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Adjetey C, Davis JC, Falck RS, Best JR, Dao E, Bennett K, Tai D, McGuire K, Eng JJ, Hsiung GYR, Middleton LE, Hall PA, Hu M, Sakakibara BM, Liu-Ambrose T. Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke. JAMA Netw Open 2023; 6:e2345687. [PMID: 38032638 PMCID: PMC10690466 DOI: 10.1001/jamanetworkopen.2023.45687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.
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Affiliation(s)
- Cassandra Adjetey
- Faculty of Management, University of British Columbia, Kelowna, Canada
- Applied Health Economics Lab, University of British Columbia, Kelowna, Canada
| | - Jennifer C. Davis
- Faculty of Management, University of British Columbia, Kelowna, Canada
- Applied Health Economics Lab, University of British Columbia, Kelowna, Canada
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Ryan S. Falck
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - John R. Best
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Elizabeth Dao
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Kim Bennett
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Daria Tai
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Katherine McGuire
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Janice J. Eng
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Ging-Yuek Robin Hsiung
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
| | - Laura E. Middleton
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Canada
- Schlegel–UW Research Institute for Aging, Waterloo, Canada
| | - Peter A. Hall
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Min Hu
- Department of Economics, Philosophy and Political Science, University of British Columbia, Kelowna, Canada
| | - Brodie M. Sakakibara
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada
- Centre for Chronic Disease Prevention and Management, Southern Medical Program, The University of British Columbia, Kelowna, Canada
| | - Teresa Liu-Ambrose
- Centre for Aging SMART at Vancouver Coastal Health, Vancouver Coastal Health Research Institute, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada
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Rantsi M, Pitkälä KH, Kautiainen H, Hyttinen V, Kankaanpää E. Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication. Age Ageing 2022; 51:6590511. [PMID: 35604803 PMCID: PMC9126199 DOI: 10.1093/ageing/afac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). Methods The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period. Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. Results The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY. Conclusion The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.
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Affiliation(s)
- Mervi Rantsi
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Kaisu H Pitkälä
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Hannu Kautiainen
- Department of General Practice, University of Helsinki, Helsinki 00014, Finland
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
| | - Eila Kankaanpää
- Department of Health and Social Management, University of Eastern Finland, Kuopio 70211, Finland
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Handling Uncertainty in Cost-Effectiveness Analysis: Budget Impact and Risk Aversion. Healthcare (Basel) 2021; 9:healthcare9111419. [PMID: 34828466 PMCID: PMC8622052 DOI: 10.3390/healthcare9111419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023] Open
Abstract
Methods to handle uncertainty in economic evaluation have gained much attention in the literature, and the cost-effectiveness acceptability curve (CEAC) is the most widely used method to summarise and present uncertainty associated with program costs and effects in cost-effectiveness analysis. Some researchers have emphasised the limitations of the CEAC for informing decision and policy makers, as the CEAC is insensitive to radial shifts of the joint distribution of incremental costs and effects in the North-East and South-West quadrants of the cost-effective plane (CEP). Furthermore, it has been pointed out that the CEAC does not incorporate risk-aversion in valuing uncertain costs and effects. In the present article, we show that the cost-effectiveness affordability curve (CEAFC) captures both dimensions of the joint distribution of incremental costs and effects on the CEP and is, therefore, sensitive to radial shifts of the joint distribution on the CEP. Furthermore, the CEAFC also informs about the budget impact of a new intervention, as it can be used to estimate the joint probability that an intervention is both affordable and cost-effective. Moreover, we show that the cost-effectiveness risk-aversion curve (CERAC) allows the analyst to incorporate different levels of risk-aversion into the analysis and can, therefore, be used to inform decision-makers who are risk-averse. We use data from a published cost-effectiveness model of palbociclib in addition to letrozole versus letrozole alone for the treatment of oestrogen-receptor positive, HER-2 negative, advanced breast cancer to demonstrate the differences between CEAC, CEAFC and CERAC, and show how these can jointly be used to inform decision and policy makers.
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Hill E, Nemec M, Marlow L, Sherman SM, Waller J. Maximising the acceptability of extended time intervals between screens in the NHS Cervical Screening Programme: An online experimental study. J Med Screen 2021; 28:333-340. [PMID: 33175638 PMCID: PMC8366181 DOI: 10.1177/0969141320970591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The NHS Cervical Screening Programme plans to increase the screening interval from 3 to 5 years for women aged 25-49 who test negative for human papillomavirus (HPV). This exploratory cross-sectional online survey tested the impact of different levels of information about the proposed change on acceptability of a longer interval. METHODS Women aged 18-45 (n = 585) were individually randomised to one of three information exposure groups differing in the level of information provided about the screening interval change: (1) basic information; (2) basic information with additional detail about timeline of HPV infection; (3) as (2) but with the addition of a diagram. Acceptability of the change (favourable and unfavourable attitudes) was assessed post-exposure alongside HPV timeline beliefs. We used ANOVA and regression analyses to test for between-group differences. RESULTS Women in Group 3 had higher scores on the favourable attitudes sub-scale compared with Group 1. Women in Groups 2 and 3 had more accurate timeline beliefs than those in Group 1. There were no between-group differences in unfavourable attitudes. After adjusting for demographic factors, a higher favourable attitudes score was independently predicted by being in Group 3 compared to Group 1, more accurate HPV timeline beliefs, and previous irregular or non-attendance at screening. CONCLUSIONS Overall, acceptability of an increased screening interval was moderate, but providing women with information about the safety and rationale for this change may improve acceptability. In particular, communicating the long timeline from HPV exposure to cervical cancer may reassure women about the safety of the proposed changes.
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Affiliation(s)
- Emily Hill
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL, London, UK
| | - Martin Nemec
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | - Laura Marlow
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL, London, UK
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
| | | | - Jo Waller
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, UCL, London, UK
- Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
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Martín-Fernández J, López-Nicolás Á, Oliva-Moreno J, Medina-Palomino H, Polentinos-Castro E, Ariza-Cardiel G. Risk aversion, trust in institutions and contingent valuation of healthcare services: trying to explain the WTA-WTP gap in the Dutch population. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:27. [PMID: 33952285 PMCID: PMC8097777 DOI: 10.1186/s12962-021-00281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background The preferences of citizens are a basic element to incorporate into the decision-making process when planning health policies. Contingent valuation (CV) is a common method for calculating the value for citizens that new technologies, interventions, and the provision of services or policies have. However, choosing the correct CV tool may not be a neutral decision. This work aims to assess the substitution of a healthcare service by comparing valuation differences between the willingness to pay (WTP) for the maintenance of the service versus the willingness to accept compensation (WTA) for its substitution, both of which are related to subject characteristics, with a particular focus on trust in institutions and risk aversion. Methods A CV study was designed to study Dutch population preferences when physician assistants replace anaesthesiologists. Differences between the distributions of WTA and WTP were compared through full decomposition methods, and conditional quantile regression was performed. Results Nearly two-thirds of surveyed citizens expressed null values for WTA and WTP. The other third systematically reported a value of WTA higher than that of WTP, which increased further with lower income and the possible presence of a strategic bias. In contrast, being more than 65 years old, having trust in government, and preferring anaesthesiologists decreased the WTA-WTP difference. Risk aversion had no clear association with the WTA-WTP gap. Conclusions Known differences between the perceived value of health services from the perspective of gains and losses could be related to people’s characteristics. Trust in government but not aversion to risk was related to the WTA-WTP differences. Identifying a profile of citizens who are averse to losing health services should be considered when designing and implementing health services or interventions or making disinvestment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00281-9.
