Healthcare rationing by proxy: cost-effectiveness analysis and the misuse of the $50,000 threshold in the US

Use of Machine Perfusion to Increase the Number of Expanded Criteria Deceased Donor Kidney Transplants: A Pharmacoeconomic Analysis

Background

The discard of expanded criteria donor (ECD) kidneys is unacceptably high, considering the growing demand for transplantation. Using machine perfusion may reduce the discard rate, increase the number of transplants, and reduce mortality on the waiting list.

Methods

We developed a 5-y Markov model to simulate incorporating the pulsatile perfusion machine into the current government-funded healthcare system. The model compared the universal use of static cold storage for all kidneys with the selective use of machine perfusion for ECD kidneys. Real-life data were used to compose the cohort characteristics in this model. This pharmacoeconomic analysis aimed to determine the cost-effectiveness and budgetary impact of using machine perfusion to preserve ECD kidneys.

Results

Compared with the universal use of static cold storage, the use of machine perfusion for ECD kidneys was associated with an increase in the number of kidney transplants (n = 1123), a decrease in the number of patients on the waiting list (n = 815), and decrease in mortality (n = 120), with a cost difference of US dollar 4 486  009 in the period. The budget impact analysis revealed an additional cost of US dollar 4 453 749 >5 y. The budget impact analysis demonstrated a progressive reduction in costs, becoming cost-saving during the last year of the analysis.

Conclusions

This stochastic model showed that incorporating machine perfusion for ECD kidneys is most often a dominant or cost-effective technology associated with an increase in the number of transplants and a reduction in the number of patients on the waiting list, reducing mortality on the waiting list.

Research trends in contemporary health economics: a scientometric analysis on collective content of specialty journals

INTRODUCTION

Health economics is a thriving sub-discipline of economics. Applied health economics research is considered essential in the health care sector and is used extensively by public policy makers. For scholars, it is important to understand the history and status of health economics-when it emerged, the rate of research output, trending topics, and its temporal evolution-to ensure clarity and direction when formulating research questions.

METHODS

Nearly 13,000 articles were analysed, which were found in the collective publications of the ten most specialised health economic journals. We explored this literature using patterns of term co-occurrence and document co-citation.

RESULTS

The research output in this field is growing exponentially. Five main research divisions were identified: (i) macroeconomic evaluation, (ii) microeconomic evaluation, (iii) measurement and valuation of outcomes, (iv) monitoring mechanisms (evaluation), and (v) guidance and appraisal. Document co-citation analysis revealed eighteen major research streams and identified variation in the magnitude of activities in each of the streams. A recent emergence of research activities in health economics was seen in the Medicaid Expansion stream. Established research streams that continue to show high levels of activity include Child Health, Health-related Quality of Life (HRQoL) and Cost-effectiveness. Conversely, Patient Preference, Health Care Expenditure and Economic Evaluation are now past their peak of activity in specialised health economic journals. Analysis also identified several streams that emerged in the past but are no longer active.

CONCLUSIONS

Health economics is a growing field, yet there is minimal evidence of creation of new research trends. Over the past 10 years, the average rate of annual increase in internationally collaborated publications is almost double that of domestic collaborations (8.4% vs 4.9%), but most of the top scholarly collaborations remain between six countries only.

Willingness to pay for cancer prevention versus treatment in China: implications for cost-effectiveness threshold

BACKGROUND

Empirical support for the appropriate cost-effectiveness threshold (CET) in China remains sparse.

OBJECTIVE

This study aimed to estimate the willingness to pay (WTP) for cancer prevention and treatment from the perspective of healthcare policy-makers (i.e. supply side) and to investigate whether there is a difference between the estimated WTP in two scenarios.

METHODS

We conducted a web-based survey from May to July 2022 among experts who offering consultation to the government. We surveyed 79 experts from a national think-tank (84.81% response rate) using contingent valuation method, a method for estimating the monetary value that individuals place on a non-market service.

RESULTS

The mean WTP for two scenarios were estimated at 1.29 times of per capita Gross Domestic Product (GDP) of China and 1.90 times of per capita GDP, respectively. There was a difference between the WTP in the two scenarios and the WTP for treatment was significantly higher than prevention.

CONCLUSION

The findings suggest that though there is a smaller gap between the two scenarios in China as compared to other countries, the WTP may vary under different scenarios. So there's a need to further refine the development of CET by adding parameters like prevention instead of defining one universal threshold.

Economic evaluation of serplulimab plus chemotherapy as the first-line treatment of oesophageal squamous cell carcinoma in China

OBJECTIVE

The ASTRUM-007 study confirmed the significant efficacy and safety of serplulimab plus chemotherapy for patients with locally advanced/metastatic, programmed cell death-ligand 1 positive oesophageal squamous cell carcinoma (OSCC). The economics of this regimen, however, is unclear. Therefore, this study aimed to evaluate the cost-effectiveness of adding serplulimab to chemotherapy for the treatment of advanced OSCC from the perspective of the Chinese healthcare system.

DESIGN

A partitioned survival model was established to simulate the costs and outcomes of chemotherapy versus serplulimab plus chemotherapy. The survival data came from the ASTRUM-007 study. Only direct medical costs were considered, and utility values were referred to the literature. Sensitivity analysis was performed to assess the effect of parameter uncertainty on the model.

OUTCOME MEASURES

Total costs, incremental costs, life years, quality-adjusted life years (QALYs), incremental QALYs and incremental cost-effectiveness ratio (ICER).

RESULTS

The base case analysis showed that the cost of serplulimab plus chemotherapy (US$69 356) was US$41 607 higher than that of chemotherapy (US$27 749), but it also gained 0.38 QALYs more (1.38 vs 1 QALYs), with an ICER of US$110 744.36/QALY, which was higher than the willingness to pay. The factors that most influenced the ICER were the price of serplulimab, weight and utility value of the progression-free survival stage. The subgroup analysis and scenario analysis also demonstrated that serplulimab plus chemotherapy was not economical.

