Community and patient values for preventing herpes zoster

Healthy ageing: Herpes zoster infection and the role of zoster vaccination

Populations are ageing worldwide, with considerable time lived in ill-health, putting upwards pressure on healthcare budgets. Healthy ageing is defined as maintaining functional ability, including the ability to: meet basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society. The risk and impact of infectious diseases increase with age due to immunosenescence. Vaccination can help to prevent disease in older adults, promoting healthy ageing and active lives. Herpes zoster (HZ) occurs when the varicella zoster virus is reactivated due to declining immunity. HZ is common, with a lifetime risk of one-third, and increases in incidence with age. HZ is associated with severe and intense pain, substantially affecting the functional status of patients as well as their overall health-related quality of life. HZ and its complications may result in prolonged morbidity, including persistent pain (post-herpetic neuralgia, PHN), hearing impairment, vision loss and increased risk of stroke and myocardial infarction. HZ and PHN are difficult to treat, substantiating the benefits of prevention. Vaccines to prevent HZ include a recombinant zoster vaccine (RZV). RZV has shown efficacy against the HZ burden of disease and HZ burden of interference on activities of daily living of over 90% in immunocompetent adults aged ≥50 years. Vaccine efficacy against HZ was maintained at over 70% at 10 years post-vaccination. Adult vaccination, including against HZ, has the potential to reduce burden of disease, thus helping to maintain functioning and quality of life to support healthy ageing in older adults.

Cost-Effectiveness of Recombinant Zoster Vaccine for the Prevention of Herpes Zoster in Hematopoietic Stem Cell Transplant Recipients and Other Immunocompromised Adults in the United States

INTRODUCTION

Immunocompromised (IC) adults are at increased risk of developing herpes zoster (HZ) and HZ-related complications due to therapy or underlying disease. This study evaluated the cost effectiveness of recombinant zoster vaccine (RZV) versus no vaccine for the prevention of HZ in hematopoietic stem cell transplant (HSCT) recipients and other IC adults aged ≥ 18 years in the United States (US).

METHODS

A static Markov model simulated cohorts of IC individuals using a 1-year cycle length and 30-year time horizon to estimate the cost effectiveness of RZV. Inputs were sourced from clinical trial results and publicly available sources/literature. Modeled populations included US adult HSCT recipients (base case), patients with human immunodeficiency virus (HIV), patients with breast cancer, patients with Hodgkin's lymphoma, and renal transplant recipients. The model reported societal costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity and threshold analyses were conducted.

RESULTS

In the base case of 19,671 US adult HSCT recipients, RZV resulted in total societal cost savings of US$0.1 million and 109 incremental QALYs versus no vaccine. RZV was a 'dominant strategy' versus no vaccine because vaccination resulted in cost savings with QALY gains. RZV was also cost saving in renal transplant recipients, and cost effective at a willingness-to-pay threshold of US$100,000 per QALY gained in patients with HIV, breast cancer, and Hodgkin's lymphoma, with ICERs of US$33,268, US$67,682, and US$95,972 per QALY gained, respectively, versus no vaccine.

CONCLUSIONS

Model results show RZV is potentially cost saving for the prevention of HZ in US adult HSCT recipients and US adults with selected immunocompromising conditions, and cost effective for others, supporting the use of RZV to prevent HZ and HZ-related complications in IC adults.

Cost-Effectiveness of Recombinant Zoster Vaccine for Adults Aged ≥50 Years in China

INTRODUCTION

Adjuvanted recombinant zoster vaccine (RZV) was the first vaccine made available for herpes zoster in China. Authors aimed to evaluate its economic and health impacts on Chinese adults aged ≥50 years.

METHODS

A lifetime Markov model was developed to compare the cost-effectiveness of RZV with that of no vaccination from a societal perspective. Model inputs were derived from published literature and analyzed in 2022. Outcomes included total costs, quality-adjusted life-years, incremental cost-effectiveness ratio, and number of herpes zoster and herpes zoster-related cases. Sensitivity analyses were performed to examine the robustness of the model results.

