Systematic Review of Health Economic Evaluation Studies Developed in Brazil from 1980 to 2013

A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America

BACKGROUND

Little is known about the quality, quantity and disease areas analysed by health economic research that inform healthcare decision-making in Central America. This study aimed to review the existing health economic evaluations (HEEs) and budget impact analyses (BIAs) evidence in Central America based on scope and reporting quality.

METHODS

HEEs and BIAs published from 2000 to April 2021 were searched in five electronic databases: PubMed, Embase, LILACS (Latin American and Caribbean Health Science Literature), EconLIT and OVID Global Health. Two reviewers assessed titles, abstracts and full texts of studies for eligibility. The quality appraisal for the reporting was based on La Torre and colleagues' version of the Drummond checklist and the ISPOR good practices for BIA. For each country, we correlated the number of studies by disease area with their respective burden of disease to identify under-researched health areas.

RESULTS

102 publications were eligible for this review. Ninety-four publications reported a HEE, six publications reported a BIA, and two studies reported both a HEE and a BIA. Costa Rica had the highest number of publications (n = 28, 27.5%), followed by Guatemala (n = 25, 24.5%). Cancer and respiratory infections were the most common types of disease studied. Diabetes mellitus, chronic kidney diseases, and mental disorders were under-researched relative to their disease burden in most of the countries. The overall mean quality reporting score for HEE and BIA studies were 71/119 points (60%) and 7/10 points (70%), respectively; however, these assessments were made on different scales.

CONCLUSION

In Central America, health economic research is sparse and is considered as suboptimal quality for reporting. The findings reported information useful to other low- and middle-income countries with similar advances in the application of economics to promote health policy decision-making.

Unit Costs in Health Economic Evaluations: Quo Vadis, Austria?

Evidence-informed healthcare decision-making relies on high quality data inputs, including robust unit costs, which in many countries are not readily available. The objective of the Department of Health Economics' Unit Cost Online Database, developed based on systematic reviews of Austrian costing studies, is to make conducting economic evaluations from healthcare and societal perspectives more feasible with publicly available unit cost information in Austria. This article aims to describe trends in unit cost data sources and reporting using this comprehensive database as a case study to encourage relevant national and international methodological discussions. Database analysis and synthesis included publication/study characteristics and costing reporting details in line with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) with the year of the database launch as the cut-off point to assess how the methods have developed over time. Forty-two full economic evaluations and 278 unit costs were analyzed (2004-2016: 34 studies/232 unit costs, 2017-2022: 8 studies/46 unit costs). Although the reporting quality of costing details including the study perspective, unit cost sources and years has improved since 2017, the unit cost estimates and sources remained heterogeneous in Austria. While methodologically standardized national-level unit costs would be the gold standard, a systematically collated list of unit costs is a first step towards supporting health economic evaluations nationally.

Does health economics research align with the disease burden in the Middle East and North Africa region? A systematic review of economic evaluation studies on public health interventions

Introduction

Economic evaluation studies demonstrate the value of money in health interventions and enhance the efficiency of the healthcare system. Therefore, this study reviews published economic evaluation studies of public health interventions from 26 Middle East and North Africa (MENA) countries and examines whether they addressed the region's major health problems.

Methods

PubMed and Scopus were utilized to search for relevant articles published up to June 26, 2021. The reviewers independently selected studies, extracted data, and assessed the quality of studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results

The search identified 61 studies. Approximately half (28 studies; 46%) were conducted in Israel and Iran. The main areas of interest for economic evaluation studies were infectious diseases (21 studies; 34%), cancers (13 studies; 21%), and genetic disorders (nine studies; 15%). Five (8%), 39 (64%), 16 (26%), and one (2%) studies were classified as excellent, high, average, and poor quality, respectively. The mean of CHEERS checklist items reported was 80.8% (SD 14%). Reporting the structure and justification of the selected model was missed in 21 studies (37%), while price and conversion rates and the analytical methods were missed in 21 studies (34%).

Conclusions

The quantity of economic evaluation studies on public health interventions in the MENA region remains low; however, the overall quality is high to excellent. There were obvious geographic gaps across countries regarding the number and quality of studies and gaps within countries concerning disease prioritization. The observed research output, however, did not reflect current and upcoming disease burden and risk factors trends in the MENA region.

Cost Effectiveness of Pharmacological Management for Osteoarthritis: A Systematic Review

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) is a highly prevalent, disabling disease requiring chronic management that is associated with an enormous individual and societal burden. This systematic review provides a global cost-effectiveness evaluation of pharmacological therapy for the management of OA.