CONCLUSIONS

Compared with chemotherapy, serplulimab coupled with chemotherapy was not cost-effective for the treatment of advanced OSCC in China.

Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking.

OBJECTIVE

To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up.

METHODS

A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility.

CONCLUSION

Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.

The social value of health: Amenable deaths and estimated the gap with the life expectancy frontier

We estimate the life expectancy gaps that can be bridged by improving the quality of public health and health care policies at the country level. Our model calculates the net effect of amenable deaths on life expectancy after controlling for time effects and factors affecting amenable deaths related to education, health policies (health expenditure to GDP and waiting lists), and per capita income in a two equation system. We further estimate the life expectancy gap that countries with lower quality health systems can bridge by catching up and reaching the existing health quality frontier and compute the social value of that upside potential.

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up.

SUMMARY OF BACKGROUND DATA

Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness.

MATERIALS AND METHODS

A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility.

CONCLUSION

Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

Cost-effectiveness of vibegron for the treatment of overactive bladder in the United States

AIMS

To evaluate the cost-effectiveness of vibegron compared with other oral pharmacologic therapies as treatment for overactive bladder (OAB).

METHODS

A semi-Markov model with monthly cycles was developed to support a lifetime horizon of vibegron 75 mg from a US commercial payor or Medicare perspective. The model incorporated efficacy (reductions in daily micturitions and urinary incontinence episodes), adverse events, OAB-related comorbidities, drug-drug interactions, anticholinergic burden, and treatment persistence. Direct costs and quality-adjusted life years (QALY) were accumulated over time. The primary outcome was the cost per QALY incremental cost-effectiveness ratio (ICER). One-way (OWSA) and probabilistic sensitivity analyses (PSA) were performed.

RESULTS

For commercial payors, vibegron was cost-effective at a willingness-to-pay (WTP) threshold of $50,000/QALY versus mirabegron 50 mg (ICER, $9,311) and at a WTP threshold of $150,000/QALY versus mirabegron 25 mg (ICER, $141,957) and versus an anticholinergic basket based on market share (ICER, $118,121). For Medicare, vibegron was cost-effective at a WTP threshold of $50,000/QALY versus mirabegron 50 mg (ICER, $12,154) and at a WTP threshold of $100,000/QALY versus mirabegron 25 mg (ICER, $99,150) and versus an anticholinergic market basket (ICER, $60,756). For commercial payors and Medicare, OWSAs for vibegron versus mirabegron indicated cost-effectiveness was most sensitive to vibegron persistence at 1 and 12 months. PSAs indicated that vibegron was cost-effective versus mirabegron 50 mg 98.6% and 100% of the time at $50,000/QALY for commercial payors and Medicare payors, respectively.

LIMITATIONS

Due to lack of real-world data available on persistence, vibegron was assumed to have the same persistence as mirabegron 50 mg. Long-term efficacy was assumed to be sustained beyond 52 weeks in the absence of clinical trials longer than 52 weeks.

CONCLUSIONS

Vibegron is cost-effective from a commercial payor (WTP threshold $150,000/QALY) and Medicare (WTP threshold $100,000/QALY) perspective when compared with other oral pharmacologic treatments for OAB.

Economic evaluation of regular transfusions for cerebral infarct recurrence in the Silent Cerebral Infarct Transfusion Trial

Children with preexisting silent cerebral infarcts on regular transfusion therapy had 50% lower hospitalization costs than standard care.

The incremental cost-effectiveness ratio for transfusion therapy to prevent infarct recurrence was $22 025 for every infarct prevented.

In 2020, the American Society of Hematology published evidence-based guidelines for cerebrovascular disease in individuals with sickle cell anemia (SCA). Although the guidelines were based on National Institutes of Health–sponsored randomized controlled trials, no cost-effectiveness analysis was completed for children with SCA and silent cerebral infarcts. We conducted a cost-effectiveness analysis comparing regular blood transfusion vs standard care using SIT (Silent Cerebral Infarct Transfusion) Trial participants. This analysis included a modified societal perspective with direct costs (hospitalization, emergency department visit, transfusion, outpatient care, and iron chelation) and indirect costs (special education). Direct medical costs were estimated from hospitalizations from SIT hospitals and unlinked aggregated hospital and outpatient costs from SIT sites by using the Pediatric Health Information System. Indirect costs were estimated from published literature. Effectiveness was prevention of infarct recurrence. An incremental cost-effectiveness ratio using a 3-year time horizon (mean SIT Trial participant follow-up) compared transfusion vs standard care. A total of 196 participants received transfusions (n = 90) or standard care (n = 106), with a mean age of 10.0 years. Annual hospitalization costs were reduced by 54% for transfusions vs standard care ($4929 vs $10 802), but transfusion group outpatient costs added $22 454 to $137 022 per year. Special education cost savings were $2634 over 3 years for every infarct prevented. Transfusion therapy had an incremental cost-effectiveness ratio of $22 025 per infarct prevented. Children with preexisting silent cerebral infarcts receiving blood transfusions had lower hospitalization costs but higher outpatient costs, primarily associated with the oral iron chelator deferasirox. Regular blood transfusion therapy is cost-effective for infarct recurrence in children with SCA. This trial is registered at www.clinicaltrials.gov as #NCT00072761.

Is the Choice of Cost-Effectiveness Threshold in Cost-Utility Analysis Endogenous to the Resulting Value of Technology? A Systematic Review

BACKGROUND

Cost-utility analysis (CUA) is widely used for health technology assessment; however, concerns exist that cost-utility analysts may suggest higher cost-effectiveness thresholds (CETs) to compensate for technologies of relatively lower value.

OBJECTIVE

We explored whether selection of a CUA study's CET was endogenous to estimated incremental cost-effectiveness ratios (ICERs).