RESULTS

RZV was more costly than no vaccination by $2.78 billion with an additional 65,008 quality-adjusted life-years gained and could avoid 1,893,530 herpes zoster cases, 295,761 postherpetic neuralgia cases, 51,734 other complications, and 229 herpes zoster-related deaths. Incremental cost-effectiveness ratios of RZV varied in a range of $34,465.5-$51,002.7 per quality-adjusted life-year. RZV for the entire cohort would be cost-effective when discount rate was <2.4%, a waning rate of 2-dose RZV efficacy decreased to <0.8%, the utility of postherpetic neuralgia was <0.496, duration of postherpetic neuralgia was >12.86 months, or the cost of RZV per dose decreased to <$229.6. In a probabilistic sensitivity analysis, the probability of RZV being cost-effective was 43.95%, 59.32%, 45.27%, and 39.50% for people aged 50-59, 60-69, 70-79, and ≥80 years, respectively, with threefold gross domestic product per capita (37,654.5 per quality-adjusted life-year) as the willingness-to-pay threshold.

CONCLUSIONS

RZV was most likely to be cost-effective in people aged 60-69 years. A slight decrease in vaccine cost would result in RZV being cost-effective in all people aged ≥50 years.

Cost-Effectiveness Analysis of Vaccination With Recombinant Zoster Vaccine Among Hematopoietic Cell Transplant Recipients and Persons With Other Immunocompromising Conditions Aged 19 to 49 Years

OBJECTIVES

This study aimed to estimate the cost-effectiveness of the use of recombinant zoster vaccine (RZV) (Shingrix), which protects against herpes zoster (HZ), among immunocompromised adults aged 19 to 49 years, as a contribution to deliberations of the Advisory Committee on Immunization Practices.

METHODS

Hematopoietic cell transplant (HCT) recipients experience a high incidence of HZ, and the efficacy of RZV in preventing HZ has been studied in clinical trials. The cost-effectiveness model calculated incremental cost-effectiveness ratios that compared vaccination with RZV with a no vaccination strategy among adults aged 19 to 49 years. Costs and outcomes were calculated until age 50 years using the healthcare sector perspective and summarized as cost per quality-adjusted life-year (QALY) gained. The base case represents HCT recipients, with scenario analyses representing persons with other immunocompromising conditions, including hematologic malignancies, human immunodeficiency virus, and autoimmune and inflammatory conditions. Uncertainty was investigated using univariate, multivariate, and probabilistic sensitivity analyses.

RESULTS

Base-case results indicated vaccination with RZV would avert approximately 35% of HZ episodes and complications, while saving approximately 11% of net costs. Compared with no vaccination, vaccination of HCT recipients with RZV generated cost-savings (ie, lower costs and improved health) in the base case and in 81% of simulations in the probabilistic analysis. In scenario analyses, vaccination cost US dollar ($) 9500/QALY among patients with hematologic malignancies, $79 000/QALY among persons living with human immunodeficiency virus, and $208 000/QALY among persons with selected autoimmune and inflammatory conditions.

CONCLUSIONS

Generally favorable economic estimates supported recommendations for vaccination of immunocompromised adults with RZV to prevent episodes of HZ and related complications.

Is tailored messaging more effective? An analysis of a digital health intervention to promote HPV vaccination intent among Latinx

Latinx populations have unique barriers to HPV vaccination. In the current study, we assessed the effectiveness of an online intervention to increase HPV vaccination intentions among patients of clinics that principally serve a Latinx population (n = 85%) as part of a randomized control trial (RCT). Participants viewed on an iPad either an individually tailored educational website (CHiCOS) or untailored information derived from the Vaccine Information Sheet (VIS) for HPV. Vaccination intention and related covariates were assessed via survey items administered before (pre-test) and after (post-test) viewing the material. No statistically significant differences were seen in changes of intention to vaccinate between groups (N = 1294). However, 16% of all (tailored and untailored combined) participants increased in their intention to vaccinate, while 7% decreased in intention. Overall 72% of participants had high intentions to vaccinate, yet far fewer actually received a vaccine dose. The current study explores implications of the demonstrated intention-behavior gap. As such, it presents opportunities to improve future interventions-specifically those that employ tailored messaging.

A Cost-effectiveness Analysis of an Adjuvanted Subunit Vaccine for the Prevention of Herpes Zoster and Post-herpetic Neuralgia

BACKGROUND

Herpes zoster (HZ) develops in up to 50% of unvaccinated individuals, accounting for >1 million cases annually in the United States. A live attenuated HZ vaccine (LAV) is Food and Drug Administration approved for those age 50 years or older, though Advisory Committee on Immunization Practices recommendations are only for those age 60 years or older. LAV efficacy is ~70% for persons 50-59 years of age, with lower efficacy in older adults. A new 2-dose adjuvanted subunit vaccine (SUV) has >95% efficacy in persons 50-69 years of age and remains ~90% efficacious in persons vaccinated at age 70 years.

