1
|
Gross AC, Freese RL, Bensignor MO, Bomberg EM, Dengel DR, Fox CK, Rudser KD, Ryder JR, Bramante CT, Raatz S, Lim F, Hur C, Kelly AS. Financial Incentives and Treatment Outcomes in Adolescents With Severe Obesity: A Randomized Clinical Trial. JAMA Pediatr 2024; 178:753-762. [PMID: 38884967 PMCID: PMC11184501 DOI: 10.1001/jamapediatrics.2024.1701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/13/2024] [Indexed: 06/18/2024]
Abstract
Importance Adolescent severe obesity is usually not effectively treated with traditional lifestyle modification therapy. Meal replacement therapy (MRT) shows short-term efficacy for body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) reduction in adolescents, and financial incentives (FIs) may be an appropriate adjunct intervention to enhance long-term efficacy. Objective To evaluate the effect of MRT plus FIs vs MRT alone on BMI, body fat, and cardiometabolic risk factors in adolescents with severe obesity. Design, Setting, and Participants This was a randomized clinical trial of MRT plus FIs vs MRT alone at a large academic health center in the Midwest conducted from 2018 to 2022. Participants were adolescents (ages 13-17 y) with severe obesity (≥120% of the 95th BMI percentile based on sex and age or ≥35 BMI, whichever was lower) who were unaware of the FI component of the trial until they were randomized to MRT plus FIs or until the end of the trial. Study staff members collecting clinical measures were blinded to treatment condition. Data were analyzed from March 2022 to February 2024. Interventions MRT included provision of preportioned, calorie-controlled meals (~1200 kcals/d). In the MRT plus FI group, incentives were provided based on reduction in body weight from baseline. Main Outcomes and Measures The primary end point was mean BMI percentage change from randomization to 52 weeks. Secondary end points included total body fat and cardiometabolic risk factors: blood pressure, triglyceride to high-density lipoprotein ratio, heart rate variability, and arterial stiffness. Cost-effectiveness was additionally evaluated. Safety was assessed through monthly adverse event monitoring and frequent assessment of unhealthy weight-control behaviors. Results Among 126 adolescents with severe obesity (73 female [57.9%]; mean [SD] age, 15.3 [1.2] years), 63 participants received MRT plus FIs and 63 participants received only MRT. At 52 weeks, the mean BMI reduction was greater by -5.9 percentage points (95% CI, -9.9 to -1.9 percentage points; P = .004) in the MRT plus FI compared with the MRT group. The MRT plus FI group had a greater reduction in mean total body fat mass by -4.8 kg (95% CI, -9.1 to -0.6 kg; P = .03) and was cost-effective (incremental cost-effectiveness ratio, $39 178 per quality-adjusted life year) compared with MRT alone. There were no significant differences in cardiometabolic risk factors or unhealthy weight-control behaviors between groups. Conclusions and Relevance In this study, adding FIs to MRT resulted in greater reductions in BMI and total body fat in adolescents with severe obesity without increased unhealthy weight-control behaviors. FIs were cost-effective and possibly promoted adherence to health behaviors. Trial Registration ClinicalTrials.gov Identifier: NCT03137433.