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Affiliation(s)
- Jesús Martín-Fernández
- Family and Community Medicine Teaching Unit Oeste, Primary Care Management, Madrid Health Service, Móstoles, Madrid, Spain. .,Faculty of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. .,Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain.
| | - Ángel López-Nicolás
- Economics Department, Faculty of Business Science, Universidad Politécnica de Cartagena (UPCT), Cartagena, Murcia, Spain
| | - Juan Oliva-Moreno
- Department of Economic Analysis and Finance, Faculty of Law and Social Sciences in Toledo, University of Castilla La-Mancha, Toledo, Spain
| | | | - Elena Polentinos-Castro
- Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain.,Primary Care Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain
| | - Gloria Ariza-Cardiel
- Family and Community Medicine Teaching Unit Oeste, Primary Care Management, Madrid Health Service, Móstoles, Madrid, Spain.,Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain
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Sendi P. Dealing with Bad Risk in Cost-Effectiveness Analysis: The Cost-Effectiveness Risk-Aversion Curve. PHARMACOECONOMICS 2021; 39:161-169. [PMID: 33128734 PMCID: PMC7867557 DOI: 10.1007/s40273-020-00969-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 06/11/2023]
Abstract
Cost-effectiveness analysis has been advocated and is widely used to inform policy and decision makers in setting priorities for resource allocation. Since the costs and effects of health care interventions are uncertain, much research interest has focused on handling uncertainty in cost-effectiveness analysis. The most widely used method to summarize uncertainty in cost-effectiveness analysis is the cost-effectiveness acceptability curve, which estimates the probability that an intervention is cost effective for a wide range of threshold ratios. However, by estimating the uncertainty associated with incremental costs and effects, information about the uncertainty associated with the costs and effects of the individual programs is lost, which may be important to inform risk-averse decision makers. In the present paper, we suggest to penalize the expected net monetary benefit (NMB) of a program for its downside risk (i.e. bad risk), which preserves the uncertainty of the individual programs and rank orders programs according to their risk-adjusted NMB. The cost-effectiveness risk-aversion curve (CERAC) is introduced, which estimates the net benefit-to-risk ratio for a wide range of threshold rations. The CERAC is a helpful additional tool to inform decision and policy makers who are risk averse, and can easily be constructed using the results of a cost-effectiveness analysis.
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Affiliation(s)
- Pedram Sendi
- Institute for Clinical Epidemiology, Basel University Hospital, Spitalstrasse 12, 4056, Basel, Switzerland.
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A Systematic Review of WTA-WTP Disparity for Dental Interventions and Implications for Cost-Effectiveness Analysis. Healthcare (Basel) 2020; 8:healthcare8030301. [PMID: 32858834 PMCID: PMC7550993 DOI: 10.3390/healthcare8030301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/16/2022] Open
Abstract
Cost-effectiveness analysis is widely adopted as an analytical framework to evaluate whether health care interventions represent value for money, and its use in dentistry is increasing. Traditionally, in cost-effectiveness analysis, one assumes that the decision maker's maximum willingness to pay (WTP) for health gain is equivalent to his minimum willingness to accept (WTA) monetary compensation for health loss. It has been documented in the literature that losses are weighted higher than equivalent gains, i.e., that WTA exceeds WTP for the same health condition, resulting in a WTA/WTP ratio greater than 1. There is a knowledge gap of published WTA/WTP ratios for dental interventions in the literature. We therefore conducted a (i) systematic review of published WTA-WTP estimates in dentistry (MEDLINE, Web of Science, Cochrane Library, London, UK) and (ii) a patient-level analysis of WTA/WTP ratios of included studies, and (iii) we demonstrate the impact of a WTA-WTP disparity on cost-effectiveness analysis. Out of 55 eligible studies, two studies were included in our review. The WTA/WTP ratio ranged from 2.58 for discontinuing water fluoridation to 5.12 for mandibular implant overdentures, indicating a higher disparity for implant rehabilitations than for dental public health interventions. A WTA-WTP disparity inflates the cost-effectiveness of dental interventions when there is a substantial risk of both lower costs and health outcomes. We therefore recommend that in these cases the results of cost-effectiveness analyses are reported using different WTA/WTP ratios in a sensitivity analysis.
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Rotteveel AH, Lambooij MS, Zuithoff NPA, van Exel J, Moons KGM, de Wit GA. Valuing Healthcare Goods and Services: A Systematic Review and Meta-Analysis on the WTA-WTP Disparity. PHARMACOECONOMICS 2020; 38:443-458. [PMID: 32096146 DOI: 10.1007/s40273-020-00890-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The objective of this systematic review was to review the available evidence on the disparity between willingness to accept (WTA) and willingness to pay (WTP) for healthcare goods and services. METHODS A tiered approach consisting of (1) a systematic review, (2) an aggregate data meta-analysis, and (3) an individual participant data meta-analysis was used. MEDLINE, EMBASE, Scopus, Scisearch, and Econlit were searched for articles reporting both WTA and WTP for healthcare goods and services. Individual participant data were requested from the authors of the included studies. RESULTS Thirteen papers, reporting WTA and WTP from 19 experiments/subgroups, were included in the review. The WTA/WTP ratios reported in these papers, varied from 0.60 to 4.01, with means of 1.73 (median 1.31) for 15 estimates of the mean and 1.58 (median 1.00) for nine estimates of the median. Individual data obtained from six papers, covering 71.2% of the subjects included in the review, yielded an unadjusted WTA/WTP ratio of 1.86 (95% confidence interval 1.52-2.28) and a WTA/WTP ratio adjusted for age, sex, and income of 1.70 (95% confidence interval 1.42-2.02). Income category and age had a statistically significant effect on the WTA/WTP ratio. The approach to handling zero WTA and WTP values has a considerable impact on the WTA/WTP ratio found. CONCLUSIONS AND IMPLICATIONS The results of this study imply that losses in healthcare goods and services are valued differently from gains (ratio > 1), but that the degree of disparity found depends on the method used to obtain the WTA/WTP ratio, including the approach to zero responses. Irrespective of the method used, the ratios found in our meta-analysis are smaller than the ratios found in previous meta-analyses.
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Affiliation(s)
- Adriënne H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA, Bilthoven, The Netherlands.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Mattijs S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA, Bilthoven, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA, Bilthoven, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Husereau D, Feagan B, Selya-Hammer C. Policy Options for Infliximab Biosimilars in Inflammatory Bowel Disease Given Emerging Evidence for Switching. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:279-288. [PMID: 29411318 PMCID: PMC5940725 DOI: 10.1007/s40258-018-0371-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Biosimilars are becoming increasingly available internationally as patents expire on the originator biologic drugs they are intended to copy. Although substitution policies seen with generic drugs are being considered as a means to reduce expenditures on biologics, some biosimilars pose particular challenges in that the act of substitution may eventually lead to increased rates of therapeutic failure. As evidence requirements from regulators do not directly address this challenge, switch trials of biosimilars have emerged that may provide further answers. Using infliximab in inflammatory bowel disease as an example, we critically examine emerging evidence from two key switch trials (NOR-SWITCH and NCT020968610) and discuss the clinical and economic implications of these and what policy options may be most reasonable for payers. Options include reimbursing biosimilars for only newly diagnosed patients, using product-listing agreements to manage uncertainty, or using tiered co-payments or other incentives to promote biosimilar use.