METHODS

Following Center for Reviews and Dissemination (CRD) guidance, a literature search strategy was undertaken using PubMed, EMBASE, Cochrane Library, Health Technology Assessment (HTA) database, and National Health Service Economic Evaluation database (NHS EED) to identify original articles containing cost-effectiveness evaluation of OA pharmacological treatment published before 4 November 2021. Risk of bias was assessed by two independent reviewers using the Joanna Briggs Institute (JBI) critical appraisal checklist for economic evaluations. The Quality of Health Economic Studies (QHES) instrument was used to assess the reporting quality of included articles.

RESULTS

Database searches identified 43 cost-effectiveness analysis studies (CEAs) on pharmacological management of OA that were conducted in 18 countries and four continents, with one study containing multiple continents. A total of four classes of drugs were assessed, including non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, symptomatic slow-acting drugs for osteoarthritis (SYSADOAs), and intra-articular (IA) injections. The methodological approaches of these studies showed substantial heterogeneity. The incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) were (in 2021 US dollars) US$44.40 to US$307,013.56 for NSAIDS, US$11,984.84 to US$128,028.74 for opioids, US$10,930.17 to US$27,799.73 for SYSADOAs, and US$258.36 to US$58,447.97 for IA injections in different continents. The key drivers of cost effectiveness included medical resources, productivity, relative risks, and selected comparators.

CONCLUSION

This review showed substantial heterogeneity among studies, ranging from a finding of dominance to very high ICERs, but most studies found interventions to be cost effective based on specific ICER thresholds. Important challenges in the analysis were related to the standardization and methodological quality of studies, as well as the presentation of results.

A Systematic Review on Economic Evaluation Studies of Diagnostic and Therapeutic Interventions in the Middle East and North Africa

INTRODUCTION

Due to the increase in healthcare budget constraint, economic evaluation (EE) evidence is increasingly required to inform resource allocation decisions. This study aimed to systematically review quantity, characteristics, and quality of full EE studies on diagnostic and therapeutic interventions conducted in 26 Middle East and North Africa (MENA) countries.

METHODS

PubMed and Scopus databases were comprehensively searched to identify the published EE studies in the MENA region. The quality of reviewed studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The search identified 69 studies. The cost-utility approach was adopted in 49 studies (71 %). More than half (38 studies; 55 %) were conducted in Iran and Turkey. Sixteen countries (62 %) did not have any EE studies. The most frequently analyzed therapeutic areas were infectious diseases (19 studies; 28 %), cardiovascular diseases (11 studies; 16 %), and malignancies (10 studies; 14 %). Ten studies (14 %), 46 (67 %), 12 (17 %), and 1 study (1 %) were classified as excellent, high, moderate, and poor quality, respectively. The mean of items reported was 85.10 % (standard deviation 13.32 %). Characterizing heterogeneity, measurement of effectiveness, time horizon, and discount rate were missed in 21 (60 %), 22 (32 %), 20 (29 %) and 15 (25 %) studies, respectively. Data on effectiveness and utility relied primarily on studies conducted outside the region.

CONCLUSIONS

The quantity of EE studies in the MENA region remains low; however, overall quality is high to excellent. The availability of local data, capacity building, and national guidelines are vital to improve both the quantity and quality of EE studies in the region.

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions

BACKGROUND

As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders.

OBJECTIVE

To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice.

METHODS

The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders.

CONCLUSIONS

Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.

Economic evaluations addressing diagnosis and treatment strategies for neglected tropical diseases: an overview

Neglected tropical diseases (NTDs) are those affecting vulnerable people and causing additional social and economic burden. The aim of this study was to carry out a general overview of the health economic assessments involving the diagnosis and treatment of six NTDs: cutaneous leishmaniasis (CL), Chagas disease, cysticercosis, filariasis, schistosomiasis and visceral leishmaniasis (VL). The literature search was based on two of the main medical literature databases (Medline and SciELO) and identified 46 studies. Twenty-six studies (57%) addressed therapeutic strategies, while other 20 (43%) assessed diagnostic or both diagnostic and therapeutic approaches. The studies were published between 1994 and 2021, and 57% of them (26/46) were carried out in four countries. Cost-effectiveness analyses were conducted in 59% (27/46) of the studies. Economic studies of NTDs have timidly increased in recent years. Despite the improvement of analytical methods, completeness and accuracy of information, there are few new technologies applied to NTDs and public health systems. In addition, economic studies for NTDs are concentrated in a few countries. Thus, this review points out the need for investment in research, development and training of human resources dedicated to the economic analysis in health, especially on NTDs, as a strategy to reduce inequalities by optimizing the use of health resources.

Health Economic Publications From the Middle East and North Africa Region: A Scoping Review of the Volume and Methods of Research

Introduction

We reviewed the scope of countries, diseases, technologies, and methods involved in the health economic evaluations published in the Middle East and North Africa (MENA) region.