Collapse
Affiliation(s)
- Amy C Gross
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Rebecca L Freese
- Biostatistical Design and Analysis Center, University of Minnesota Clinical and Translational Science Institute, Minneapolis
| | - Megan O Bensignor
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Eric M Bomberg
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Donald R Dengel
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- University of Minnesota School of Kinesiology, Minneapolis
| | - Claudia K Fox
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Kyle D Rudser
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis
| | - Justin R Ryder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Carolyn T Bramante
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Medicine, University of Minnesota, Minneapolis
| | - Sarah Raatz
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Aaron S Kelly
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| |
Collapse
|
2
|
Mizoguchi N, Kano K, Okuda T, Koge H, Shima S, Tsuchida K, Takakusagi Y, Kawashiro S, Yoshida M, Kitani Y, Hashimoto K, Furukawa M, Shirai K, Kamada T, Yoshida D, Katoh H. Adjuvant Therapy with Immune Checkpoint Inhibitors after Carbon Ion Radiotherapy for Mucosal Melanoma of the Head and Neck: A Case-Control Study. Cancers (Basel) 2024; 16:2625. [PMID: 39123353 PMCID: PMC11311030 DOI: 10.3390/cancers16152625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/15/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
The development of new treatment strategies to improve the prognosis of mucosal malignant melanoma of the head and neck (MMHN) after carbon ion radiotherapy (CIRT) is essential because of the risk of distant metastases. Therefore, our objective was to evaluate the outcomes of immune checkpoint inhibitor (ICI) treatment to justify its inclusion in the regimen after CIRT. Thirty-four patients who received CIRT as an initial treatment were included in the analysis and stratified into three groups: those who did not receive ICIs (Group A), those who received ICIs after recurrence or metastasis (Group B), and those who received ICIs as adjuvant therapy after CIRT (Group C). In total, 62% of the patients (n = 21) received ICIs. The 2-year local control and overall survival (OS) rates for all patients were 90.0% and 66.8%, respectively. The 2-year OS rates for patients in Groups A, B, and C were 50.8%, 66.7%, and 100%, respectively. No significant differences were observed between Groups A and B (p = 0.192) and Groups B and C (p = 0.112). However, a significant difference was confirmed between Groups A and C (p = 0.017). Adjuvant therapy following CIRT for MMHN may be a promising treatment modality that can extend patient survival.
Collapse
Affiliation(s)
- Nobutaka Mizoguchi
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan;
| | - Kio Kano
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Tatsuya Okuda
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Hiroaki Koge
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Satoshi Shima
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Keisuke Tsuchida
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Yosuke Takakusagi
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Shohei Kawashiro
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Manatsu Yoshida
- Department of Head and Neck Surgery, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (M.Y.); (Y.K.); (K.H.); (M.F.)
| | - Yuka Kitani
- Department of Head and Neck Surgery, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (M.Y.); (Y.K.); (K.H.); (M.F.)
| | - Kaori Hashimoto
- Department of Head and Neck Surgery, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (M.Y.); (Y.K.); (K.H.); (M.F.)
| | - Madoka Furukawa
- Department of Head and Neck Surgery, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (M.Y.); (Y.K.); (K.H.); (M.F.)
| | - Katsuyuki Shirai
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama 330-8503, Japan;
- Department of Radiation Oncology, Jichi Medical University Hospital, Tochigi 329-0498, Japan
| | - Tadashi Kamada
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Daisaku Yoshida
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| | - Hiroyuki Katoh
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama 241-8515, Japan; (K.K.); (T.O.); (H.K.); (S.S.); (K.T.); (Y.T.); (S.K.); (T.K.); (D.Y.); (H.K.)
| |
Collapse
|
3
|
Espinosa O, Rodríguez-Lesmes P, Romano G, Orozco E, Basto S, Ávila D, Mesa L, Enríquez H. Use of Cost-Effectiveness Thresholds in Healthcare Public Policy: Progress and Challenges. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00900-5. [PMID: 38995492 DOI: 10.1007/s40258-024-00900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
The article offers a comparative analysis of the influence of cost-effectiveness thresholds in the decision-making processes in financing policies, coverage, and price regulation of health technologies in nine countries. We investigated whether countries used cost-effectiveness thresholds for public health policy decision making and found that few countries have adopted the cost-effectiveness threshold as an official criterion for financing, reimbursement, or pricing. However, in countries where it is applied, such as Thailand, the results have been very favorable in terms of minimizing health technology prices and ensuring the financial sustainability of the health system. Although the cost-effectiveness threshold has opportunities for improvement, particularly in certain institutional contexts and with adequate participation of the different strategic actors in the formulation of public policy, its potential use and added value are significant in various aspects.