METHODS

To estimate the relative cost-effectiveness of SUV, LAV, and no vaccination (NoV) strategies, a Markov model was developed based on published data on vaccine efficacy, durability of protection, quality of life, resource utilization, costs, and disease epidemiology. The perspective was US societal, and the cycle length was 1 year with a lifelong time horizon. SUV efficacy was estimated to wane at the same rate as LAV. Outcomes evaluated included lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios (ICERs).

RESULTS

For individuals vaccinated at age 50 years, the ICER for LAV vs NoV was $118 535 per quality-adjusted life-year (QALY); at age 60 years, the ICER dropped to $42 712/QALY. SUV was more expensive but had better ICERs than LAV. At age 50, the ICER was $91 156/QALY, and it dropped to $19 300/QALY at age 60.

CONCLUSIONS

Vaccination with SUV was more cost-effective than LAV in all age groups studied. Vaccination with SUV at age 50 years appears cost-effective, with an ICER <$100 000/QALY.

A Cost-Effectiveness Analysis of Vaccination for Prevention of Herpes Zoster and Related Complications: Input for National Recommendations

BACKGROUND

The U.S. Advisory Committee on Immunization Practices recently developed recommendations for use of a new recombinant zoster vaccine (RZV).

OBJECTIVE

To evaluate the cost-effectiveness of vaccination with RZV compared with zoster vaccine live (ZVL) and no vaccination, the cost-effectiveness of vaccination with RZV for persons who have previously received ZVL, and the cost-effectiveness of preferential vaccination with RZV over ZVL.

DESIGN

Simulation (state-transition) model using U.S. epidemiologic, clinical, and cost data.

DATA SOURCES

Published data.

TARGET POPULATION

Hypothetical cohort of immunocompetent U.S. adults aged 50 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal and health care sector.

INTERVENTION

Vaccination with RZV (recommended 2-dose regimen), vaccination with ZVL, and no vaccination.

OUTCOME MEASURES

The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS OF BASE-CASE ANALYSIS

For vaccination with RZV compared with no vaccination, ICERs ranged by age from $10 000 to $47 000 per quality-adjusted life-year (QALY), using a societal perspective and assuming 100% completion of the 2-dose RZV regimen. For persons aged 60 years or older, ICERs were less than $60 000 per QALY. Vaccination with ZVL was dominated by vaccination with RZV for all age groups 60 years or older.

RESULTS OF SENSITIVITY ANALYSIS

Results were most sensitive to changes in vaccine effectiveness, duration of protection, herpes zoster incidence, and probability of postherpetic neuralgia. Vaccination with RZV after previous administration of ZVL yielded an ICER of less than $60 000 per QALY for persons aged 60 years or older. In probabilistic sensitivity analyses, RZV remained the preferred strategy in at least 95% of simulations, including those with 50% completion of the second dose.

LIMITATION

Few data were available on risk for serious adverse events, adherence to the recommended 2-dose regimen, and probability of recurrent zoster.

CONCLUSION

Vaccination with RZV yields cost-effectiveness ratios lower than those for many recommended adult vaccines, including ZVL. Results are robust over a wide range of plausible values.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Determining the optimal strategy for the live-attenuated herpes zoster vaccine in adults

The optimal strategy for the vaccinating against herpes zoster (HZ) vaccine remains unknown. Cost-effectiveness analyses provide insight to the most cost-effective age groups but results vary across studies. The optimal strategy is important given that vaccine efficacy and duration vary depending on vaccination age. Therefore, small changes from the optimal age can affect long-term outcomes and produce sub-optimal results. The objective of this research was to determine the optimal timing policy for HZ vaccination. We simulated cohorts of men and women and use stochastic dynamic programming to evaluate the decision to vaccinate or defer each year from age 50 to 100. If the decision was to defer, the cohort risked developing HZ. If HZ occurred, the cohort was subjected to cost and quality-adjusted life year (QALY) loss for a typical HZ infection (including complications) at that age. If HZ did not occur, the decision was evaluated at the next age. Then, we extend the model to consider the case in which a booster vaccine is available. A set of probabilistic sensitivity analyses were conducted to check model robustness. Results show the optimal policy for women is to vaccinate between ages 66 and 77, and for men between ages 66 and 74, assuming a willingness to pay (WTP) of $100,000 per QALY. It becomes optimal to vaccinate earlier if a booster vaccine is available, and women have a wider range of ages than men. This research is the first to examine exactly when the HZ vaccine should be administered. It is also the first study, to our knowledge, that used stochastic dynamic programming to examine the question of a second dose for any vaccine. This research provides the first simple policy on when to vaccinate and re-vaccinate against HZ.