Methods

PRISMA guidelines were followed. A PubMed search was conducted up to December 15, 2019. English language full-text articles were included if they reported original research on humans; involved the local population from Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, or Yemen; reported costs; and involved a full or partial health economic analysis comparing alternative health technologies. Data on publication year, country of origin, disease area according to ICD-10, type of health technology, and applied methods were extracted.

Results

From 105 eligible articles, 57.1% were published between 2015 and 2019. Egypt (30.5%) and Saudi Arabia (27.6%) were the most frequently involved countries. Infectious diseases were most often studied (27.6%). The assessed technology was a system (eg, infection control, screening, coverage/access, hospital management, or healthcare delivery program) in 41.9% of studies. Cost-utility analysis (CUA) was the most frequent method (29.5%) and was growing rapidly. Health system perspective was adopted in 52.4% of studies, whereas societal perspective was scarce (8.6%). The majority of studies (46.7%) were published in Scimago Q1 journals. Over half of the studies (54.2%) did not report or did not have a funding source.

Conclusions

From 2015, health economic analysis became more frequent in the MENA region, providing input to value-based health policy and financing. For further growth, in addition to the development of the institutional background, valid and more standardized local cost and outcome data should be available.

Modeling the Pharmacotherapy Cost and Outcomes of Primary Open-Angle Glaucoma With Dry Eye

We aimed to analyze and model the cost and results of current outpatient pharmacotherapy practice in patients with primary open-angle glaucoma concomitant with dry-eye disease (POAG+DE). The point of view is that of the health care system and patients, and the time horizon was 1 year. Data were collected through a prospective, observational, real-life study of therapy practice in patients admitted to the specialized ophthalmology clinic at the Alexandrovska University Hospital in Sofia. Pharmacotherapy was recorded and analyzed by therapeutic group and INN. The probability of being prescribed preservative-free or non-free formulations was calculated, as were the cost of yearly therapy, reimbursed cost, and patient co-payment. A decision tree exploring the cost-effectiveness of preservative-free and preservative non-free formulations was built. Outcomes were recorded through three tests measuring tear film stability: TMS, NIBUT Ave, and ST. TMS values below 3, ST above 10 mm, and NIBUT Ave above 14 s were considered as indicators of good disease control. A total of 140 eyes were diagnosed with POAG, of which 64 had concomitant dry-eye disease and were included in the analysis. Monotherapy was prescribed to 34: 14 on preservative-free formulations and 20 on non-free. Meanwhile, 30 eyes received combination therapy: six on preservative-free and 24 on non-free. The monotherapy product was most commonly Prostaglandin Analogs (PG−73.5%), followed by beta-blockers (BB−26.5%). No carbonic anhydrase inhibitors (Ca AA) or alpha-2 adrenergic agonists (alfa 2 AA) were prescribed as monotherapy. The majority of patients showed poor disease control according to all three measures. The incremental cost-effectiveness ratio (ICER) was 744 BGN for TMS and 131 BGN for NUBIT for each successfully controlled eye—far below three times GDP per capita. For ST, the ICER was negative, benefiting non-free formulations. Therapy of POAG+DED with preservative-free formulations is cost-effective according to the WHO threshold of three times GDP. The median costs of the two treatment modalities were similar. Current practice shows that patients experience a higher burden in terms of co-payment than do institutions such as the NHIF.

Comparative financing analysis and political economy of noncommunicable diseases

The pandemic of chronic non-communicable diseases (NCDs) poses substantial challenges to the health financing sustainability in high-income and low/middle income countries (LMICs). The aim of this review is to identify the bottle neck inefficiencies in NCDs attributable spending and propose sustainable health financing solutions. The World Health Organization (WHO) introduced the "best buy" concept to scale up the core intervention package against NCDs targeted for LMICs. Population- and individual-based NCD best buy interventions are projected at US$170 billion over 2011-2025. Appropriately designed health financing arrangements can be powerful enablers to scale up the NCD best buys. Rapidly developing emerging nations dominate the landscape of LMICs. Their capability and willingness to invest resources for eradicating NCDs could strengthen WHO outreach efforts in Asia, Africa, and Latin America, much beyond current capacities. There has been a declining trend in international donor aid intended to cope with NCDs over the past decade. There is also a serious misalignment of these resources with the actual needs of recipient countries. Globally, the momentum towards the financing of intersectoral actions is growing, and this presents a cost-effective solution. A budget discrepancy of 10:1 in WHO and multilateral agencies remains in donor aid in favour of communicable diseases compared to NCDs. LMICs are likely to remain a bottleneck of NCDs imposed financing sustainability challenge in the long-run. Catastrophic household health expenditure from out of pocket spending on NCDs could plunge almost 150 million people into poverty worldwide. This epidemiological burden coupled with population ageing presents an exceptionally serious sustainability challenge, even among the richest countries which are members of the Organization for Economic Co-operation and Development (OECD). Strategic and political leadership of WHO and multilateral agencies would likely play essential roles in the struggle that has just begun.