Collapse
Affiliation(s)
- Oscar Espinosa
- Economic Models and Quantitative Methods Research Group, Centro de Investigaciones para el Desarrollo, Universidad Nacional de Colombia and Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | | | - Giancarlo Romano
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Esteban Orozco
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
- School of Economics, Universidad de Antioquia, Bogotá, DC, Colombia
| | - Sergio Basto
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Diego Ávila
- Economic Models and Quantitative Methods Research Group, Centro de Investigaciones para el Desarrollo, Universidad Nacional de Colombia and Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Lorena Mesa
- Directorate of Qualitative Methods and Social Research, Instituto de Evaluación Tecnológica en Salud (IETS), Duitama, Colombia
| | - Hernán Enríquez
- School of Economics, Universidad del Rosario, Bogotá, DC, Colombia
| |
Collapse
|
4
|
Carter MJ, Fife CE. Counting the Cost of Cellular and/or Tissue-Based Products in Diabetic Foot Ulcers: Is There a Justifiable Price Limit per Square Centimeter? Adv Wound Care (New Rochelle) 2024. [PMID: 38832861 DOI: 10.1089/wound.2024.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Objective: To identify how cellular and/or tissue-based products (CTPs) relate to value in terms of cost per quality-adjusted life years (QALYs) in wound care in comparison with treatments in other medical fields. Approach: This is a cross-sectional study and a cost-effectiveness analysis. Payment limits for each CTP were obtained via the Healthcare Common Procedure Coding System Q codes and formulated as cost inputs into a cost-utility model published for treatment of Wagner 1 diabetic foot ulcers using dehydrated human amnion and chorion allograft versus standard of care (SOC). Additional changes to cap the number of CTP applications and adjustments for recent inflation were made. The literature was searched for other cost-utility models in other diabetes-related diseases as a comparison. Results: When the payment limit was ≤$140 per square centimeter, interventions were dominant (less costly, better outcomes) compared with SOC. When the limit exceeded $430 per square centimeter, the cost-effectiveness threshold of $100,000/QALY was exceeded. Newer Q codes are generally much more expensive and likely to not be cost-effective, similar to the results for many other chronic diabetes-related diseases . Innovation: This study presents decision makers with tools, by which they can determine as to whether a given CTP is likely to be cost-effective for patients. Conclusion: Over a third of all CTPs will very likely result in noncost-effective interventions. This number is likely to be higher when wounds are larger or used in other wound types where they are less efficacious. The recent trend in much higher costs for CTPs is worrisome.
Collapse
Affiliation(s)
| | - Caroline E Fife
- Intellicure, LLC, The Woodlands, TX, USA
- U.S. Wound Registry (501 3C nonprofit), The Woodlands, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
5
|
Uhlman K, Bonert M, Murphy J, Duku E, Naqvi A, Thoma A. Routine Pathological Examination of Clinically Presumed Dupuytren Disease: Does It Add Value? Hand (N Y) 2024; 19:783-789. [PMID: 36314350 PMCID: PMC11284986 DOI: 10.1177/15589447221128982] [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] [Indexed: 02/10/2023]
Abstract
BACKGROUND In surgery for Dupuytren disease (DD), palmar fascia specimens are routinely submitted for pathological evaluation. The purpose of this study was to determine the rate of discordant diagnosis and the value of, and costs associated with, routine pathological analysis of palmar fascia tissue extracted in surgery for clinically diagnosed DD. METHODS All pathology reports for in-house palmar fascia specimens obtained in surgery for clinically diagnosed DD (time period: January 2001 to December 2020) were retrieved from one academic institution. All specimens were classified by a hierarchical free-text string matching algorithm (HFTSMA) and searched for evidence of malignancy. The primary outcome was percentage of concordant, discrepant, and discordant diagnoses. Secondary outcomes included anatomical location and costs. The HFTSMA was used to capture the anatomical location. Costs included professional, laboratory processing, and ancillary fees based on the Ontario Schedule of Benefits. RESULTS The search retrieved 1323 pathology reports, with 1480 palmar fascia specimens, from 1078 individual patients. By diagnosis, 96.1% of specimens (1422/1480) were concordant (fibromatosis), 3.9% (58/1480) were discrepant (scarring/fibrosis, benign fascia/connective tissue, or other benign findings), and 0% (0/1480) were discordant. The most common location was ring finger (n = 381, 48.7%). Ancillary testing was minimal. The cost per palmar fascia specimen was estimated to be CAD $34.57. The institutional costs were approximately CAD $2558.18/year. CONCLUSIONS Routine pathological examination of specimens in cases of clinically diagnosed DD does not yield additional clinically important findings and may not warrant their costs.
