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Salisbury A, Pearce A, Howard K, Norris S. Impact of Structural Differences on the Modeled Cost-Effectiveness of Noninvasive Prenatal Testing. Med Decis Making 2024; 44:811-827. [PMID: 39092556 PMCID: PMC11492563 DOI: 10.1177/0272989x241263368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 05/24/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Noninvasive prenatal testing (NIPT) was developed to improve the accuracy of prenatal screening to detect chromosomal abnormalities. Published economic analyses have yielded different incremental cost-effective ratios (ICERs), leading to conclusions of NIPT being dominant, cost-effective, and cost-ineffective. These analyses have used different model structures, and the extent to which these structural variations have contributed to differences in ICERs is unclear. AIM To assess the impact of different model structures on the cost-effectiveness of NIPT for the detection of trisomy 21 (T21; Down syndrome). METHODS A systematic review identified economic models comparing NIPT to conventional screening. The key variations in identified model structures were the number of health states and modeling approach. New models with different structures were developed in TreeAge and populated with consistent parameters to enable a comparison of the impact of selected structural variations on results. RESULTS The review identified 34 economic models. Based on these findings, demonstration models were developed: 1) a decision tree with 3 health states, 2) a decision tree with 5 health states, 3) a microsimulation with 3 health states, and 4) a microsimulation with 5 health states. The base-case ICER from each model was 1) USD$34,474 (2023)/quality-adjusted life-year (QALY), 2) USD$14,990 (2023)/QALY, (3) USD$54,983 (2023)/QALY, and (4) NIPT was dominated. CONCLUSION Model-structuring choices can have a large impact on the ICER and conclusions regarding cost-effectiveness, which may inadvertently affect policy decisions to support or not support funding for NIPT. The use of reference models could improve international consistency in health policy decision making for prenatal screening. HIGHLIGHTS NIPT is a clinical area in which a variety of modeling approaches have been published, with wide variation in reported cost-effectiveness.This study shows that when broader contextual factors are held constant, varying the model structure yields results that range from NIPT being less effective and more expensive than conventional screening (i.e., NIPT was dominated) through to NIPT being more effective and more expensive than conventional screening with an ICER of USD$54,983 (2023)/QALY.Model-structuring choices may inadvertently affect policy decisions to support or not support funding of NIPT. Reference models could improve international consistency in health policy decision making for prenatal screening.
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Affiliation(s)
- Amber Salisbury
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Alison Pearce
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Sarah Norris
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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Si Y, Chen C, Tang Y, Zhang M, Tang J, Pu K. Economic evaluation of GnRH-agonist long protocol and GnRH-antagonist protocol in IVT/ICSI among the Chinese population: using pharmacoeconomic models. BMJ Open 2024; 14:e079715. [PMID: 39153788 PMCID: PMC11331823 DOI: 10.1136/bmjopen-2023-079715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 07/17/2024] [Indexed: 08/19/2024] Open
Abstract
OBJECTIVE This paper uses health economics methods to discuss the cost-effectiveness value of long protocol and antagonist protocol for in vitro fertilisation and embryo transfer (ET) in the Chinese population. DESIGN Health economic evaluation study. SETTING The data needed to construct the model for this study were derived from published studies and other secondary sources in China. PARTICIPANTS No patients participated in the study. MEASURES The main outcomes were live birth rate (LBR) and cost. From the societal perspective, we considered the direct and indirect costs over the course of the treatment cycles. A cost-effectiveness was measured using the incremental cost-effectiveness ratio and the probability that a protocol has higher net monetary benefit. Sensitivity analysis was carried out to verify the reliability of the simulation results. RESULTS For the Chinese population, the long protocol resulted in a higher LBR than the antagonist protocol (29.33% vs 20.39%), but at the same time, it was more expensive (¥29 146.26 (US$4333.17) vs ¥23 343.70 (US$3470.51)), in the case of considering only one fresh ET cycle. It was the same when considering subsequent frozen ET (FET) cycles (51.78% vs 42.81%; ¥30 703.02 (US$4564.62) vs ¥24 740.95 (US$3678.24)). The results of most subgroups were consistent with the results of the basic analysis. However, for certain populations, the long protocol was the inferior protocol (less effective and more expensive). CONCLUSION For the Chinese population, when the monetary value per live birth was greater than ¥65 420 (US$9726) and ¥66 400 (US$9872), respectively, considering only one fresh cycle and considering subsequent frozen cycles, the long protocol is the preferred protocol. This threshold also varies for women of different ages and ovarian response capacities. For women in POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) group 2, group 3 and group 4, antagonist protocol is recommended as the preferred protocol. The results of this study need to be verified by further large-scale randomised controlled trials.