Bleeding out the quality-adjusted life years: evaluating the burden of primary dysmenorrhea using time trade-off and willingness-to-pay methods

Primary dysmenorrhea (PD), or painful menstruation in the absence of identified uterine pathology, affects 5 to 9 in every 10 reproductive-aged women. Despite its high prevalence, just a few studies with very small patient numbers have focused on health-related quality of life impairment in PD. We aimed to assess health-related quality of life values for a severe and a mild hypothetical PD health state using 10-year time trade-off and willingness-to-pay methods. In 2015, a nationwide convenience sample of women, aged between 18 and 40 years, was recruited using an Internet-based cross-sectional survey in Hungary. Respondents with a known history of secondary dysmenorrhea were excluded. Data on 1836 and 160 women, with and without a history of PD, respectively, were analysed. Mean utility values for the severe and mild health states were 0.85 (median 0.95) and 0.94 (median 1), respectively. Participants were willing to pay a mean of &OV0556;1127 (median &OV0556;161) and &OV0556;142 (median &OV0556;16) for a complete cure from the severe and mild PD health states. Compared with the non-PD group, women with PD valued both health states worse according to willingness to pay (P < 0.05) but similar in the time trade-off. It seems that PD substantially contributes to the quality-adjusted life year loss in this age group, which is comparable with losses from chronic diseases such as type 1 diabetes, asthma, atopic eczema, or chronic migraine. Our findings provide a useful input to cost-effectiveness and cost-benefit analyses of PD treatments.

A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest

Background

The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers.

Objective

To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer’s disease. This manuscript describes the development and pretest of the app.

Methods

We used Research Electronic Data Capture (REDCap) to build the TTO app. The app’s modular structure and REDCap’s object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use.

Results

Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease.

Conclusions

We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes.

Psychometric properties of the incontinence utility index among patients with idiopathic overactive bladder: data from two multicenter, double-blind, randomized, Phase 3, placebo-controlled clinical trials

BACKGROUND

Overactive bladder is a prevalent and burdensome condition. Generic utility measures may fail to reflect its full impact on patients' health status. The Incontinence Utility Index (IUI) is a community-based preference index derived from the Incontinence Quality of Life Questionnaire (I-QOL) developed to value health states related to urinary symptoms in patients with neurogenic detrusor overactivity. This study assessed the measurement properties of the IUI in patients with idiopathic overactive bladder (OAB).

METHODS

Data were used from two clinical trials which recruited patients with OAB whose symptoms were inadequately managed with ≥ 1 anticholinergic medication. Psychometric evaluation included: Differential Item Functioning (DIF) analysis, concordance between I-QOL and IUI (Intraclass correlation coefficient [ICC], criterion and convergent validity according to relevant patient reported outcomes and clinical variables (Spearman's correlation coefficient, rho), responsiveness, and agreement between utility measures (ICC and Bland-Altman method).

RESULTS

A total of 1,105 idiopathic OAB patients were included. Mean age (range) was 60.4 years (18-90), 87.8% (n = 970) were female. DIF was identified in 3 items, none of which are contained in the IUI. ICC (CI95%) was 0.944 (0.936-0.950). Statistically significant differences (p < 0.001) were found in IUI scores for patients improving according to the Treatment Benefit Scale (TBS). Moderate to strong correlations (rho > |0.6|) were found in the expected direction with daily incontinence, urgency episodes and disease-specific domains of King's Health Questionnaire (KHQ). Low to moderate correlations (rho:<|0.6|) were found with Short Form version 2 (SF-12v2) summary components. A large effect size was found for patients reporting improvement (0.98-1.21) or great improvement (1.87-2.56) in the TBS, as well as in patients responding to treatment (1.19-2.40). Across utility measures, directional trends were consistent with OAB symptom profile, however, a lack of agreement in absolute values was observed.

CONCLUSIONS

The IUI presents good psychometric properties for valuing the impact of UI-related problems in idiopathic OAB patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00910845 and NCT00910520.

Vaccination in the elderly: what can be recommended?

The age-associated increased susceptibility to infectious disease would suggest that vaccination should be a route to promote healthy aging and keep our seniors autonomous and independent. While vaccination represents a cost-effective and efficient strategy at community level, the ability of the immune system to mount a protective immune response is still unpredictable at the level of the individual. Thus, at a similar age, some individuals, including the elderly, might still be 'good' responders while some other, even younger, would definitely fail to mount a protective response. In this review, the current burden of vaccine-preventable diseases in the aging and aged population will be detailed with the aim to identify the ideal vaccine candidates over the age of 50 years. This article will conclude with potential strategies to reduce, as best as possible, this burden and the imperative need to overcome barriers in extending current vaccine coverage towards to a lifelong vaccine schedule.