Collapse
Affiliation(s)
| | - Michael Bonert
- McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
| | | | - Eric Duku
- McMaster University, Hamilton, ON, Canada
| | - Asghar Naqvi
- McMaster University, Hamilton, ON, Canada
- St. Joseph’s Healthcare Hamilton, ON, Canada
| | | |
Collapse
|
6
|
Welford E, Martin TCS, Martin NK, Tilghman W, Little SJ. Relative Cost and Infectious Days Averted Associated With Rapid Gonorrhea and Chlamydia Testing Among Men Who Have Sex With Men. Sex Transm Dis 2024; 51:388-392. [PMID: 38733972 PMCID: PMC11090409 DOI: 10.1097/olq.0000000000001956] [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] [Indexed: 05/13/2024]
Abstract
BACKGROUND Standard-of-care nucleic acid amplification tests (routine NAATs) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can take several days to result and therefore delay treatment. Rapid point-of-care GC/CT NAAT (rapid NAAT) could reduce the time to treatment and therefore onward transmission. This study evaluated the incremental cost per infectious day averted and overall cost of implementation associated with rapid compared with routine NAAT. METHODS Prospective sexually transmitted infection (STI) treatment data from men who have sex with men and transgender women in San Diego who received rapid NAAT between November 2018 and February 2021 were evaluated. Historical time from testing to treatment for routine NAAT was abstracted from the literature. Costs per test for rapid and routine NAAT were calculated using a micro-costing approach. The incremental cost per infectious day averted comparing rapid to routine NAAT and the costs of rapid GC/CT NAAT implementation in San Diego Public Health STI clinics were calculated. RESULTS Overall, 2333 individuals underwent rapid NAAT with a median time from sample collection to treatment of 2 days compared with 7 to 14 days for routine NAAT equating to a reduction of 5 to 12 days. The cost of rapid and routine GC/CT NAAT was $57.86 and $18.38 per test, respectively, with a cost-effectiveness of between $2.43 and $5.82 per infectious day averted. The incremental cost of rapid NAAT improved when at least 2000 tests were performed annually. CONCLUSIONS Although rapid GC/CT NAAT is more expensive than routine testing, the reduction of infectious days between testing and treatment may reduce transmission and provide improved STI treatment services to patients.
Collapse
Affiliation(s)
- Elliott Welford
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Thomas C S Martin
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Natasha K Martin
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| | - Winston Tilghman
- County of San Diego Health & Human Services Agency, San Diego, CA
| | - Susan J Little
- From the Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego
| |
Collapse
|
7
|
Frye CC, Sullivan J, Sanka SA, Smith ER, Goetz B, Brunt LM, Gillanders W, Brown TC, Olson JA, Hall B, Pandian TK. Cost-Effectiveness of Parathyroid Cryopreservation and Autotransplantation. JAMA Surg 2024; 159:634-641. [PMID: 38506884 PMCID: PMC10955396 DOI: 10.1001/jamasurg.2024.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/24/2023] [Indexed: 03/21/2024]
Abstract
Importance Delayed autotransplantation of cryopreserved parathyroid tissue (DACP) is the only surgical treatment for permanent postoperative hypoparathyroidism. Studies suggest that only a small minority of cryopreserved samples are ultimately autotransplanted with highly variable outcomes. For these reasons, many have questioned the economic utility of the process, although, to the authors' knowledge, this has never been formally studied. Objective To report the clinical outcomes of parathyroid cryopreservation and DACP at a large academic institution and to determine the cost-effectiveness of this treatment. Design, Setting, and Participants An institutional review board-approved, retrospective review of patients at a single institution who underwent DACP over a 17-year period was conducted with a median follow-up of 48.2 months. A forward-looking cost-utility analysis was then performed to determine the economic utility of cryopreservation/DACP vs usual care (monitoring and supplementation). Patients who had parathyroid tissue in cryopreserved storage between August 2005 to September 2022 at a single-center, academic, quaternary care center were identified. Exposure Parathyroid cryopreservation and DACP. Main Outcomes and Measures Graft functionality, clinical outcomes, and cost utility using a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results A total of 591 patients underwent cryopreservation. Of these, 10 patients (1.7%; mean [SD] age, 45.6 [17.9] years; 6 male [60%]) underwent DACP. A minority of autografts (2 [20%]) were subsequently fully functional, one-half (5 [50%]) were partially functional, and 3 (30%) were not functional. The cost-utility model estimated that at a large academic center over 10 years, the additional cost of 591 patients undergoing cryopreservation and 10 patients undergoing autotransplantation would be $618 791.64 (2022 dollars) and would add 8.75 QALYs, resulting in a cost per marginal QALY of $70 719.04, which is less than the common willingness-to-pay threshold of $100 000/QALY. Conclusions and Relevance The reimplantation rate of cryopreserved tissue was low (<2%), but when implanted, autografts were at least partially functional 70% of the time. In the first-ever, to the authors' knowledge, formal cost analysis for this treatment, results of the current model suggest that cryopreservation and autotransplantation were cost-effective compared with the usual care for hypoparathyroidism at a large, academic institution. It is recommended that each surgical center consider whether the economic and logistical commitments necessary for cryopreservation are worthwhile for their individual needs.