METHODS

We systematically reviewed the US cost-effectiveness literature between 2000 and 2017 where studies with explicit CET and ICERs were included. We classified the ratio of studies hypothesized to analyze cost-effective technologies at low CETs (i.e., less than $100,000/quality-adjusted life-year [QALY]) vs higher CETs (i.e., $100,000-$150,000/QALY) relative to their ICER, using a Chi square test to examine whether technologies that were cost effective at high CETs would still be cost effective at lower thresholds. We also performed fixed-effects linear regression exploring the associations between ICERs and reported CETs over time.

RESULTS

Among 317 ICERs reviewed: (A) 185 had an ICER < $50,000/QALY; (B) 53 had $50,000 ≤ ICER, < $100,000; (C) 20 had $100,000 ≤ ICER < $150,000; and (D) 59 had an ICER ≥ $150,000. Chi square testing showed a strong association (p < 0.001) between estimated ICER values and chosen CET, illustrating a lack of independence between the two. The regression analysis indicated that CETs have a baseline value of $52,000 and grow by $0.37 for each dollar increase in the estimated ICER.

CONCLUSIONS

Cost-effectiveness thresholds represent the hypothesis tests of typical CUAs. Our analysis highlights that most CUAs that cite high CETs also result in greater ICERs for the novel interventions that they investigate; thus, these interventions would otherwise not have been cost effective at lower CETs. Selection of a CET may come after the ICER is calculated to infer value that suits a hypothesis.

Wide Area Transepithelial Sampling with Computer-Assisted Analysis (WATS3D) Is Cost-Effective in Barrett's Esophagus Screening

BACKGROUND

Wide area transepithelial sampling with three-dimensional computer-assisted analysis (WATS^3D) is an adjunct to the standard random 4-quadrant forceps biopsies (FB, "Seattle protocol") that significantly increases the detection of Barrett's esophagus (BE) and associated neoplasia in patients undergoing screening or surveillance.

AIMS

To examine the cost-effectiveness of adding WATS^3D to the Seattle protocol in screening patients for BE.

METHODS

A decision analytic model was used to compare the effectiveness and cost-effectiveness of two alternative BE screening strategies in chronic gastroesophageal reflux disease patients: FB with and without WATS^3D. The reference case was a 60-year-old white male with gastroesophageal reflux disease (GERD). Effectiveness was measured by the number needed to screen to avert one cancer and one cancer-related death, and quality-adjusted life years (QALYs). Cost was measured in 2019 US$, and the incremental cost-effectiveness ratio (ICER) was measured in $/QALY using thresholds for cost-effectiveness of $100,000/QALY and $150,000/QALY. Cost was measured in 2019 US$. Cost and QALYs were discounted at 3% per year.

RESULTS

Between 320 and 337 people would need to be screened with WATS^3D in addition to FB to avert one additional cancer, and 328-367 people to avert one cancer-related death. Screening with WATS^3D costs an additional $1219 and produced an additional 0.017 QALYs, for an ICER of $71,395/QALY. All one-way sensitivity analyses resulted in ICERs under $84,000/QALY.

CONCLUSIONS

Screening for BE in 60-year-old white male GERD patients is more cost-effective when WATS^3D is used adjunctively to the Seattle protocol than with the Seattle protocol alone.

Nutrition Therapy Cost‐Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health Systems

Background

Method

Results

Conclusion

Empirical Monetary Valuation of a Quality-Adjusted Life-Year in the Kingdom of Saudi Arabia: A Willingness-to-Pay Analysis

BACKGROUND

No willingness-to-pay (WTP) per quality-adjusted life-year (QALY) value exists for the Kingdom of Saudi Arabia (KSA).

OBJECTIVE

The primary objective of this study was to determine the WTP for a QALY in the KSA.

METHODS

Adult citizens of the KSA, patients with cancer, or members of the general public (MGP) were recruited to participate in a time trade-off survey to elicit health utilities. Cancer was chosen as the disease of interest for patients and the MGP, with a scenario describing stage 3 colorectal cancer, because it is a disease condition that impacts on both quality of life and survival time. In a second step, respondents were asked about their WTP to move from the estimated health state to a state of perfect health for 1 year (QALY). Finally, that amount was processed to generate the WTP for a full QALY. The second step was repeated with a 5-year horizon. Sensitivity analyses were performed without outliers.

RESULTS

From 400 participants, data from 378 subjects were obtained and usable: 177 patients, 201 MGP; 278 male, 100 female subjects; 231 aged 26-65 years. Demographic distribution varied widely between the two subgroups for age, education level, and employment status, but with less variation in sex and income. Elicited health utilities were 0.413 (0.472 after adjustment) for the overall group, 0.316 (0.416) for patients, and 0.499 (0.508) for MGP. Overall WTP for a QALY was $US25,600 (adjusted $US32,000) for the 1-year horizon and $US19,200 (adjusted $US22,720) for the 5-year horizon.

CONCLUSION

This was the first empirical attempt to estimate the WTP per QALY for the KSA. Results are comparable to those in some other countries and to gross domestic product figures for the KSA. Further research in a country-wide sample is warranted.

Cost-effectiveness of surgery for drug-resistant temporal lobe epilepsy in the US

OBJECTIVE

Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general.

METHODS

We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective.

RESULTS

Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving ($328,000 vs $423,000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon.

CONCLUSION

For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds.

Immunogenicity and safety of a quadrivalent inactivated influenza vaccine in healthy subjects aged 3 to 17 years old: A phase III, open label, single-arm study

BACKGROUND

Quadrivalent influenza vaccines are particularly valuable during seasons in which a mismatch occurs between the predicted influenza B lineage for the trivalent influenza vaccine and the circulating strain. This study evaluated the immunogenicity and safety of a quadrivalent inactivated influenza vaccine AdimFlu-S manufactured in Taiwan for the 2016-2017 influenza season in healthy children.