Cost-effectiveness analysis of a new 8% capsaicin patch compared to existing therapies for postherpetic neuralgia

OBJECTIVE

The purpose of this study was to compare the cost effectiveness of a new 8% capsaicin patch, compared to the current treatments for postherpetic neuralgia (PHN), including tricyclic antidepressants (TCAs), topical lidocaine patches, duloxetine, gabapentin, and pregabalin.

METHODS

A 1-year Markov model was constructed for PHN with monthly cycles, including dose titration and management of adverse events. The perspective of the analysis was from a payer perspective, managed-care organization. Clinical trials were used to determine the proportion of patients achieving at least a 30% improvement in PHN pain, the efficacy parameter. The outcome was cost per quality-adjusted life-year (QALY); second-order probabilistic sensitivity analyses were conducted.

RESULTS

The effectiveness results indicated that 8% capsaicin patch and topical lidocaine patch were significantly more effective than the oral PHN products. TCAs were least costly and significantly less costly than duloxetine, pregabalin, topical lidocaine patch, 8% capsaicin patch, but not gabapentin. The incremental cost-effectiveness ratio for the 8% capsaicin patch overlapped with the topical lidocaine patch and was within the accepted threshold of cost per QALY gained compared to TCAs, duloxetine, gabapentin, and pregablin. The frequency of the 8% capsaicin patch retreatment assumption significantly impacts its cost-effectiveness results. There are several limitations to this analysis. Since no head-to-head studies were identified, this model used inputs from multiple clinical trials. Also, a last observation carried forward process was assumed to have continued for the duration of the model. Additionally, the trials with duloxetine may have over-predicted its efficacy in PHN. Although a 30% improvement in pain is often an endpoint in clinical trials, some patients may require greater or less improvement in pain to be considered a clinical success.

CONCLUSIONS

The effectiveness results demonstrated that 8% capsaicin and topical lidocaine patches had significantly higher effectiveness rates than the oral agents used to treat PHN. In addition, this cost-effectiveness analysis found that the 8% capsaicin patch was similar to topical lidocaine patch and within an accepted cost per QALY gained threshold compared to the oral products.

The effect of time of onset on community preferences for health states: an exploratory study

BACKGROUND

Health state descriptions used to describe hypothetical scenarios in community-perspective utility surveys commonly omit detail on the time of onset of a condition, despite our knowledge that among patients who have a condition, experience affects the value assigned to that condition. The debate regarding whose values to use in cost utility analysis is based in part on this observed difference between values depending on the perspective from which they are measured. This research explores the effect on community preferences for hypothetical health states of including the time of onset of a health condition in the health state description, to investigate whether this information induces community respondents to provide values closer to those of patients with experience with a condition. The goal of the research is to bridge the gap between patient and community preferences.

METHODS

A survey of community-perspective preferences for hypothetical health states was conducted among a convenience sample of healthy adults recruited from a hospital consortium's research volunteer pool. Standard gambles for three hypothetical health states of varying severity were compared across three frames describing time of onset: six months prior onset, current onset, and no onset specified in the description. Results were compared within health state across times of onset, controlling for respondent characteristics known to affect utility scores. Sub-analyses were conducted to confirm results on values meeting inclusion criteria indicating a minimum level of understanding and compliance with the valuation task.

RESULTS

Standard gamble scores from 368 completed surveys were not significantly different across times of onset described in the health state descriptions regardless of health condition severity and controlling for respondent characteristics. Similar results were found in the subset of 292 responses that excluded illogical and invariant responses.

CONCLUSIONS

The inclusion of information on the time of onset of a health condition in community-perspective utility survey health state descriptions may not be salient to or may not induce expression of preferences related to disease onset among respondents. Further research is required to understand community preferences regarding condition onset, and how such information might be integrated into health state descriptions to optimize the validity of utility data. Improved understanding of how the design and presentation of health state descriptions affect responses will be useful to eliciting valid preferences for incorporation into decision making.

Economic burden of herpes zoster among skilled nursing facility residents in the United States

OBJECTIVES

To evaluate health care resource use and direct medical costs attributable to herpes zoster (HZ) among elderly residents of skilled nursing facilities (SNF).