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Affiliation(s)
- Don Husereau
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada.
| | - Brian Feagan
- Robarts Clinical Trials, Robarts Research, University of Western Ontario, London, Canada
- Department of Medicine, University of Western Ontario, London, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Canada
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Burgers LT, Redekop WK, Al MJ, Lhachimi SK, Armstrong N, Walker S, Rothery C, Westwood M, Severens JL. Cost-effectiveness analysis of new generation coronary CT scanners for difficult-to-image patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:731-742. [PMID: 27650359 DOI: 10.1007/s10198-016-0824-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/04/2016] [Indexed: 06/06/2023]
Abstract
AIMS New generation dual-source coronary CT (NGCCT) scanners with more than 64 slices were evaluated for patients with (known) or suspected of coronary artery disease (CAD) who are difficult to image: obese, coronary calcium score > 400, arrhythmias, previous revascularization, heart rate > 65 beats per minute, and intolerance of betablocker. A cost-effectiveness analysis of NGCCT compared with invasive coronary angiography (ICA) was performed for these difficult-to-image patients for England and Wales. METHODS AND RESULTS Five models (diagnostic decision model, four Markov models for CAD progression, stroke, radiation and general population) were integrated to estimate the cost-effectiveness of NGCCT for both suspected and known CAD populations. The lifetime costs and effects from the National Health Service perspective were estimated for three strategies: (1) patients diagnosed using ICA, (2) using NGCCT, and (3) patients diagnosed using a combination of NGCCT and, if positive, followed by ICA. In the suspected population, the strategy where patients only undergo a NGCCT is a cost-effective option at accepted cost-effectiveness thresholds. The strategy of using NGCCT in combination with ICA is the most favourable strategy for patients with known CAD. The most influential factors behind these results are the percentage of patients being misclassified (a function of both diagnostic accuracy and the prior likelihood), the complication rates of the procedures, and the cost price of a NGCCT scan. CONCLUSION The use of NGCCT might be considered cost-effective in both populations since it is cost-saving compared to ICA and generates similar effects.
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Affiliation(s)
- L T Burgers
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - W K Redekop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M J Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - S K Lhachimi
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Research Group for Evidence-Based Public Health, BIPS -Leibniz-Institute für Prevention Research und Epidemiology, Bremen, Germany
| | | | - S Walker
- Centre for Health Economics, University of York, York, UK
| | - C Rothery
- Centre for Health Economics, University of York, York, UK
| | - M Westwood
- Kleijnen Systematic Reviews Ltd, York, UK
| | - J L Severens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Vanier A, Mariette X, Tubach F, Fautrel B. Cost-Effectiveness of TNF-Blocker Injection Spacing for Patients with Established Rheumatoid Arthritis in Remission: An Economic Evaluation from the Spacing of TNF-Blocker Injections in Rheumatoid Arthritis Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:577-585. [PMID: 28407999 DOI: 10.1016/j.jval.2017.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/15/2016] [Accepted: 01/11/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND In patients with rheumatoid arthritis in remission, a disease activity-driven tapering of adalimumab or etanercept relying on progressive injection spacing has not been shown to be equivalent to a maintenance strategy at full dose in terms of disease activity in the Spacing of TNF-blocker injections in Rheumatoid ArthritiS Study (STRASS) trial. OBJECTIVES To evaluate the cost-effectiveness of such a spacing strategy based on the data of the STRASS trial. METHODS This is a cost-utility analysis of the STRASS trial, a French multicenter 18-month equivalence randomized open-label controlled trial that included patients at stable dose for at least 1 year, in remission for at least 6 months. Effectiveness was assessed in quality-adjusted life-years (QALYs). Costs involved in the study period were assessed from a payer perspective. The decremental cost-effectiveness ratio (DCER) was calculated in the complete cases sample (n = 98). Several sensitivity analyses were conducted and the impact of missing data on DCER estimate was investigated. An acceptability analysis was performed. RESULTS In the spacing arm, TNF-blockers were stopped for 34.1% of the patients, tapered for 43.2%, and maintained at full dose for 18.2%. The spacing strategy was associated with less QALYs gain (mean difference of -0.158; 95% confidence interval [CI] -0.085 to -0.232) and reduced costs (mean difference of -€8,440; 95% CI -6,507 to -10,212). The estimated DCER of the spacing strategy over the maintenance at full dose was €53,417 saved per QALY lost (95% CI 32,230 to 104,700). CONCLUSIONS The spacing strategy appears cost-effective, but the acceptability of such a QALY loss reported to the cost avoided remains to be evaluated, because no consensual threshold has been determined for willingness to accept as compared with willingness to pay.
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Affiliation(s)
- Antoine Vanier
- Sorbonne Universités, UPMC Université and APHP, Hôpitaux Universitaires Pitié-Salpêtrière Charles-Foix, Département de Biostatistique Santé Publique et Information Médicale, Paris, France.
| | - Xavier Mariette
- Université Paris-Sud and APHP, Hôpitaux Universitaires Paris-Sud, Département de Rhumatologie, Le Kremlin Bicêtre, Paris, France
| | - Florence Tubach
- Sorbonne Paris Cité, Univ Paris-Diderot, Paris, France; APHP, Hôpital Bichat, Département d'Epidémiologie et Recherche Clinique, Paris, France; INSERM CIC-EC 1425, Paris, France
| | - Bruno Fautrel
- Sorbonne Universités, UPMC Université Paris, GRC-08 (EEMOIS), Paris, France; APHP Hôpitaux Universitaires Pitié-Salpêtrière Charles-Foix, Département de Rhumatologie, Paris, France
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Tanajewski L, Franklin M, Gkountouras G, Berdunov V, Harwood RH, Goldberg SE, Bradshaw LE, Gladman JRF, Elliott RA. Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial). PLoS One 2015; 10:e0140662. [PMID: 26684872 PMCID: PMC4687694 DOI: 10.1371/journal.pone.0140662] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months. OBJECTIVE To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. METHODS Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%). RESULTS The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded. CONCLUSIONS The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation. TRIAL REGISTRATION ClinicalTrials.gov NCT01136148.
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Affiliation(s)
- Lukasz Tanajewski
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Matthew Franklin
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | | | - Vladislav Berdunov
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Rowan H. Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, United Kingdom
| | - Sarah E. Goldberg
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Lucy E. Bradshaw
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, United Kingdom
| | - John R. F. Gladman
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, United Kingdom
| | - Rachel A. Elliott
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
- * E-mail:
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Govers TM, Patel S, Takes RP, Merkx T, Rovers M, Grutters J. Cost-effectiveness of selective neck dissection versus modified radical neck dissection for treating metastases in patients with oral cavity cancer: A modelling study. Head Neck 2015; 37:1762-8. [PMID: 24990207 DOI: 10.1002/hed.23833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Choosing between a more or less extensive neck dissection implies a tradeoff between survival, quality of life, and costs. The purpose of this study was to determine if selective neck dissection (level I-III or I-IV) is cost-effective compared with modified radical neck dissection (level I-V) in patients with cT1-2 oral squamous cell carcinoma (OSCC) with singular nodal disease confined to level I or II. METHODS A decision-analytic model was developed to model quality-adjusted life years (QALYs) and costs over a lifetime horizon, based on literature. RESULTS The selective neck dissection strategy resulted in an expected health loss of 0.06 QALY and savings of €1351 per patient compared to modified radical neck dissection. The results were sensitive to differences in regional failure probabilities between the strategies. CONCLUSION With the evidence used in this model, selective neck dissection was not cost-effective compared to modified radical neck dissection. Prospective research on regional failure is needed to provide optimal treatment for patients with OSCC.