METHODS

A total of 174 healthy children aged 3 to 17 years old were separated into 3 groups (Group A: 3-8 years old, vaccine naïve; Group B: 3-8 years old, vaccine non-naïve; Group C: 9-17 years old, any vaccine status). Sera was collected pre and post vaccination for each participant. A hemagglutination inhibition (HAI) assay was utilized to calculate geometric mean titer (GMT), seroprotection rate, and seroconversion rate.

RESULTS

All enrolled participants completed the study. For the four vaccine strains four weeks after the last vaccination, geometric mean titer ratios (GMTRs) were between 2.9 and 20.9, seroconversion rates were between 42.9% and 90.9%, and seroprotection rates were all above 96.4%. This achieved all immunogenicity endpoints and fulfilled the criteria of the European Medical Agency's Committee for Medicinal Products for Human Use (CHMP). No serious adverse events (AEs) were reported during the follow-up period of 6 months.

CONCLUSION

This quadrivalent influenza vaccine is demonstrated to be well tolerated and displays robust immunogenicity for each influenza strain. This could potentially improve protection against the antigenically distinct B/Yamagata and B/Victoria lineages.

Value in Hepatitis C Virus Treatment: A Patient-Centered Cost-Effectiveness Analysis

BACKGROUND

Innovations in hepatitis C virus (HCV) therapy included in traditional comparative evaluations focus on sustained virologic response (SVR) without addressing challenges patients report beyond virologic cure. This study aims to evaluate the cost-effectiveness of HCV drug therapy with a patient-centered approach.

METHODS

An individual-based Markov model was constructed using guidance from a stakeholder advisory board (SAB), a patient Delphi panel, and published literature to evaluate direct-acting antivirals (DAAs) compared to no treatment. The United States (US) health sector and societal perspectives were considered for 10- and 20-year time horizons. Inputs for treatment costs and effectiveness reflect a generic regimen. Indirect costs used for the societal model included estimates from self-reported productivity in a matched-control sample. Beyond the traditional quality-adjusted life-year (QALY) health outcome, this study included two novel measures developed from the Delphi panel and SAB: infected life-years and workdays missed. All costs were measured in 2018 US dollars.

RESULTS

Health sector costs and QALYs were higher in the treatment group in both 10- and 20-year models. Total infected life-years and workdays missed were reduced in the treatment group for both models. When costs of absenteeism, presenteeism, and patient/caregiver time were included, the DAA intervention was cost-saving at both 10 and 20 years. Health sector results were sensitive to drug costs and utility estimates for post-SVR health states. Societal results were sensitive to presenteeism estimates and drug costs.

CONCLUSION

Treatment was cost-effective from a health sector perspective and cost-saving when including non-health costs such as patient/caregiver time and productivity.

Cost Effectiveness of Interval Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy in Stage III Ovarian Cancer on the Basis of a Randomized Phase III Trial

PURPOSE

In the randomized open-label phase III OVHIPEC trial, the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improved recurrence-free and overall survival in patients with stage III ovarian cancer. We studied the cost effectiveness of the addition of HIPEC to interval CRS in patients with ovarian cancer.

PATIENTS AND METHODS

We constructed a Markov health-state transition model to measure costs and clinical outcomes. Transition probabilities were derived from the OVHIPEC trial by fitting survival distributions. Incremental cost-effectiveness ratio (ICER), expressed as euros per quality-adjusted life-year (QALY), was calculated from a Dutch societal perspective, with a time horizon of 10 years. Univariable and probabilistic sensitivity analyses were conducted to evaluate the decision uncertainty.

RESULTS

Total health care costs were €70,046 (95% credibility interval [CrI], €64,016 to €76,661) for interval CRS compared with €85,791 (95% CrI, €78,766 to €93,935) for interval CRS plus HIPEC. The mean QALY in the interval CRS group was 2.12 (95% CrI, 1.66 to 2.64 QALYs) and 2.68 (95% CrI, 2.11 to 3.28 QALYs) in the interval CRS plus HIPEC group. The ICER amounted to €28,299/QALY. In univariable sensitivity analysis, the utility of recurrence-free survival and the number of days in the hospital affected the calculated ICER most.

CONCLUSION

On the basis of the trial data, treatment with interval CRS and HIPEC in patients with stage III ovarian cancer was accompanied by a substantial gain in QALYs. The ICER is below the willingness-to-pay threshold in the Netherlands, indicating interval CRS and HIPEC is cost effective for this patient population. These results lend additional support for reimbursing the costs of treating these patients with interval CRS and HIPEC in countries with comparable health care systems.

Cost Effectiveness of Achieving Targets of Low-Density Lipoprotein Particle Number Versus Low-Density Lipoprotein Cholesterol Level

A recent analysis of a commercially insured US population found fewer cardiovascular disease (CVD) events in high-risk patients attaining low levels of low-density lipoprotein (LDL), as measured by LDL particle number (LDL-P) versus low LDL cholesterol (LDL-C). Here, we investigated the cost effectiveness of LDL-lowering therapy guided by LDL-P. Patients were selected from the HealthCore Integrated Research Database and followed for 12 to 36 months. Patients who achieved LDL-P <1,000 nmol/l were placed into the LDL-P cohort, whereas those without LDL-P tests, but who achieved LDL-C <100 mg/dl, were placed into the LDL-C cohort. CVD-related costs included all health plan paid amounts related to CVD events or lipid management. Cost effectiveness was assessed through incremental cost-effectiveness ratios, defined as difference in total costs across the cohorts divided by difference in CVD events, measured over follow-up. Each cohort included 2,094, 1,242, and 705 patients over 12-, 24-, and 36-month follow-up. Patients in the LDL-P cohort received more aggressive lipid-lowering therapy and had fewer CVD events during follow-up compared to patients in the LDL-C cohort. This led to greater pharmacy costs and lower medical costs over time. Incremental cost-effectiveness ratio estimates ranged from $23,131 per CVD event avoided at 12 months to $3,439 and -$4,555 at 24- and 36-month follow-up, suggesting a high likelihood that achieving LDL-P <1,000 nmol/l is cost effective. In conclusion, LDL-lowering therapy guided by LDL-P was demonstrated to be cost effective, with greater clinical and economic benefit seen over longer time horizons and with the increased use of generic statins.