Health Economics and Outcomes Research Knowledge Needs Assessment for Latin America

BACKGROUND

An increasing awareness of the importance of health economics and outcomes research (HEOR) skills has been reported in Latin America. There is, however, no published study directly assessing perceived knowledge levels and knowledge gaps on specific HEOR topics among professionals and students in the region.

OBJECTIVES

To assess perceived HEOR knowledge levels and identify knowledge gaps in Latin America.

METHODS

An online needs assessment survey was developed to quantify perceived HEOR knowledge levels and identify knowledge gaps. Members of the International Society for Pharmacoeconomics and Outcomes Research in the Latin American region, regional chapters, and student chapter presidents were invited to participate in the survey. The survey, developed using the SurveyMonkey tool, was distributed to participants electronically. Data were extracted from the survey and analyzed using Microsoft Excel. Data analysis was conducted using descriptive statistics to summarize the survey respondents' demographic information, current and desired knowledge levels, and preferred method/format for delivery of educational training.

RESULTS

Survey responses were collected from 106 participants. The largest knowledge gap was calculated for methods for integrating medication adherence and persistence in health economic evaluations (mean = 2.30 ± 1.48). The smallest knowledge gap was calculated for types of healthcare costs (mean = 1.01 ± 1.17). Most respondents (74% [n = 66]) preferred to receive educational materials related to HEOR topics through online learning and continuing education programs.

CONCLUSIONS

The knowledge gap assessment provided current knowledge gap perceptions among members of the International Society for Pharmacoeconomics and Outcomes Research in Latin America. The survey data collected support a need for developing educational programs for topics with the highest perceived knowledge gap.

Health Economic Evaluations of Cancer in Brazil: A Systematic Review

Background: A large number of health economic evaluation (HEE) studies have been published in developed countries. However, Brazilian HEE literature in oncology has not been studied.

OBJECTIVE

To investigate whether the scientific literature has provided a set of HEE in oncology capable of supporting decision making in the Brazilian context. Methods: A systematic review was conducted to identify and characterize studies in this field. We searched multiple databases selecting partial and full HEE studies in oncology (1998-2013). Results: Fifty-five articles were reviewed, of these, 33 (60%) were full health economic evaluations. Type of cancers most frequently studied were: breast (38.2%), cervical (14.6%), lung (10.9%) and colorectal (9.1%). Procedures (47.3%) were the technologies most frequently evaluated. In terms of the intended purposes of the technologies, most (63.6%) were treatments. The majority of the incremental cost-effectiveness ratios (ICERs) reported have been below the cost-effectiveness threshold suggested by the World Health Organization (WHO). Conclusions: There has been an increase in the number of HEEs related to cancer in Brazil. These studies may support decision-making processes regarding the coverage of and reimbursement of healthcare technologies for cancer treatment in Brazil.

Challenges to decision-making processes in the national HTA agency in Brazil: operational procedures, evidence use and recommendations

Background

The quality of the evidence used in health technology assessment (HTA) agency reports has been considered essential for decision-making processes and their legitimacy. In Brazil, CONITEC is the agency responsible for defining data mandatory for the submission of proposals for the incorporation of new technologies. The objective of this study was to analyse CONITEC recommendation reports, the type of scientific evidence used in them and their compliance with operational procedures.

Methods

This is a descriptive study based on CONITEC official reports from July 2012 through December 2016. Data were collected with a specific extraction form and analysed using descriptive statistics.

Results

We evaluated 199 CONITEC recommendation reports. The annual number of reports increased during the study period. The absolute annual number of new technologies incorporated in 2013 (n = 24) was similar to that observed for 2014 (n = 24) and 2015 (n = 22), decreasing in 2016 (n = 13). The type of technology most frequently evaluated was ‘drugs’ (68.3%), followed by ‘procedures’ (20.1%). Overall, 117 (58.8%) reports were internal demands, 75 (37.7%) were external demands and 7 (3.5%) were mixed demands. There were differences between internal and external demands in terms of the evidence used in the reports and the decision regarding the recommendation to incorporate the technologies. Among the internal demands, the recommendation to incorporate the new technology was made for 70.9% of the reports, only 9.6% of which included full HTAs. Among the external demands, the incorporation of the new technology was recommended for 17.3% of the reports, 76.9% of which included full HTAs. Of the 101 reports in which incorporation of the new technology was recommended, 88 (87.1%) did not include a full health economic evaluation and ICER calculation. There are compliance difficulties with the recommendations in the CONITEC internal regulations regarding the type and quality of evidence considered in the analysis of recommendation reports.

Conclusions

The characteristics of the evidence used in recommendation reports and those considered to be mandatory were very different, indicating problems in decision-making processes. There is a need to study, with a broader perspective, the factors that influence the type of evidence used in decision-making processes in order to contribute to the development of better practices and policies.