METHODS

This was a retrospective matched cohort study using data from 300 SNF in the United States. A total of 404 patients with HZ were matched with 1616 patients with no documented HZ or post-herpetic neuralgia using propensity scores. The study period included a 1-month pre-index period and the 90-day acute/subacute phase following the HZ index date. Health care resource utilization was captured from the long term care minimum dataset (MDS) and SNF admission-discharge records. The direct medical costs consisted of the SNF net bed revenue and hospitalization cost.

RESULTS

Over the 4-month study period, significantly more patients were hospitalized among the HZ (20.5%) than non-HZ cohort (14.4%). Both the numbers of hospitalization episodes and hospitalization days were greater for HZ than for non-HZ patients. An average additional 0.09 hospitalization episodes and 0.55 days of hospitalization were estimated in a multivariate model for patients in the HZ compared with the non-HZ cohort. The incremental direct medical costs, which are composed of the incremental medical costs incurred in the SNF, and the incremental costs attributable to hospitalization, were estimated between $1079 and $1673 for patients with HZ.

CONCLUSION

In the SNF setting, the presence of HZ imposes significant health care resource utilization and direct medical costs.

The impact of herpes zoster and post-herpetic neuralgia on quality-of-life

BACKGROUND

The potentially serious nature of herpes zoster (HZ) and the long-term complication post-herpetic neuralgia (PHN) are often underestimated. One in four people will contract herpes zoster in their lifetime, with this risk rising markedly after the age of 50 years, and affecting one in two in elderly individuals. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. In the acute phase, pain is usually moderate or severe, with patients ranking HZ pain as more intense than post-surgical or labour pains. Up to 20% of patients with HZ develop PHN, which is moderate-to-severe chronic pain persisting for months or years after the acute phase. We review the available data on the effect of HZ and PHN on patients' quality-of-life.

DISCUSSION

Findings show that HZ, and particularly PHN, have a major impact on patients' lives across all four health domains--physical, psychological, functional and social. There is a clear correlation between increasing severity of pain and greater interference with daily activities. Non-pain complications such as HZ ophthalmicus can increase the risk of permanent physical impairment. Some elderly individuals may experience a permanent loss of independence after an acute episode of HZ. Current challenges in the management of HZ and PHN are highlighted, including the difficulty in administering antiviral agents before pain becomes established and the limited efficacy of pain treatments in many patients. We discuss the clinical rationale for the HZ vaccine and evidence demonstrating that the vaccine reduces the burden of the disease. The Shingles Prevention Study, conducted among >38,000 people aged >or=60 years old, showed that the HZ vaccine significantly reduces the burden of illness and the incidence of both HZ and PHN. In the entire study population, zoster vaccination reduced the severity of interference of HZ and PHN with activities of daily living by two-thirds, as measured by two questionnaires specific to HZ.

SUMMARY

A vaccination scheme may positively impact the incidence and course of HZ disease, thereby improving patients' quality-of-life.

Compliance with herpes zoster vaccination in young and adult individuals in two regions of Italy

BACKGROUND

The purpose of this work was to explore the knowledge and acceptance of Varicella Zoster Virus (VZV)-Herpes Zoster (HZ) vaccination in the general Italian population, where the HZ vaccine has not yet been distributed, using a prevalence study of subjects from two regions in Italy.

METHODS

A group of 3,173 individuals were interviewed using a questionnaire. The youngest age group (<or= 20 year) was composed of students interviewed at university. The middle age group (21-40 years) and the older age group (>or= 41 years) were interviewed by general practitioners in their office.

RESULTS

In both regions, the majority of subjects had been infected with varicella, and only 165 (5.2%) subjects reported receiving the VZV vaccination. Regarding HZ, 2,749 (86.6%) individuals stated that they knew of the virus and 2,233 (70%) were willing to be vaccinated against HZ. The majority of people willing to be vaccinated were in the middle and older age groups (36.6% and 44.7%, respectively).

CONCLUSION

Compliance versus vaccination results were satisfactory and probably, with the upcoming availability of the HZ vaccine in Italy, adults will be favourably disposed towards vaccination.