Performance Ratio Based Resource Allocation Decision-Making in Genomic Medicine

In modern healthcare systems, the available resources may influence the morbidity, mortality, and-consequently-the level of healthcare provided in every country. This is of particular interest in developing countries where the resources are limited and must be spent wisely to address social justice and the right for equal access in healthcare services by all the citizens in economically viable terms. In this light, the current allocation is, in practice, inefficient and rests mostly on each country's individual political and historical context and, thus, does not always incorporate decision-making enabled by economic models. In this study, we present a new economic model, specifically for resource allocation for genomic medicine, based on performance ratio, with potential applications in diverse healthcare sectors, which are particularly appealing for developing countries and low-resource environments. The model proposes a new method for resource allocation taking into account (1) the size of innovation of a new technology, (2) the relative effectiveness in comparison with social preferences, and (3) the cost of the technology, which permits the measurement of effectiveness to be determined differently in the context of a specific disease and then to be expressed in a relative form using a common performance ratio. The present work expands on previous work for innovation in economic models pertaining to genomic medicine and supports translational science.

The Impact of Recent Generic Drug Price Policies on Pharmaceutical Innovation: A Theoretical Rationale and Proposal of a Method Supporting Innovation in Areas of Unmet Medical Need

New discoveries are a critical priority for the pharmaceutical industry. However, the use of fixed incremental cost-effectiveness (ICER) thresholds for health technology assessment (HTA) may compromise incentives to innovate and affect future treatment options. This paper highlights the impact of generic drug price policies on pharmaceutical innovation in the context of fixed ICER thresholds and proposes a new consideration for the cost-effectiveness analysis (CEA). There is a direct causal relationship between HTA and the market price of a drug; in jurisdictions where HTA agencies apply fixed ICER thresholds as an important reimbursement listing criterion, the incremental cost of a new drug is expected to be proportional to its incremental benefit over the comparator. However, the comparator price is subject to market forces or sudden policies and may change markedly affecting the cost-effectiveness assessment (e.g. where the comparator patent has expired). Since recent generic price regulations increased the price gap between drugs' generic and patented versions, it is harder to achieve a sufficient level of incremental benefits in order to offset incremental prices of new treatments. Consequently, even promising drugs may have challenges to show attractive ICERs and research and development (R&D) investments may become unattractive in certain disease area. In order to promote innovation in therapeutic fields with unmet medical needs, a compromise would be to include the comparator's patented price in the CEA instead of the generic drug. By identifying the relevant disease areas, decision makers and HTA authorities could therefore convey the importance of investing in these therapeutic areas to manufacturers.

Cost-effectiveness analysis of quadrivalent versus trivalent influenza vaccine in Taiwan: A lifetime multi-cohort model

A government-funded trivalent influenza vaccine (TIV) program to prevent seasonal influenza was implemented in Taiwan since 1998. However, mismatch between the vaccine and circulating strains may occur. Alternatively, a quadrivalent influenza vaccine (QIV) includes all 4 influenza lineages could minimize the risk of mismatches. Therefore, QIV could be considered as an alternative strategy to enhance protection against seasonal influenza. The objective of the study was to analyze, from a governmental perspective, the cost-effectiveness of using QIV vs. TIV as a vaccination strategy in Taiwan. A lifetime multi-cohort, static Markov model was constructed with 9 age groups to assess the costs and effectiveness of QIV vs. TIV. Direct costs were obtained from a database released by the Ministry of Health and Welfare. Outcomes included life-years gained, quality-adjusted life years (QALYs) gained, influenza cases avoided and incremental cost-effectiveness ratios (ICERs). The discount rate of costs and effectiveness was set at 3.5% and the time horizon used in the model was 100 y. Results show that a vaccination strategy utilizing QIV instead of TIV would bring an additional 10,557 QALYs at an extra cost of US$39.4 million, yielding an ICER of US$3,015.07 per QALY gained. When setting the willingness-to-pay threshold at US$10,000, compared to TIV, the probability that QIV would be cost-effective was 98%. Sensitivity analyses show that ICER was sensitive to the changes of circulation of influenza virus subtypes and vaccine mismatch. From a governmental perspective, the QIV vaccination could be considered as a cost-effective strategy within the context of public health in Taiwan.

Systematic overview of cost-effectiveness thresholds in ten countries across four continents

AIM

To provide an overview of thresholds for incremental cost-effectiveness ratios (ICERs) representing willingness-to-pay (WTP) across multiple countries and insights into exemptions pertaining to the ICER (e.g., cancer). To compare ICER thresholds to individual country's estimated ability-to-pay.

MATERIALS & METHODS

We included AHRQ/USA, BIQG-GOEG/Austria, CADTH/Canada, DAHTA@DIMDI/Germany, DECIT-CGATS/Brazil, HAS/France, HITAP/Thailand, IQWiG/Germany, LBI-HTA/Austria, MSAC/Australia, NICE/England/Wales and SBU/Sweden. ICER thresholds were derived from systematic literature/website search/expert surveys. WTP was compared with ATP using Spearman's rank correlation.

RESULTS

Two general and explicitly acknowledged thresholds (England/Wales, Thailand), implicit thresholds in six countries and different ICER thresholds/decision-making rules in oncology were identified. Correlation between WTP and ability-to-pay was moderate.

DISCUSSION

Our overview supports country-specific discussions on WTP and on how to define value(s) within societies.