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Affiliation(s)
- Yuxin Si
- School of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Chunlan Chen
- School of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Yalan Tang
- School of Pharmacy, Chongqing Medical University, Chongqing, China
| | - Min Zhang
- School of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Junying Tang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kexue Pu
- School of Medical Informatics, Chongqing Medical University, Chongqing, China
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Si Y, Tan T, Pu K. Systematic review of the economic evaluation model of assisted reproductive technology. HEALTH ECONOMICS REVIEW 2024; 14:34. [PMID: 38767759 PMCID: PMC11103951 DOI: 10.1186/s13561-024-00509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND With the increasing demand for fertility services, it is urgent to select the most cost-effective assisted reproductive technology (ART) treatment plan and include it in medical insurance. Economic evaluation reports are an important reference for medical insurance negotiation. The aim of this study is to systematically evaluate the economic evaluation research of ART, analyze the existing shortcomings, and provide a reference for the economic evaluation of ART. METHODS PubMed, EMbase, Web of Science, Cochrane Library and ScienceDirect databases were searched for relevant articles on the economic evaluation of ART. These articles were screened, and their quality was evaluated based on the Comprehensive Health Economics Evaluation Report Standard (CHEERS 2022), and the data on the basic characteristics, model characteristics and other aspects of the included studies were summarized. RESULTS One hundred and two related articles were obtained in the preliminary search, but based on the inclusion criteria, 12 studies were used for the analysis, of which nine used the decision tree model. The model parameters were mainly derived from published literature and included retrospective clinical data of patients. Only two studies included direct non-medical and indirect costs in the cost measurement. Live birth rate was used as an outcome indicator in half of the studies. CONCLUSION Suggesting the setting of the threshold range in the field of fertility should be actively discussed, and the monetary value of each live birth is assumed to be in a certain range when the WTP threshold for fertility is uncertain. The range of the parameter sources should be expanded. Direct non-medical and indirect costs should be included in the calculation of costs, and the analysis should be carried out from the perspective of the whole society. In the evaluation of clinical effect, the effectiveness and safety indexes should be selected for a comprehensive evaluation, thereby making the evaluation more comprehensive and reliable. At least subgroup analysis based on age stratification should be considered in the relevant economic evaluation.
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Affiliation(s)
- Yuxin Si
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China
| | - Tao Tan
- Chongqing Health Statistics Information Center, Chongqing, 401120, China.
| | - Kexue Pu
- School of Medical Informatics, Chongqing Medical University, Chongqing, 400016, China.
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Feng Q, Li W, Callander EJ, Wang R, Mol BW. Applying a simplified economic evaluation approach to evaluate infertility treatments in clinical practice. Hum Reprod 2024; 39:448-453. [PMID: 38148026 PMCID: PMC10905501 DOI: 10.1093/humrep/dead265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/20/2023] [Indexed: 12/28/2023] Open
Abstract
IVF is the backbone of infertility treatment, but due to its costs, it is not affordable for everyone. The cost of IVF is further escalated by interventions added to the routine treatment, which are claimed to boost pregnancy rates, so-called add-ons. Consequently, it is critical to offset the increased costs of an intervention against a potentially higher benefit. Here, we propose using a simplified framework considering the cost of a standard IVF procedure to create one live-born baby as a benchmark for the cost-effectiveness of other fertility treatments, add-ons inclusive. This framework is a simplified approach to a formal economic evaluation, enabling a rapid assessment of cost effectiveness in clinical settings. For a 30-year-old woman, assuming a 44.6% cumulative live birth rate and a cost of $12 000 per complete cycle, the cost to create one live-born baby would be ∼$27 000 (i.e. willingness to pay). Under this concept, the decision whether to accept or reject a new treatment depends from an economic perspective on the incremental cost per additional live birth from the new treatment/add-on, with the $27 000 per live-born baby as a reference threshold. This threshold can vary with women's age, and other factors such as the economic perspective and risk of side effects can play a role. If a new add-on or treatment costs >$27 000 per live birth, it might be more rational to invest in a new IVF cycle rather than spending on the add-on. With the increasing number of novel technologies in IVF and the lack of a rapid approach to evaluate their cost-effectiveness, this simplified framework will help with a more objective assessment of the cost-effectiveness of infertility treatments, including add-ons.