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Affiliation(s)
- Tim M Govers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sejal Patel
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thijs Merkx
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska Rovers
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke Grutters
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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Alberts SR, Yu TM, Behrens RJ, Renfro LA, Srivastava G, Soori GS, Dakhil SR, Mowat RB, Kuebler JP, Kim GP, Mazurczak MA, Hornberger J. Comparative economics of a 12-gene assay for predicting risk of recurrence in stage II colon cancer. PHARMACOECONOMICS 2014; 32:1231-43. [PMID: 25154747 PMCID: PMC4244576 DOI: 10.1007/s40273-014-0207-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Prior economic analysis that compared the 12-gene assay to published patterns of care predicted the assay would improve outcomes while lowering medical costs for stage II, T3, mismatch-repair-proficient (MMR-P) colon cancer patients. This study assessed the validity of those findings with real-world adjuvant chemotherapy (aCT) recommendations from the US third-party payer perspective. METHODS Costs and quality-adjusted life-years (QALYs) were estimated for stage II, T3, MMR-P colon cancer patients using guideline-compliant, state-transition probability estimation methods in a Markov model. A study of 141 patients from 17 sites in the Mayo Clinic Cancer Research Consortium provided aCT recommendations before and after knowledge of the 12-gene assay results. Progression and adverse events data with aCT regimens were based on published literature. Drug and administration costs for aCT were obtained from 2014 Medicare Fee Schedule. Sensitivity analyses evaluated the drivers and robustness of the primary outcomes. RESULTS After receiving the 12-gene assay results, physician recommendations in favor of aCT decreased 22 %; fluoropyrimidine monotherapy and FOLFOX recommendations each declined 11 %. Average per-patient drugs, administration, and adverse events costs decreased $US2,339, $US733, and $US3,211, respectively. Average total direct medical costs decreased $US991. Average patient well-being improved by 0.114 QALYs. Savings are expected to persist even if the cost of oxaliplatin drops by >75 % due to generic substitution. CONCLUSIONS This study provides evidence that real-world changes in aCT recommendations due to the 12-gene assay are likely to reduce direct medical costs and improve well-being for stage II, T3, MMR-P colon cancer patients.
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Affiliation(s)
| | - Tiffany M. Yu
- Cedar Associates LLC, 3715 Haven Avenue, Suite 100, Menlo Park, CA 94025 USA
| | - Robert J. Behrens
- Medical Oncology and Hematology Associates, 1221 Pleasant St, Des Moines, IA 50309 USA
| | | | | | - Gamini S. Soori
- Alegant Bergan Mercy Cancer Center, 7500 Mercy Rd, Omaha, NE 68124 USA
| | - Shaker R. Dakhil
- Cancer Center of Kansas, 818 N Emporia Ave, Wichita, KS 67214 USA
| | - Rex B. Mowat
- Toledo Clinic, 4235 Secor Rd, Toledo, OH 43623 USA
| | - John P. Kuebler
- Columbus Oncology Associates, 810 Jasonway Ave, Columbus, OH 43214 USA
| | - George P. Kim
- Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 USA
| | | | - John Hornberger
- Cedar Associates LLC, 3715 Haven Avenue, Suite 100, Menlo Park, CA 94025 USA
- Stanford University School of Medicine, 291 Campus Dr, Stanford, CA 94305 USA
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Bang H, Zhao H. Cost-effectiveness analysis: a proposal of new reporting standards in statistical analysis. J Biopharm Stat 2014; 24:443-60. [PMID: 24605979 PMCID: PMC3955019 DOI: 10.1080/10543406.2013.860157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 10/29/2012] [Indexed: 10/25/2022]
Abstract
Cost-effectiveness analysis (CEA) is a method for evaluating the outcomes and costs of competing strategies designed to improve health, and has been applied to a variety of different scientific fields. Yet there are inherent complexities in cost estimation and CEA from statistical perspectives (e.g., skewness, bidimensionality, and censoring). The incremental cost-effectiveness ratio that represents the additional cost per unit of outcome gained by a new strategy has served as the most widely accepted methodology in the CEA. In this article, we call for expanded perspectives and reporting standards reflecting a more comprehensive analysis that can elucidate different aspects of available data. Specifically, we propose that mean- and median-based incremental cost-effectiveness ratios and average cost-effectiveness ratios be reported together, along with relevant summary and inferential statistics, as complementary measures for informed decision making.
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Affiliation(s)
- Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Hongwei Zhao
- Department of Epidemiology and Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
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Hiligsmann M, Cooper C, Arden N, Boers M, Branco JC, Luisa Brandi M, Bruyère O, Guillemin F, Hochberg MC, Hunter DJ, Kanis JA, Kvien TK, Laslop A, Pelletier JP, Pinto D, Reiter-Niesert S, Rizzoli R, Rovati LC, Severens JL(H, Silverman S, Tsouderos Y, Tugwell P, Reginster JY. Health economics in the field of osteoarthritis: An Expert's consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum 2013; 43:303-13. [DOI: 10.1016/j.semarthrit.2013.07.003] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/01/2013] [Accepted: 07/08/2013] [Indexed: 01/01/2023]
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Goossens LMA, Utens CMA, Smeenk FWJM, van Schayck OCP, van Vliet M, van Litsenburg W, Braken MW, Rutten-van Mölken MPMH. Cost-effectiveness of early assisted discharge for COPD exacerbations in The Netherlands. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:517-528. [PMID: 23796285 DOI: 10.1016/j.jval.2013.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Hospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands. METHODS In the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs. RESULTS Seven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]-0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%-36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI-0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:-€244 (treatment phase, 95% CI-€315 to-€168) and-€168 (3 months, 95% CI-€1253 to €922). Societal perspective:-€65 (treatment phase, 95% CI-€152 to €25) and €908 (3 months, 95% CI-€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant. CONCLUSIONS No clear evidence was found to conclude that either treatment was more effective or less costly.
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Affiliation(s)
- Lucas M A Goossens
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
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van Wier MF, Lakerveld J, Bot SDM, Chinapaw MJM, Nijpels G, van Tulder MW. Economic evaluation of a lifestyle intervention in primary care to prevent type 2 diabetes mellitus and cardiovascular diseases: a randomized controlled trial. BMC FAMILY PRACTICE 2013; 14:45. [PMID: 23557482 PMCID: PMC3662579 DOI: 10.1186/1471-2296-14-45] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 03/18/2013] [Indexed: 11/18/2022]
Abstract
Background Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases, addressing ‘real-world’ implementation, are needed. This study examines the cost-effectiveness of a primary care intervention from a societal perspective, compared with provision of health brochures, alongside a randomized controlled trial. Methods Adults aged 30-50 years, at risk of type 2 diabetes (T2DM) and/or cardiovascular disease (CVD), were recruited from twelve general practices in The Netherlands. They were randomized to the intervention (n = 314) or control group (n = 308). The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse, followed by three-monthly sessions by phone. Costs were collected using three-monthly retrospective questionnaires. Quality of life was measured with the EuroQol-5D-3L, at baseline, 6, 12 and 24 months. Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae, respectively, based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points. Results Small, statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years (QALYs) gained. The mean difference in costs between the intervention and control group was €-866 (95% confidence interval -2372; 370). The probability that the intervention was cost-effective varied from 93% at €8000/QALY to 88% at €80,000/QALY. Conclusion A primary care lifestyle intervention aimed at adults at increased risk of T2DM and/or CVD could result in cost savings over a two-year period. However, due to methodological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practices. Trial registration Current Controlled Trials ISRCTN59358434.