On the Estimation of the Cost-Effectiveness Threshold: Why, What, How?

BACKGROUND

Many health care systems claim to incorporate the cost-effectiveness criterion in their investment decisions. Information on the system's willingness to pay per effectiveness unit, normally measured as quality-adjusted life-years (QALYs), however, is not available in most countries. This is partly because of the controversy that remains around the use of a cost-effectiveness threshold, about what the threshold ought to represent, and about the appropriate methodology to arrive at a threshold value.

OBJECTIVES

The aim of this article was to identify and critically appraise the conceptual perspectives and methodologies used to date to estimate the cost-effectiveness threshold.

METHODS

We provided an in-depth discussion of different conceptual views and undertook a systematic review of empirical analyses. Identified studies were categorized into the two main conceptual perspectives that argue that the threshold should reflect 1) the value that society places on a QALY and 2) the opportunity cost of investment to the system given budget constraints.

RESULTS

These studies showed different underpinning assumptions, strengths, and limitations, which are highlighted and discussed. Furthermore, this review allowed us to compare the cost-effectiveness threshold estimates derived from different types of studies. We found that thresholds based on society's valuation of a QALY are generally larger than thresholds resulting from estimating the opportunity cost to the health care system.

CONCLUSIONS

This implies that some interventions with positive social net benefits, as informed by individuals' preferences, might not be an appropriate use of resources under fixed budget constraints.

Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold

BACKGROUND

Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence.

OBJECTIVES

(1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes.

METHODS

Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs.

RESULTS

The most relevant 'central' threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008-10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional 'structural' uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs.

LIMITATIONS

The central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold.

CONCLUSIONS

The methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more 'known' in social decisions.

FUNDING

The National Institute for Health Research-Medical Research Council Methodology Research Programme.

How much might a society spend on life-saving interventions at different ages while remaining cost-effective? A case study in a country with detailed data

Objective

We aimed to estimate the maximum intervention cost (EMIC) a society could invest in a life-saving intervention at different ages while remaining cost-effective according to a user-specified cost-effectiveness threshold.

Methods

New Zealand (NZ) was used as a case study, and a health system perspective was taken. Data from NZ life tables and morbidity data from a burden of disease study were used to estimate health-adjusted life-years (HALYs) gained by a life-saving intervention. Health system costs were estimated from a national database of all publicly funded health events (hospitalizations, outpatient events, pharmaceuticals, etc.). For illustrative purposes we followed the WHO-CHOICE approach and used a cost-effectiveness threshold of the gross domestic product (GDP) per capita (NZ$45,000 or US$30,000 per HALY). We then calculated EMICs for an “ideal” life-saving intervention that fully returned survivors to the same average morbidity, mortality, and cost trajectories as the rest of their cohort.

Findings

The EMIC of the “ideal” life-saving intervention varied markedly by age: NZ$1.3 million (US$880,000) for an intervention to save the life of a child, NZ$0.8 million (US$540,000) for a 50-year-old, and NZ$0.235 million (US$158,000) for an 80-year-old. These results were predictably very sensitive to the choice of discount rate and to the selected cost-effectiveness threshold. Using WHO data, we produced an online calculator to allow the performance of similar calculations for all other countries.

Conclusions

We present an approach to estimating maximal cost-effective investment in life-saving health interventions, under various assumptions. Our online calculator allows this approach to be applied in other countries. Policymakers could use these estimates as a rapid screening tool to determine if more detailed cost-effectiveness analyses of potential life-saving interventions might be worthwhile or which proposed life-saving interventions are very unlikely to benefit from such additional research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-015-0052-2) contains supplementary material, which is available to authorized users.

Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated.

OBJECTIVE

To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines.

METHODS

We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a "treat all" strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas.

RESULTS

We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.

CONCLUSION

Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.

Bevacizumab in recurrent, persistent, or advanced stage carcinoma of the cervix: is it cost-effective?

OBJECTIVE

Evaluate the cost-effectiveness of incorporating bevacizumab into the treatment regimen for recurrent, persistent, or advanced stage carcinoma of the cervix following publication of a recent phase III trial that demonstrated an overall survival (OS) benefit with the addition of bevacizumab.

METHODS

A cost-effectiveness decision model was constructed using recently published results from a Gynecologic Oncology Group phase III study, comparing a standard chemotherapy regimen (Chemo) to the experimental regimen (Chemo + Bev) consisting of the standard regimen+bevacizumab. Costs and adverse events were incorporated and sensitivity analyses assessed model uncertainties.

RESULTS

The cost of Chemo + Bev was $53,784 compared to $5,688 for the Chemo arm. The 3.7 month OS advantage with Chemo+Bev came at an incremental cost-effectiveness ratio (ICER) of $155K per quality-adjusted life year (QALY). Chemo + Bev becomes cost-effective with an ICER ≤ $100K in sensitivity analysis when the cost of bevacizumab is discounted >37.5% or the dose is reduced from 15 to 7.5 mg/kg, an effective dose in ovarian cancer.

CONCLUSIONS

With an ICER of $155K/QALY, the addition of bevacizumab to standard chemotherapy approaches common cost-effectiveness standards. Moderately discounting the cost of bevacizumab or using a smaller dose significantly alters its affordability.

Cost-effectiveness of surgical treatment for degenerative spondylolisthesis and spinal stenosis

STUDY DESIGN

Systematic review.

OBJECTIVE

To identify cost-effective treatment strategies for lumbar spine degenerative diseases.

SUMMARY OF BACKGROUND DATA

There is a paucity of literature assisting physicians and society regarding the cost-efficiency of management of lumbar spine conditions. Limited articles on selective operative and nonoperative therapies have been published for a variety of lumbar conditions.