Coalition of advocates to vaccinate of Western European citizens aged 60 years and older

The high burden of infectious diseases in adults aged 60 years and older is disproportionate, considering that many of these diseases are vaccine-preventable. Based on careful analysis of the reasons for vaccination barriers/failures in the European population, the two European geriatric and gerontological societies (the European Union Geriatric Medicine Society [EUGMS] and the International Association of Gerontology and Geriatrics - European Region [IAGG-ER]) propose careful adaptation of current vaccine guidelines to promote preventive aspects, concerning both life threatening-diseases (influenza, pneumococcal pneumonia and tetanus/diphtheria) and diseases which adversely impact patients' quality of life (pertussis and herpes zoster). This consensus statement is designed to support official recommendations and improve the willingness to vaccinate the most rapidly growing segment of the population. The following guidelines are based on the importance of the sustainability of vaccine programs from midlife till extreme old age: - Promote healthy aging by optimizing health determinants of daily functions, active participation in society and individual quality of life; - Provide useful information to contribute toward harmonizing vaccine strategies at European level; - Support the public health, social and economic values of vaccination. Both healthcare professionals and consumers associations have a critical role to play in the implementation of such consensus clinical guidelines.

Identifying factors that affect patients' willingness to pay for inhaled insulin

Predictors of patients' willingness to pay for inhaled insulin are unknown. This study found patients with higher annual household income and those who were dissatisfied with their current insulin therapy were willing to pay for inhaled products.

BACKGROUND

Not all diabetes patients are receptive to taking injectable insulin and may therefore be noncompliant. Inhaled insulin has been shown to be as efficacious as subcutaneous insulin, but determinants of patients' willingness to pay (WTP) for inhaled insulin are unknown.

OBJECTIVES

The objective of this study was to determine the relationship between various patient characteristics and patient satisfaction variables with WTP for inhaled insulin.

METHODS

Exploratory cross-sectional study using a random sample of patients with diabetes from a national database. Data were collected using a mailed survey focusing on patient satisfaction with current insulin therapy, WTP, and general patient information. Any WTP (categorical) and the amount (continuous) patients were willing to pay were the 2 dependent variables in the study. Data were analyzed using SPSS v.15.0. Descriptive statistics as well as linear and logistic regression analyses were conducted.

RESULTS

One hundred twenty-eight patients responded. The logistic regression analysis indicated that annual household income (P=.038) and patient satisfaction (P=.002) predict WTP. Additionally, the current cost of insulin therapy (P=.009) and annual household income (P=.049) were found to predict the amount patients were willing to pay. On average, patients were willing to pay $55.49 out of pocket for inhaled insulin per month.

CONCLUSIONS

The out-of-pocket cost that patients were willing to pay was the same as the amount patients pay presently for their insulin and syringes. Although Exubera is no longer on the market, the study findings can have an impact on pharmaceutical companies working on new inhaled insulin products in their efforts to care for patients with diabetes.

Incremental 1-year medical resource utilization and costs for patients with herpes zoster from a set of US health plans

BACKGROUND

Nearly 1 million new episodes of herpes zoster (HZ) occur annually in the US, yet little is known about the medical resource utilization (RU) and costs associated with HZ and its complications.

OBJECTIVES

To describe the medical RU and cost burden of HZ in the first 90 days and the first year after diagnosis from the health insurer perspective and to stratify this burden for patients diagnosed with post-herpetic neuralgia (PHN) and those who are immunocompromised. In addition, this study explores costs from the societal perspective as a result of work loss in the first year after diagnosis.

METHODS

The medical RU and cost data were obtained from the MarketScan Research Database for the years 1998-2003. This database contains inpatient, outpatient and prescription drug data for approximately 14 million individuals of all ages, covered under a variety of fee-for-service and capitated provider reimbursement arrangements, including those with Medicare and private insurance. The work loss estimates were based on the MarketScan Health and Productivity Management Database. Claims for services incurred between 1 January 1998 and 31 December 2003 were screened to identify a cohort of HZ patients based on the presence of at least one International Classification of Diseases, 9th Revision (ICD-9) diagnosis code 053.xx. Each patient was assigned an index date based on the earliest observed occurrence of an HZ diagnosis. A cohort of PHN patients was identified as a subset of the HZ cohort with ICD-9 codes 053.12, 053.13, 053.19 or 729.2x in the period of 90 days to 12 months after the index date. Multivariable regression was used to compare HZ cases with matched controls after adjusting for demographic characteristics, insurance status, co-morbidities and medical expenditure in the 6 months prior to diagnosis for each of the endpoints. Separate regression models were developed, in which age and immune status were stratified. All costs were adjusted to March 2008 values using the medical care component of the Consumer Price Index. The average per patient cost of all HZ cases was $US605 in the first 90 days after diagnosis and $US1052 at 1 year. For the subset with PHN, the average per patient cost of HZ at 1 year was $US3815. For the subset with an immunocompromising condition, the average HZ cost at 1 year was $US1745. The majority of the costs were the result of outpatient visits and prescription drugs. The subset of HZ cases that had both absence hour and short-term disability (STD) records available had 26.5 absence hours and 2.9 STD days. Healthcare utilization, medical care costs and work loss all increased with age for all HZ cases. Based on the results from the present study, the direct medical cost burden of HZ in the US is high, exceeding $US1000 per HZ patient. This direct medical cost may be nearly twice as high in immunocompromised patients and four times as high in the subset of HZ cases with PHN. The direct medical cost burden of HZ may exceed $US1 billion annually in the US. The majority of medical RU and cost burden is incurred by the elderly. Although many people with HZ may no longer be in the workforce, HZ does contribute to lost work time.