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Cost-effectiveness of N-terminal pro-B-type natriuretic-guided therapy in elderly heart failure patients: results from TIME-CHF (Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure). JACC-HEART FAILURE 2013; 1:64-71. [PMID: 24621800 DOI: 10.1016/j.jchf.2012.08.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/16/2012] [Accepted: 08/22/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study aimed to assess cost-effectiveness of N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided versus symptom-guided therapy in heart failure (HF) patients ≥60 years old. BACKGROUND Cost-effectiveness of NT-proBNP guidance in HF patients is unclear. It may create additional costs with uncertain benefits. METHODS In the TIME-CHF (Trial of Intensified versus Standard Medical Therapy in Elderly Patients with Congestive Heart Failure), patients with left ventricular ejection fraction (LVEF) of ≤45% were randomized to receive intensified NT-proBNP-guided therapy or standard, symptom-guided therapy. For cost-effectiveness analysis, 467 (94%) patients (age 76 ± 7 years, 66% male) were eligible. Incremental cost-effectiveness was calculated as incremental costs per gained life-year and quality-adjusted life-year (QALY) within the 18-month trial period, as defined per protocol. RESULTS NT-proBNP-guided therapy was dominant (i.e., more effective and less costly) over symptom-guided therapy, saving $2,979 USD (2.5 to 97.5% confidence interval [CI]: $8,758 to $3,265) per patient, with incremental effectiveness of +0.07 life-years and +0.05 QALYs. The probability of NT-proBNP-guided therapy being dominant was 80%, and the probability of saving 1 life-year or QALY at a cost of $50,000 was 97% and 93%, respectively. Exclusion of residence costs resulted in an incremental cost-effectiveness ratio (ICER) of $5,870 per life-year gained. Cost-effectiveness of NT-proBNP-guided therapy was most pronounced in patients <75 years old and in those with <2 significant comorbidities, being dominant in all sensitivity analyses. In the worst-case scenario (excluding residence costs in those with ≥2 comorbidities), the ICER was $11,935 per life-year gained. CONCLUSIONS NT-proBNP-guided therapy has a high probability of being cost effective in HF patients with reduced LVEF, particularly in patients age 60 to 75 years or with less than 2 comorbidities. (Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure [TIME-CHF]; ISRCTN43596477).
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van Gestel A, Webers CA, Severens JL, Beckers HJ, Jansonius NM, Hendrikse F, Schouten JS. The long-term outcomes of four alternative treatment strategies for primary open-angle glaucoma. Acta Ophthalmol 2012; 90:20-31. [PMID: 22289192 DOI: 10.1111/j.1755-3768.2011.02318.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the long-term effects and costs of four treatment strategies for primary open-angle glaucoma compared to usual care. METHODS Cost-effectiveness analyses with a lifelong horizon were made from a societal perspective. Data were generated with a patient-level model based on discrete event simulation. The model structure and parameter estimates were based on literature, particularly clinical studies on the natural course of glaucoma and the effect of treatment. We simulated heterogeneous cohorts of 3000 patients and explored the impact of uncertainty with sensitivity analyses. RESULTS The incremental cost-effectiveness ratio (ICER) of initial treatment with a prostaglandin analogue compared with a β-blocker was €12.931 per quality-adjusted life year (QALY) gained. A low initial target pressure (15 mmHg) resulted in 0.115 QALYs gained and €1550 saved compared to a gradual decrease from 21 to 15 mmHg upon progression. Visual field (VF) measurements every 6 rather than 12 months lead to health gains at increased costs (ICER €173,486 per QALY gained), whereas measurements every 24 months lead to health losses at reduced costs (ICER €21,516 per QALY lost). All treatment strategies were dominant over 'withholding treatment'. CONCLUSIONS From a cost-effectiveness point of view, it seems advantageous to aim for a low intraocular pressure in all glaucoma patients. The feasibility of this strategy should therefore be investigated. Additionally, the cost-effectiveness outcomes of initiating monotherapy with a prostaglandin analogue and reducing the frequency of VF testing may be acceptable.
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Affiliation(s)
- Aukje van Gestel
- University Eye Clinic, Maastricht University Medical Center, Maastricht, The Netherlands
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21
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van Gestel A, Grutters J, Schouten J, Webers C, Beckers H, Joore M, Severens J. The role of the expected value of individualized care in cost-effectiveness analyses and decision making. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:13-21. [PMID: 22264967 DOI: 10.1016/j.jval.2011.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 06/03/2011] [Accepted: 07/07/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To explore the feasibility and potential role of the expected value of individualized care (EVIC) framework. METHODS The EVIC quantifies how much benefits are forgone when a treatment decision is based on the best-expected outcomes in the population rather than in the individual patient. We have reviewed which types of patient-level attributes contribute to the EVIC and how they affect the interpretation of the outcomes. In addition, we have applied the EVIC framework to the outcomes of a microsimulation-based cost-effectiveness analysis for glaucoma treatment. RESULTS For EVIC outcomes to inform decisions about clinical practice, we need to calculate the parameter-specific EVIC of known or knowable patient-level attributes and compare it with the real costs of implementing individualized care. In the case study, the total EVIC was €580 per patient, but patient-level attributes known at treatment decision had minimal impact. A subgroup policy based on individual disease progression could be worthwhile if a predictive test for glaucoma progression could be developed and implemented for less than €130 per patient. CONCLUSIONS The EVIC framework is feasible in cost-effectiveness analyses and can be informative for decision making. The EVIC outcomes are particularly informative when they are (close to) zero. When the EVIC has a high value, implications depend on the type of patient-level attribute. EVIC can be a useful tool to identify opportunities to improve efficiency in health care by individualization of care and to quantify the maximal investment opportunities for implementing subgroup policy.
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Affiliation(s)
- Aukje van Gestel
- University Eye Clinic, Maastricht University Medical Center, Maastricht, The Netherlands
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Jafar TH, Islam M, Bux R, Poulter N, Hatcher J, Chaturvedi N, Ebrahim S, Cosgrove P. Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial. Circulation 2011; 124:1615-25. [PMID: 21931077 DOI: 10.1161/circulationaha.111.039990] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies. METHODS AND RESULTS Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were $3.99, $3.34, and $0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of $23 (95 confidence interval, 6-99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications. CONCLUSIONS The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure.
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Affiliation(s)
- Tazeen H Jafar
- Departments of Medicine and Community Health Sciences, Aga Khan University, Stadium Rd, Karachi, Pakistan.