METHODS

A systematic search of PubMed, EMBASE, the Cochrane Collaboration data base, University of York, Centre for Reviews and Dissemination (National Health Services Economic Evaluation Database and health technology assessment), and the Tufts CEA Registry was conducted through December 16, 2013. Three specific questions were addressed for adult patients: (1) What is the evidence that surgery is cost-effective compared with nonsurgical management for lumbar degenerative spondylolisthesis or stenosis? (2) What is the evidence that fusion is cost-effective compared with no fusion for degenerative spondylolisthesis or stenosis? and (3) What is the evidence that instrumentation is cost-effective compared with none for degenerative spondylolisthesis? The Quality of Health Economic Studies instrument was used to provide an initial basis for critical appraisal of included economic studies. Articles were further refined with individual review based on inclusion/exclusion criteria.

RESULTS

Initial search resulted in 122 potentially relevant citations, 115 of which were excluded at title and abstract levels and 3 at full-text reviews, leaving 5 for analysis. No non-English language text met inclusion/exclusion criteria. All studies illustrated a clinical benefit of surgical treatment as measured by quality-adjusted life year (0.11-8.05). Surgical treatments had a greater financial cost than nonoperative care ($5883-$26,035). Incremental cost-effectiveness ratio calculations noted operative treatment over nonoperative treatment for spondylolisthesis ($59,487-$115,600) per quality-adjusted life year. However, cost for patients without spondylolisthesis varied greatly from nonoperative treat dominating to $77,600 per quality-adjusted life year favoring surgery. Because the articles had heterogeneous methods and patient population, conclusion differed greatly on cost assessment.

CONCLUSION

Limited quality data exist on cost-effective treatment of degenerative lumbar spinal conditions, despite more recent interest related to this topic. It is important that future research efforts focus on constructing higher quality trials in this area to help determine the most cost-effective care.

LEVEL OF EVIDENCE

3.

Economic analysis of revision amputation and replantation treatment of finger amputation injuries

BACKGROUND

The purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios.

METHODS

The study was conducted from the societal perspective. Decision tree models were created for the reference case (two-finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A Web-based time trade-off survey was created to determine quality-adjusted life-years for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and quality-adjusted life-years for revision amputation and replantation were calculated for each decision tree. An incremental cost-effectiveness ratio was calculated if a treatment was more costly but more effective.

RESULTS

The authors had a 64 percent response rate (n = 437). Replantation treatment had greater costs and quality-adjusted life-years compared with revision amputation in all injury scenarios. Replantation of single-digit injuries had the highest incremental cost-effectiveness ratio ($136,400 per quality-adjusted life-year gained). Replantation of three- and four-digit amputation injuries had relatively low cost-to-benefit ratios ($27,100 and $23,800 per quality-adjusted life-year, respectively). Replantation for distal thumb amputation had a relatively low incremental cost-effectiveness ratio ($26,300 per quality-adjusted life-year) compared with replantation of nonthumb distal amputations ($60,200 per quality-adjusted life-year).

CONCLUSIONS

The relative cost per quality-adjusted life-year gained with replantation treatment varied greatly among the injury scenarios. Situations in which indications for replantation are debated had higher cost per quality-adjusted life-year gained. This study highlights variability in value for replantation among different injury scenarios.

Medical resource use, costs, and quality of life in patients with acute decompensated heart failure: findings from ASCEND-HF

BACKGROUND

The Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) randomly assigned 7,141 participants to nesiritide or placebo. Dyspnea improvement was more often reported in the nesiritide group, but there were no differences in 30-day all-cause mortality or heart failure readmission rates. We compared medical resource use, costs, and health utilities between the treatment groups.

METHODS AND RESULTS

There were no significant differences in inpatient days, procedures, and emergency department visits reported for the first 30 days or for readmissions to day 180. EQ-5D health utilities and visual analog scale ratings were similar at 24 hours, discharge, and 30 days. Billing data and regression models were used to generate inpatient costs. Mean length of stay from randomization to discharge was 8.5 days in the nesiritide group and 8.6 days in the placebo group (P = .33). Cumulative mean costs at 30 days were $16,922 (SD $16,191) for nesiritide and $16,063 (SD $15,572) for placebo (P = .03). At 180 days, cumulative costs were $25,590 (SD $30,344) for nesiritide and $25,339 (SD $29,613) for placebo (P = .58).

CONCLUSIONS

The addition of nesiritide contributed to higher short-term costs and did not significantly influence medical resource use or health utilities compared with standard care alone.

Cost-effectiveness of biological agents used in ulcerative colitis

Ulcerative colitis (UC) produces bloody diarrhoea, severe abdominal pain, and need for clinic visits, hospitalizations, and surgeries. UC results in reduced health-related quality of life for patients and large direct medical and indirect costs for health systems and employers. Patients with the most severe disease require the most medical services, and these patients have larger costs than patients with mild or moderate disease. Despite biological therapies being quite expensive, they are indicated for patients unresponsive to initial standard therapies. Future hospitalizations may be reduced by starting a biological treatment. Cost-effectiveness results vary between countries, health systems, and model designs. Since restorative proctocolectomy can be curative, this surgery dominates biological therapy by being both less costly and more effective when measuring health system costs and patient quality-adjusted life years for 20 years. However the dose, duration, and effectiveness of biological treatments significantly impact estimates of their cost-effectiveness.

A systematic review of economic studies on biological agents used to treat Crohn's disease

BACKGROUND

Identifying clinical scenarios that maximize the cost-effectiveness of biological treatments can lead to optimized health care cost-saving and clinical effectiveness from a society's perspective.

METHODS

Published articles between January 1995 and June 2012 were searched in PubMed, EMBASE, ABI/INFORM, Tuft's Cost-Effectiveness Analysis Registry Database, Cochrane National Health Service Economic Evaluation Database, International Pharmaceutical Abstracts, Web of Science, and Google Scholar. Studies of interest included the following: (1) cost studies, (2) economic evaluations, or (3) narrative or systematic reviews related to economic evaluations of biological treatments for moderate-to-severe Crohn's disease (CD). The primary outcomes of interest included costs associated with biological treatments and cost-effectiveness measures, including incremental cost-effectiveness ratios. A threshold of $100,000/quality-adjusted life year (£60,000/quality-adjusted life year) gained was used for treatment cost-effectiveness.