Willingness to pay for a QALY based on community member and patient preferences for temporary health states associated with herpes zoster

BACKGROUND AND OBJECTIVES

A clear sense of what society is willing to pay for a QALY could enhance the usefulness of cost-effectiveness analysis as a field. Scant information exists on willingness to pay (WTP) for a QALY based on direct elicitation of preferences from community members or patients. We had the opportunity to evaluate WTP per QALY using data from a survey on temporary health outcomes related to herpes zoster. Our aims were to (i) describe how much community members are willing to pay to save a QALY based on scenarios describing temporary health states; (ii) evaluate how WTP per QALY varies based on experience with the disease being described and with demographic variables; and (iii) evaluate how the duration and intensity of pain in a scenario influences WTP per QALY.

METHODS

Community members drawn from a nationally representative survey research panel (n = 478) completed an Internet-based survey using time trade-off (TTO) and WTP questions to value a series of scenarios that described herpes zoster cases of varying pain intensity (on a scale of 0-10) and duration (30 days to 1 year). Patients with shingles (n = 354) or postherpetic neuralgia (PHN; n = 120) [defined as having symptoms for 90 days or more] from two large healthcare systems completed telephone interviews with similar questions. Mean and median WTP per QALY values were calculated by dividing the WTP amount by the discounted time traded for each scenario. Responses with a WTP value of more than zero and a TTO value of zero (which would have resulted in an undefined value) were excluded. TTO values were discounted by 3% per year. WTP per QALY means were calculated after trimming the top and bottom 2.5% of responses. Multivariate analyses were conducted using generalized linear mixed models that assumed a negative binomial distribution.

RESULTS

Among all respondents, the WTP per QALY ranged from a median of $US7000 to $US11,000 and a trimmed mean of $US26 000 to $US45,000 (year 2005 values), depending on the scenario described. WTP per QALY values varied significantly with respondent characteristics, as well as among respondents with similar characteristics. In multivariate analyses, the mean WTP per QALY was higher among respondents who were younger, male or had higher educational or income levels. After adjusting for these demographic variables, patients who had experienced shingles gave responses with the highest WTP per QALY values. Patients who had experienced PHN gave the lowest values, and community members gave values intermediate to the shingles and PHN groups. In multivariate models that evaluated the effects of pain and duration of the hypothetical zoster scenario, lower duration was associated with higher WTP per QALY. This effect appeared to be due to people increasing the amounts of time they would be willing to trade as duration increased, without proportional increases in the amounts of money they would be willing to pay.

CONCLUSIONS

Community members and patients gave mean WTP per QALY values that varied significantly based on age, sex, socioeconomic status, experience with shingles and duration of the health state evaluated. The variability in WTP per QALY suggests that it may be difficult to define a unitary threshold of dollars per QALY for policy making based on cost-effectiveness analyses.

Methods for measuring temporary health States for cost-utility analyses

A variety of methods are available to measure preferences for temporary health states for cost-utility analyses. The objectives of this review were to summarize the available temporary health-state valuation methods, identify advantages and disadvantages of each, and identify areas for future research. We describe the key aspects of each method and summarize advantages and disadvantages of each method in terms of consistency with QALY theory, relevance to temporary health-state-specific domains, ease of use, time preference, and performance in validation studies. Two broad categories of methods were identified: traditional and adapted. Traditional methods were health status instruments, time trade-off (TTO), and the standard gamble (SG). Methods adapted specifically for temporary health-state valuation were TTO with specified duration of the health state, TTO with a lifespan modification, waiting trade-off, chained approaches for TTO and SG, and sleep trade-off. Advantages and disadvantages vary by method and no 'gold standard' method emerged. Selection of a method to value temporary health states will depend on the relative importance of the following considerations: ability to accurately capture the unique characteristics of the temporary health state, level of respondent burden and cognition, theoretical consistency of elicited preference values with the overall purpose of the study, and resources available for study development and data collection. Further research should focus on evaluating validity, reliability and feasibility of temporary health-state valuation methods.