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Gruschkus SK, Lairson D, Dunn JK, Risser J, Du XL. Cost-effectiveness of white blood cell growth factor use among a large nationwide cohort of elderly non-Hodgkin's lymphoma patients treated with chemotherapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:253-262. [PMID: 21402294 DOI: 10.1016/j.jval.2010.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 07/09/2010] [Accepted: 09/10/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness (as measured as cost per life-year saved) of white blood cell growth factor or colony-stimulating factor (CSF) use among a large cohort of elderly non-Hodgkin's lymphoma (NHL) patients in a real-world setting. METHODS We identified 13,203 NHL patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database who received the diagnosis from 1992 to 2002 and who received chemotherapy within 12 months of diagnosis. Benefit (effectiveness) of CSF use (primary and secondary prophylaxis) was measured as observed improvement in overall survival. Costs for each patient were calculated by adding the cumulative reimbursement amounts from Medicare claims. Cost-effectiveness was estimated by modeling the joint influence of CSF use on both costs and effectiveness using a propensity-score net monetary benefit approach. RESULTS Primary prophylactic CSF use was cost-effective at lower willingness-to-pay thresholds, whereas at higher thresholds, not providing prophylactic CSF became the cost-effective strategy. For secondary prophylactic CSF use among patients experiencing neutropenia, fever, and/or infection, the opposite trend was observed. For low willingness-to-pay thresholds (<$20,000 per life-year gained), not administering CSF was the cost-effective strategy, whereas CSF use became cost-effective as willingness to pay increased (from $100,000+ per life-year gained). CONCLUSION To our knowledge, this is the first large population-based study to empirically measure the cost-effectiveness of CSF among NHL patients treated with chemotherapy. CSF use as primary or secondary prophylaxis may be a cost-effective strategy depending on society's (or payers') willingness to pay for improvements in outcomes.
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Affiliation(s)
- Stephen K Gruschkus
- Division of Epidemiology and Disease Control, University of Texas School of Public Health, Houston, TX 77030, USA
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Martín-Fernández J, del Cura-González MI, Gómez-Gascón T, Oliva-Moreno J, Domínguez-Bidagor J, Beamud-Lagos M, Pérez-Rivas FJ. Differences between willingness to pay and willingness to accept for visits by a family physician: a contingent valuation study. BMC Public Health 2010; 10:236. [PMID: 20459714 PMCID: PMC2883536 DOI: 10.1186/1471-2458-10-236] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 05/10/2010] [Indexed: 11/22/2022] Open
Abstract
Background The economic value attributed by users of health services in public health systems can be useful in planning and evaluation. This value can differ from the perspectives of Willingness to Pay (WTP) and Willingness to Accept [Compensation] (WTA). Our objective was to study the perceptions of the patient about the service provided by the family physician by means of the WTA/WTP ratio. Methods An economic evaluation study by the Contingent Valuation Method was designed. Interviews were conducted with 451 subjects at six health centres (four urban and two rural) in areas with different socioeconomic characteristics. A payment card was used to measure the WTP and WTA. Other characteristics of the subject or service that could influence these responses were collected. An explicative model was constructed to study the WTA/WTP relationship. Results Four hundred and four subjects (89.6%) expressed a WTP and WTA different from zero. The WTA/WTP quotient showed a median of 1.55 (interquartile range 1-3.08) and a mean of 3.30 (IC 95%: 2.84-3.75). The WTA/WTP ratio increases with age and in low-income areas. It decreases in professional groups with more specialized activities, with growing family income, and in the chronically ill. Other characteristics related to the perception of state of health, accessibility to the service, satisfaction, or perception of risk were not explicative. Conclusions Subjects who were older and had a less favourable socioeconomic situation expressed a higher WTA/WTP ratio when valuing the visit to the family physician. These characteristics could identify a profile of "aversion to loss" with respect to this service.
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Affiliation(s)
- Jesús Martín-Fernández
- San Martín de Valdeiglesias Health Center, 8th Primary Care Area Madrid Health Service, Spain.
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Scholtissen S, Bruyère O, Neuprez A, Severens JL, Herrero-Beaumont G, Rovati L, Hiligsmann M, Reginster JY. Glucosamine sulphate in the treatment of knee osteoarthritis: cost-effectiveness comparison with paracetamol. Int J Clin Pract 2010; 64:756-62. [PMID: 20518951 DOI: 10.1111/j.1742-1241.2010.02362.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The aim of this study was to explore the cost-effectiveness of glucosamine sulphate (GS) compared with paracetamol and placebo (PBO) in the treatment of knee osteoarthritis. For this purpose, a 6-month time horizon and a health care perspective was used. MATERIAL AND METHODS The cost and effectiveness data were derived from Western Ontario and McMaster Universities Osteoarthritis Index data of the Glucosamine Unum In Die (once-a-day) Efficacy trial study by Herrero-Beaumont et al. Clinical effectiveness was converted into utility scores to allow for the computation of cost per quality-adjusted life year (QALY) For the three treatment arms Incremental Cost-Effectiveness Ratio were calculated and statistical uncertainty was explored using a bootstrap simulation. RESULTS In terms of mean utility score at baseline, 3 and 6 months, no statistically significant difference was observed between the three groups. When considering the mean utility score changes from baseline to 3 and 6 months, no difference was observed in the first case but there was a statistically significant difference from baseline to 6 months with a p-value of 0.047. When comparing GS with paracetamol, the mean baseline incremental cost-effectiveness ratio (ICER) was dominant and the mean ICER after bootstrapping was -1376 euro/QALY indicating dominance (with 79% probability). When comparing GS with PBO, the mean baseline and after bootstrapping ICER were 3617.47 and 4285 euro/QALY, respectively. CONCLUSION The results of the present cost-effectiveness analysis suggested that GS is a highly cost-effective therapy alternative compared with paracetamol and PBO to treat patients diagnosed with primary knee OA.
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Affiliation(s)
- S Scholtissen
- Department of Public Health, University of Liege, Liege, Belgium
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Modeling the value for money of changing clinical practice change: a stochastic application in diabetes care. Med Care 2009; 47:1053-61. [PMID: 19648827 DOI: 10.1097/mlr.0b013e31819e1ee9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Decision making about resource allocation for guideline implementation to change clinical practice is inevitably undertaken in a context of uncertainty surrounding the cost-effectiveness of both clinical guidelines and implementation strategies. Adopting a total net benefit approach, a model was recently developed to overcome problems with the use of combined ratio statistics when analyzing decision uncertainty. OBJECTIVE To demonstrate the stochastic application of the model for informing decision making about the adoption of an audit and feedback strategy for implementing a guideline recommending intensive blood glucose control in type 2 diabetes in primary care in the Netherlands. METHODS An integrated Bayesian approach to decision modeling and evidence synthesis is adopted, using Markov Chain Monte Carlo simulation in WinBUGs. Data on model parameters is gathered from various sources, with effectiveness of implementation being estimated using pooled, random-effects meta-analysis. Decision uncertainty is illustrated using cost-effectiveness acceptability curves and frontier. RESULTS Decisions about whether to adopt intensified glycemic control and whether to adopt audit and feedback alter for the maximum values that decision makers are willing to pay for health gain. Through simultaneously incorporating uncertain economic evidence on both guidance and implementation strategy, the cost-effectiveness acceptability curves and cost-effectiveness acceptability frontier show an increase in decision uncertainty concerning guideline implementation. CONCLUSIONS The stochastic application in diabetes care demonstrates that the model provides a simple and useful tool for quantifying and exploring the (combined) uncertainty associated with decision making about adopting guidelines and implementation strategies and, therefore, for informing decisions about efficient resource allocation to change clinical practice.