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Affiliation(s)
- Qian Feng
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Emily J Callander
- Discipline for Health Services Management, School of Public Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, University of Aberdeen, Aberdeen, UK
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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties. PURPOSE To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives. DATA SOURCES HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED. STUDY SELECTION All economic evaluations of MAR published from 2010 to 2022. DATA EXTRACTION A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed. DATA SYNTHESIS The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion. LIMITATIONS Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective. CONCLUSIONS Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development. HIGHLIGHTS The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Skedgel C, Cubi-Molla P, Mott D, Gameiro S, Boivin J, Al-Janabi H, Brazier J, Markert M, Andersson FL, Jofre-Bonet M. Unmet Parenthood Goals, Health-Related Quality of Life and Apparent Irrationality: Understanding the Value of Treatments for Infertility. PHARMACOECONOMICS - OPEN 2023; 7:337-344. [PMID: 36920719 PMCID: PMC10016171 DOI: 10.1007/s41669-023-00402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 05/11/2023]
Abstract
An increasing number of prospective parents are experiencing infertility along with associated negative impacts on mental health and life satisfaction that can extend across a network of individuals and family members. Assistive reproductive technologies (ART) can help prospective parents achieve their parenthood goals but, like any health technology, they must demonstrate acceptable 'value for money' to qualify for public funding. We argue that current approaches to understanding the value of ART, including quality-adjusted life-year (QALY) gains based on changes in health-related quality of life (HRQOL) and, more often, cost per live birth, are too narrow to capture the full impact of unmet parenthood goals and ART. We see a fundamental disconnect between measures of HRQOL and broader measures of wellbeing associated with met and unmet parenthood goals. We also suggest that simple concepts such as 'patient' and 'carer' are of limited applicability in the context of ART, where 'spillovers' extend across a wide network of individuals, and the person receiving treatment is often not the infertile individual. Consideration of individual and societal wellbeing beyond HRQOL is necessary to understand the full range of negative impacts associated with unmet parenthood goals and the corresponding positive impacts of successful ART. We suggest moving towards a wellbeing perspective on value to achieve a fuller understanding of value and promote cross-sector allocative efficiency.
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Affiliation(s)
- Chris Skedgel
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK.
| | - Patricia Cubi-Molla
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
| | - David Mott
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
| | - Sofia Gameiro
- School of Psychology, University of Cardiff, Cardiff, UK
| | - Jacky Boivin
- School of Psychology, University of Cardiff, Cardiff, UK
| | - Hareth Al-Janabi
- Health Economics Unit, Institute of Applied Health Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - John Brazier
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Mireia Jofre-Bonet
- Office of Health Economics, Goldings House, 2nd Floor, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
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Keller E, Botha W, Chambers GM. Does in vitro fertilization (IVF) treatment provide good value for money? A cost-benefit analysis. Front Glob Womens Health 2023; 4:971553. [PMID: 36937042 PMCID: PMC10014591 DOI: 10.3389/fgwh.2023.971553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/30/2023] [Indexed: 03/05/2023] Open
Abstract
Background Using traditional health technology assessment (HTA) outcome metrics, such as quality-adjusted life-years, to assess fertility treatments raises considerable methodological challenges because the objective of fertility treatments is to create new life rather than extend, save, or improve health-related quality of life. Objective The aim of this study was to develop a novel cost-benefit framework to assess value for money of publicly funded IVF treatment; to determine the number of cost-beneficial treatment cycles for women of different ages; and to perform an incremental cost-benefit analysis from a taxpayer perspective. Methods We developed a Markov model to determine the net monetary benefit (NMB) of IVF treatment by female age and number of cycles performed. IVF treatment outcomes were monetized using taxpayers' willingness-to-pay values derived from a discrete choice experiment (DCE). Using the current funding environment as the comparator, we performed an incremental analysis of only funding cost-beneficial cycles. Similar outputs to cost-effectiveness analyses were generated, including net-benefit acceptability curves and cost-benefit planes. We created an interactive online app to provide a detailed and transparent presentation of the results. Results The results suggest that at least five publicly funded IVF cycles are cost-beneficial in women aged <42 years. Cost-benefit planes suggest a strong taxpayer preference for restricting funding to cost-beneficial cycles over current funding arrangements in Australia from an economic perspective. Conclusions The provision of fertility treatment is valued highly by taxpayers. This novel cost-benefit method overcomes several challenges of conventional cost-effectiveness methods and provides an exemplar for incorporating DCE results into HTA. The results offer new evidence to inform discussions about treatment funding arrangements.
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