RESULTS

Thirty-eight studies were identified, including 15 economic evaluations and 23 cost studies or reviews of economic evaluations. Economic evaluations found that infliximab and adalimumab were more cost-effective than standard therapy for luminal CD when provided as an induction therapy followed by episodic therapy over 5 or more years. The cost-effectiveness of infliximab and adalimumab versus standard therapy for luminal CD was less certain when used as 1-year maintenance treatment with or without previous induction therapy. Cost studies revealed that infliximab therapy reduced health care resource utilization and cost. Older reviews were inconclusive about the cost-effectiveness of biological treatments used for CD.

CONCLUSIONS

Current evidence suggests that biological treatments may be cost-effective for CD under certain clinical scenarios. Future studies evaluating all biological treatments are needed to compare their respective benefits and costs.

Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan?

PURPOSE

In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective.

METHODS

A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios.

RESULTS

Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained.

CONCLUSIONS

Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.

Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals

OBJECTIVES/HYPOTHESIS

There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals.

STUDY DESIGN

Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database.

METHODS

There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions.

RESULTS

Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA.

CONCLUSIONS

Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night.

LEVEL OF EVIDENCE

4.

Treatment of ulnar neuropathy at the elbow: cost-utility analysis

PURPOSE

The choice of surgical treatment for ulnar neuropathy at the elbow (UNE) remains controversial. A cost-utility analysis was performed for 4 surgical UNE treatment options. We hypothesized that simple decompression would emerge as the most cost-effective strategy.

METHODS

A cost-utility analysis was performed from the societal perspective. A decision analytic model was designed comparing 4 strategies: (1) simple decompression followed by a salvage surgery (anterior submuscular transposition) for a poor outcome, (2) anterior subcutaneous transposition followed by a salvage surgery for a poor outcome, (3) medial epicondylectomy followed by a salvage surgery for a poor outcome, and (4) anterior submuscular transposition. A poor outcome when anterior submuscular transposition was the initial surgery was considered an end point in the model. Preference values for temporary health states for UNE, the surgical procedures, and the complications were obtained through a time trade-off survey administered to family members and friends who accompanied patients to physician visits. Probabilities of clinical outcomes were derived from a Cochrane Collaboration meta-analysis and a systematic MEDLINE and EMBASE search of the literature. Medical care costs (in 2009 U.S. dollars) were derived from Medicare reimbursement rates. The model estimated quality-adjusted life-years and costs for a 3-year time horizon. A 3% annual discount rate was applied to costs and quality-adjusted life-years. Incremental cost-effectiveness ratios were calculated, and sensitivity analyses performed.

RESULTS

Simple decompression as an initial procedure was the most cost-effective treatment strategy. A multi-way sensitivity analysis varying the preference values for the surgeries and a model structure sensitivity analysis varying the model assumptions did not change the conclusion. Under all evaluated scenarios, simple decompression yielded incremental cost-effectiveness ratios less than US$2,027 per quality-adjusted life-year.

CONCLUSIONS

Simple decompression as an initial treatment option is cost-effective for UNE according to commonly used cost-effectiveness thresholds.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis III.

Economic impact of human papillomavirus-associated head and neck cancers in the United States

Cases of human papillomavirus (HPV)-associated head and neck cancers are rapidly increasing in the United States. Little is known about the economic burden of these cancers. A literature review identified 7 studies that characterized aspects of the overall economic burden of HPV-associated head and neck cancers in the United States. Other cost studies are detailed to highlight the clinical reality in treating these patients. As the clinical awareness of the role of HPV in head and neck cancers continues, the economic impact of cancers caused by this virus will have implications for the role of various preventive measures.

The long-term cost-effectiveness of obesity prevention interventions: systematic literature review

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Decision analysis, economic evaluation, and newborn screening: challenges and opportunities

The number of conditions included in newborn screening panels has increased rapidly in the United States during the past decade, and many more conditions are under consideration for addition to state panels. The rare nature of candidate conditions for newborn screening makes their evaluation challenging. The scarcity of data on the costs of screening, follow-up, treatment, and long-term disability must be addressed to improve the evaluation process for nominated conditions. Decision analyses and economic evaluations can help inform policy decisions for newborn screening programs by providing a systematic approach to synthesizing available evidence and providing projected estimates of long-term clinical and economic outcomes when long-term data are not available. In this review, we outline the types of data required for the development of decision analysis and cost-effectiveness models for newborn screening programs and discuss the challenges faced when applying these methods in the arena of newborn screening to help inform policy decisions.Genet Med advance online publication 5 April 2012.

Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act

OBJECTIVE

The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation.

STUDY DESIGN

We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios.

RESULTS

Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled.

CONCLUSION

Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

Modeling the cost-effectiveness of health programs: HIV testing and early treatment in the USA

The recent results from the NIH HIV Prevention Trials Network (HPTN) 052 trial, confirmed the relationship between plasma viral load and degree of infectivity of people living with HIV (PLHIV); when PLHIV are treated with antiretroviral therapy (ART), their infectivity is significantly reduced. This reiterates the importance of 'treatment for prevention', as well as the therapeutic function of ART. This and other studies raise a number of important questions, including when to start ART. Given the substantial number of PLHIV that are unaware that they are infected, should policy-makers set-up specific programs to identify these PLHIV and get them into treatment early? Long et al. tried to answer this question by modeling the cost-effectiveness of an expanded screening and treatment program in the USA but how good was their model, how can modeling exercises assist policy-makers in answering these difficult questions and what are some of the broader implications?