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Health economic assessment: a methodological primer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2009; 6:2950-66. [PMID: 20049237 PMCID: PMC2800325 DOI: 10.3390/ijerph6122950] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 11/23/2009] [Indexed: 11/17/2022]
Abstract
This review article aims to provide an introduction to the methodology of health economic assessment of a health technology. Attention is paid to defining the fundamental concepts and terms that are relevant to health economic assessments. The article describes the methodology underlying a cost study (identification, measurement and valuation of resource use, calculation of costs), an economic evaluation (type of economic evaluation, the cost-effectiveness plane, trial- and model-based economic evaluation, discounting, sensitivity analysis, incremental analysis), and a budget impact analysis. Key references are provided for those readers who wish a more advanced understanding of health economic assessments.
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Meckley LM, Greenberg D, Cohen JT, Neumann PJ. The Adoption of Cost-Effectiveness Acceptability Curves in Cost-Utility Analyses. Med Decis Making 2009; 30:314-9. [DOI: 10.1177/0272989x09344749] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Cost-effectiveness acceptability curves (CEACs) plot the probability that one health intervention is more cost-effective than alternatives, as a function of societal willingness to pay for additional units of health (e.g., life-years or quality-adjusted life-years gained). Objectives. To quantify the adoption of CEACs in published cost-utility analyses (CUAs), and to identify factors associated with CEAC use. Methods. Data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), a database with detailed information on approximately 1,400 CUAs published in the peer reviewed literature through 2006, was analyzed. The registry includes data on study origin, study methodology, reporting of results, whether CEACs were presented, and a subjective quality score. Univariate and multivariate logistic regression analyses were used to identify factors predicting CEAC use, from their introduction in 1994 through 2006. Results. Approximately 15% of CUAs published since 1994 present a CEAC. The use of CEACs has increased rapidly in recent years, from 2.1% of published CUAs in 2001 to 32.6% in 2006 (P < 0.0001). The most significant predictors of CEAC use were study quality (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.80, 2.85), recent publication (OR: 1.99; 95% CI: 1.73, 2.29), and whether studies pertain to the UK (OR: 5.66; 95% CI: 3.67, 8.72) or Sweden (OR: 3.76; 95% CI: 1.67, 8.44). Conclusions. CEAC use is increasing in the published cost-effectiveness literature, especially in UK-based studies.
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Affiliation(s)
- Lisa M. Meckley
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts,
| | - Dan Greenberg
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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Hövels AM, Heesakkers RAM, Adang EMM, Barentsz JO, Jager GJ, Severens JL. Cost-effectiveness of MR Lymphography for the Detection of Lymph Node Metastases in Patients with Prostate Cancer. Radiology 2009; 252:729-36. [DOI: 10.1148/radiol.2531071360] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fiddelers AA, Dirksen CD, Dumoulin JC, van Montfoort AP, Land JA, Janssen JM, Evers JL, Severens JL. Cost-effectiveness of seven IVF strategies: results of a Markov decision-analytic model. Hum Reprod 2009; 24:1648-55. [DOI: 10.1093/humrep/dep041] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Grutters JPC, Kessels AGH, Dirksen CD, van Helvoort-Postulart D, Anteunis LJC, Joore MA. Willingness to accept versus willingness to pay in a discrete choice experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:1110-9. [PMID: 18489505 DOI: 10.1111/j.1524-4733.2008.00340.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES Our main objective was to compare willingness to accept (WTA) and willingness to pay (WTP) in a discrete choice experiment on hearing aid provision. Additionally, income effect and endowment effect were explored as possible explanations for the disparity between WTA and WTP, and the impact of using a WTA and/or WTP format to elicit monetary valuations on the net benefit of the new organization of hearing aid provision was examined. METHODS Choice sets were based on five attributes: performer of the initial assessment; accuracy of the initial assessment; duration of the pathway; follow-up at the ear, nose, and throat specialist; and costs. Persons with hearing complaints randomly received a WTP (costs defined as extra payment) or WTA (costs defined as discount) version of the experiment. In the versions, except for the cost attribute, all choice sets were equal. RESULTS The cost coefficient was statistically significantly higher in the WTP format. Marginal WTA was statistically significantly higher than marginal WTP for the attributes accuracy and follow-up. Disparity was higher in the high educational (as proxy for income) group. We did not find proof of an experience endowment effect. Implementing the new intervention would only be recommended when using WTP. CONCLUSIONS WTA exceeds WTP, also in a discrete choice experiment. As this affects monetary valuations, more research on when to use a payment or a discount in the cost attribute is needed before discrete choice results can be used in cost-benefit analyses.
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Affiliation(s)
- Janneke P C Grutters
- Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, Maastricht, The Netherlands.
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Severens JL, Severens JLH. Loss aversion and cost effectiveness of healthcare programmes: whose aversion counts anyway? PHARMACOECONOMICS 2008; 26:899-900. [PMID: 18850759 DOI: 10.2165/00019053-200826110-00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Johan L Severens
- CAPHRI School for Public Health and Primary Care, Department of Health Organisation, Policy and Economics, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands.
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Affiliation(s)
- Afschin Gandjour
- Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
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Abstract
Contingent valuation (CV) studies in health care have used the willingness to pay (WTP) approach, to the virtual exclusion of willingness to accept (WTA). Outside the health care field, disparities between WTP and WTA values have been observed. Were such disparities to be demonstrated for health care technologies, the conventional assumption of a linear cost-effectiveness plane would be invalidated. This paper employs data derived from interviews with users of the UK's paediatric cochlear implantation (PCI) programme based in Nottingham (i) to assess the feasibility of estimating WTA for the potential discontinuation of an existing technology, and (ii) to investigate any WTA-WTP disparity which might be revealed. Only one-third of subjects providing WTP values were willing and able to offer a corresponding WTA value. Our qualitative data revealed that modes of response differed between the two valuation approaches. In particular, the presumption of fungibility of the health care intervention was a far more serious obstacle to completing the WTA task than it was for WTP. Among those prepared to offer values under both approaches, mean WTA was approximately four times mean WTP. Until more health studies are conducted, it remains unclear whether or not the findings are specific both to the intervention and to the elicitation format.
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Affiliation(s)
- David K Whynes
- School of Economics, University of Nottingham, Nottingham NG7 2RD, UK.
