assessment guidance on RA health-related QoL instruments must be provided, and data including long-term disease progression must be made available.

Cost Utility of Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Metformin Monotherapy Failed Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

Type 2 diabetes mellitus (T2DM) and associated ailments are leading economic burdens to society. Sodium glucose cotransporter-2 (SGLT2) inhibitors are recent antidiabetic medications with beneficial clinical efficacy. This meta-analysis was conducted to quantitatively pool the incremental net benefit of SGLT2 inhibitors in T2DM patients who failed metformin monotherapy.

METHODS

Relevant economic evaluation studies of T2DM patients were identified from PubMed, Scopus, ProQuest, the Cochrane Library, and the Tufts Cost-Effective Analysis Registry until June 2018. Studies were eligible if they studied T2DM patients who failed metformin monotherapy and assessed the cost-effectiveness/utility between SGLT2 inhibitors and other treatments. Details of the study characteristics, economic model inputs, costs, and outcomes were extracted. Risk of bias was assessed using the biases in economic studies (ECOBIAS) checklist. The incremental net benefit was calculated with monetary units adjusting for purchasing power parity for 2017 US dollars. This was then pooled across studies stratified by the country's level of income using a random-effect model if heterogeneity was present and with a fixed-effect model otherwise. Heterogeneity was assessed using the Q test and I² statistic.

RESULTS

A total of 13 studies with 22 comparisons, mainly from high-income countries, were eligible. Six and 4 studies compared SGLT2 with dipeptidyl peptidase-4 inhibitors (DPP4i) and sulfonylureas, respectively. The pooled incremental net benefits (95% confidence interval) for these corresponding comparisons were $164.95 (-$534.71 to $864.61; I² = 0%) and $3675.09 ($1656.46-$5693.71; I² = 85.4%), respectively. These results indicate that SGLT2s were cost-effective in comparison with sulfonylureas but not DPP4i.

CONCLUSION

SGLT2s were cost-effective as compared with sulfonylureas but not DPP4i. Most of the evidence was from high-income countries with few comparative drug groups, and the results might not be representative of the actual global scenario. Further studies from middle and lower economies and other comparators are still required.

Cost-effectiveness analyses and cost analyses in castration-resistant prostate cancer: A systematic review

Background

Treatment of metastatic prostate cancer is associated with high personal and economic burden. Recently, new treatment options for castration-resistant prostate cancer became available with promising survival advantages. However, cost-effectiveness of those new treatment options is sometimes ambiguous or given only under certain circumstances. The aim of this study was to systematically review studies on the cost-effectiveness of treatments and costs of castration-resistant prostate cancer (CRPC) and metastasizing castration-resistant prostate cancer (mCRPC) on their methodological quality and the risk of bias.

Methods

A systematic literature search was performed in the databases PubMed, CINAHL Complete, the Cochrane Library and Web of Science Core Collection for costs-effectiveness analyses, model-based economic evaluations, cost-of-illness analyses and budget impact analyses. Reported costs were inflated to 2015 US$ purchasing power parities. Quality assessment and risk of bias assessment was performed using the Consolidated Health Economic Evaluation Reporting Standards checklist and the Bias in Economic Evaluations checklist, respectively.

Results

In total, 38 articles were identified by the systematic literature search. The methodological quality of the included studies varied widely, and there was considerable risk of bias. The cost-effectiveness treatments for CRPC and mCRPC was assessed with incremental cost-effectiveness ratios ranging from dominance for mitoxantrone to $562,328 per quality-adjusted life year gained for sipuleucel-T compared with prednisone alone. Annual costs for the treatment of castration-resistant prostate cancer ranged from $3,067 to $77,725.

Conclusion

The cost-effectiveness of treatments of CRPC strongly depended on the willingness to pay per quality-adjusted life year gained/life-year saved throughout all included costs-effectiveness analyses and model-based economic evaluations. High-quality cost-effectiveness analyses based on randomized controlled trials are needed in order to make informed decisions on the management of castration-resistant prostate cancer and the resulting financial impact on the healthcare system.