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Brunenberg DEM, Wetzels GEC, Nelemans PJ, Dirksen CD, Severens JL, Stoffers HEJH, Schouten JSAG, Prins MH, de Leeuw PW, Joore MA. Cost effectiveness of an adherence-improving programme in hypertensive patients. PHARMACOECONOMICS 2007; 25:239-51. [PMID: 17335309 DOI: 10.2165/00019053-200725030-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Non-adherence to antihypertensive drugs is high, and the economic consequences of non-adherence may be substantial. The Medication Events Monitoring System (MEMS), which is a method to improve adherence, has been shown to be a useful tool for the management of adherence problems. OBJECTIVE To assess the cost effectiveness of the MEMS compared with usual care in a population of hypertensive patients with poor adherence. The MEMS programme consisted of provision of containers fitted with electronic caps together with adherence training if indicated. METHODS In a randomised controlled trial, 164 hypertensive patients in the experimental strategy and 89 patients in the usual care strategy were followed for 5 months. Patients who had a systolic blood pressure (SBP) > or = 160 mm Hg and/or diastolic BP (DBP) > or = 95 mm Hg despite the use of antihypertensive drugs were eligible. Patients were recruited by a GP, and treatment took place in general practice. In the experimental strategy, electronic monitoring of the intake of antihypertensive drugs was introduced without change of medication. Unsatisfactory adherence was defined as < 85% of days with the number of doses taken as prescribed. In the usual care strategy, antihypertensive treatment was intensified by the addition or change of antihypertensive drugs, if necessary, without provision of an electronic monitor. Outcome parameters included the proportion of patients with normalised blood pressure (NBP) at 5 months and QALYs. Costs were quantified from the healthcare and societal perspective. Non-parametric bootstrap simulations were performed to quantify the uncertainty around the mean estimates and cost-effectiveness acceptability curves were presented. In addition, a number of univariate sensitivity analyses were performed on deterministic variables. RESULTS At 5 months, 3.1% (95% UI [uncertainty interval] -9.7%, +15.8%) more patients had NBP, and 0.003 (95% UI -0.005, +0.010) more QALYs were generated in the experimental strategy. A statistically significant lower percentage of patients had a dose escalation in the experimental strategy. Irrespective of the ceiling ratio for cost effectiveness, the cost-effectiveness probability was between 75% and 80% for the analysis from the healthcare perspective using proportion of patients with NBP as the outcome parameter. For the analysis from the societal perspective using QALYs as the outcome parameter, this probability was between 45% and 51%. CONCLUSION For a time horizon of 5 months, a difference in both cost and effect could not be detected between an adherence-improving programme compared with usual care for hypertensive patients. The probability that the adherence-improving programme is cost effective is at best moderate. Moreover, the cost-effectiveness result is surrounded with considerable uncertainty and large-scale implementation warrants additional research into the economic consequences of this intervention. Patients may benefit from the use of a MEMS monitor in situations where BP targets are not reached because of suspected non-adherence and both patient and GP are reluctant to increase the dose or number of antihypertensive drugs.
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Affiliation(s)
- Danielle E M Brunenberg
- Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, Maastricht, The Netherlands
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Fiddelers AAA, Severens JL, Dirksen CD, Dumoulin JCM, Land JA, Evers JLH. Economic evaluations of single- versus double-embryo transfer in IVF. Hum Reprod Update 2006; 13:5-13. [PMID: 17099208 DOI: 10.1093/humupd/dml053] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multiple pregnancies lead to complications and induce high costs. The most successful way to decrease multiple pregnancies in IVF is to transfer only one embryo, which might reduce the efficacy of treatment. The objective of this review is to determine which embryo-transfer policy is most cost-effective: elective single-embryo transfer (eSET) or double-embryo transfer (DET). Several databases were searched for (cost* or econ*) and (single embryo* or double embryo* or one embryo* or two embryo* or elect* embryo or multip* embryo*). On the basis of five exclusion criteria, titles and abstracts were screened by two individual reviewers. The remaining papers were read for further selection, and data were extracted from the selected studies. A total of 496 titles were identified through the searches and resulted in the selection of one observational study and three randomized studies. Study characteristics, total costs and probability of live births were extracted. Besides this, cost-effectiveness and incremental cost-effectiveness were derived. It can be concluded that DET is the most expensive strategy. DET is also most effective if performed in one fresh cycle. eSET is only preferred from a cost-effectiveness point of view when performed in good prognosis patients and when frozen/thawed cycles are included. If frozen/thawed cycles are excluded, the choice between eSET and DET depends on how much society is willing to pay for one extra successful pregnancy.
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Affiliation(s)
- A A A Fiddelers
- Department of Clinical Epidemiology and Medical Technology Assessment, Research Institute Grow & Development and Care and Public Health Research Institute, Academic Hospital Maastricht, Maastricht, The Netherlands.
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Fiddelers AAA, van Montfoort APA, Dirksen CD, Dumoulin JCM, Land JA, Dunselman GAJ, Janssen JM, Severens JL, Evers JLH. Single versus double embryo transfer: cost-effectiveness analysis alongside a randomized clinical trial. Hum Reprod 2006; 21:2090-7. [PMID: 16613886 DOI: 10.1093/humrep/del112] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Twin pregnancies after IVF are still frequent and are considered high-risk pregnancies leading to high costs. Transferring one embryo can reduce the twin pregnancy rate. We compared cost-effectiveness of one fresh cycle elective single embryo transfer (eSET) versus one fresh cycle double embryo transfer (DET) in an unselected patient population. METHODS Patients starting their first IVF cycle were randomized between eSET and DET. Societal costs per couple were determined empirically, from hormonal stimulation up to 42 weeks after embryo transfer. An incremental cost-effectiveness ratio (ICER) was calculated, representing additional costs per successful pregnancy. RESULTS Successful pregnancy rates were 20.8% for eSET and 39.6% for DET. Societal costs per couple were significantly lower after eSET (7334 euro) compared with DET (10,924 euro). The ICER of DET compared with eSET was 19,096 euro, meaning that each additional successful pregnancy in the DET group will cost 19,096 euro extra. CONCLUSIONS One cycle eSET was less expensive, but also less effective compared to one cycle DET. It depends on the society's willingness to pay for one extra successful pregnancy, whether one cycle DET is preferred from a cost-effectiveness point of view.
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Affiliation(s)
- Audrey A A Fiddelers
- Department of Clinical Epidemiology and Medical Technology Assessment, Academic Hospital Maastricht, The Netherlands.
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Abstract
This article reviews the development of economic evaluation of health technologies in the UK and its impact on decision making. After a long period of limited impact from studies mainly carried out as academic exercises, the advent of the National Institute for Health and Clinical Excellence (NICE) in 1999 provided a transparent decision-making context where economic evaluation plays a central role. This article reviews some of the key characteristics about the way NICE works, for example, the way NICE has defined the form of analysis that it requires, reflecting its objective of maximising health gain (QALYs) from the predetermined and limited UK NHS budget. Two broad areas of widespread concern are noted. The first relates to the cost-effectiveness thresholds that NICE uses and the basis for them. The second is the patchy implementation of NICE guidance and the possible reasons for this. But even within the UK, NICE is the exception in making extensive and explicit use of economic evaluation and this article goes on to suggest that if there is to be a more widespread and consistent use of economic evaluation at both central and local levels, then health economists and others need to address three issues. The first is to be clear about what is the correct conceptual basis for determining the cost-effectiveness threshold and then to ensure that NICE has the empirical evidence to set it appropriately. The second is to recognise that even using the limited view of costs adopted by NICE, economic evaluations imply temporal and cross-service budgetary flexibility that the NHS locally does not in practice enjoy. The third issue is that with academic pressures for ever-increasing sophistication of 'state of the art' economic evaluation analysis, the NHS has more and more precise understanding of the cost effectiveness of just a few new technologies and little or no analysis of most. This limits the value of the former by reducing further the scope for appropriately disinvesting from cost-ineffective technologies to meet the additional costs of investing in cost-effective new ones. Whilst NICE stands out as an example of a context where high-quality economic evaluation plays a major role in decision making, the process is far from perfect and certainly is not representative of the use made of economic evaluation by the NHS as a whole. Health economists need to engage with the public and the health service to better understand their perspectives, rather than focusing on academic concerns relating to details of theory and analytical method.
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Affiliation(s)
- Martin J Buxton
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
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Affiliation(s)
- Jack Dowie
- Public Health and Policy Department, London School of Hygiene and Tropical Medicine, London, UK.
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