Collapse
Affiliation(s)
- C. Corbin Frye
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Janessa Sullivan
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Sai Anusha Sanka
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Eileen R. Smith
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Brian Goetz
- Siteman Cancer Center, Washington University School of Medicine, Barnes Jewish Hospital, St Louis, Missouri
| | - L. Michael Brunt
- Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, St Louis, Missouri
| | - William Gillanders
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Taylor C. Brown
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - John A. Olson
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Bruce Hall
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
- BJC HealthCare, St Louis, Missouri
| | - T. K. Pandian
- Department of Surgery, Section of Surgical Oncology, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
8
|
Oluwole OO, Ray MD, Zur RM, Ferrufino CP, Doble B, Patel AR, Bilir SP. Cost-effectiveness of treating relapsed or refractory 3L+ follicular lymphoma with axicabtagene ciloleucel vs mosunetuzumab in the United States. Front Immunol 2024; 15:1393939. [PMID: 38855109 PMCID: PMC11157123 DOI: 10.3389/fimmu.2024.1393939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Novel therapies for 3L+ relapsed/refractory (r/r) follicular lymphoma (FL) have been approved recently by the US Food and Drug Administration including anti-CD19 CAR-T therapies such as axicabtagene ciloleucel (axi-cel) and CD20 × CD3 T-cell-engaging bispecific monoclonal antibodies such as mosunetuzumab (mosun). The objective of this study was to assess the cost-effectiveness of axi-cel compared to mosun in 3L+ r/r FL patients from a US third-party payer perspective. Methods A three-state (progression-free, progressed disease, and death) partitioned-survival model was used to compare two treatments over a lifetime horizon in a hypothetical cohort of US adults (age ≥18) receiving 3L+ treatment for r/r FL. ZUMA-5 and GO29781 trial data were used to inform progression-free survival (PFS) and overall survival (OS). Mosun survival was modeled via hazard ratios (HRs) applied to axi-cel survival curves. The PFS HR value was estimated via a matching-adjusted indirect comparison (MAIC) based on mosun pseudo-individual patient data and adjusted axi-cel data to account for trial populations differences. One-way sensitivity analysis (OWSA) and probabilistic sensitivity analyses (PSA) were conducted. Scenario analyses included: 1) the mosun HRs were applied to the weighted (adjusted) ZUMA-5 24-month data to most exactly reflect the MAIC, 2) mosun HR values were applied to axi-cel 48-month follow-up data, and 3) recent axi-cel health state utility values in diffuse large B-cell lymphoma patients. Results The analysis estimated increases of 1.82 LY and 1.89 QALY for axi-cel compared to mosun. PFS for axi-cel patients was 6.42 LY vs. 1.60 LY for mosun. Increase of $257,113 in the progression-free state was driven by one-time axi-cel treatment costs. Total incremental costs for axi-cel were $204,377, resulting in an ICER of $108,307/QALY gained. The OWSA led to ICERs ranging from $240,255 to $75,624, with all but two parameters falling below $150,000/QALY. In the PSA, axi-cel had an 64% probability of being cost-effective across 5,000 iterations using a $150,000 willingness-to-pay threshold. Scenarios one and two resulted in ICERs of $105,353 and $102,695, respectively. Discussion This study finds that axi-cel is cost-effective compared to mosun at the commonly cited $150,000/QALY US willingness-to-pay threshold, with robust results across a range of sensitivity analyses accounting for parameter uncertainty.
Collapse
MESH Headings
- Humans
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/economics
- Lymphoma, Follicular/mortality
- Cost-Benefit Analysis
- United States
- Biological Products/therapeutic use
- Biological Products/economics
- Male
- Antibodies, Bispecific/therapeutic use
- Antibodies, Bispecific/economics
- Female
- Immunotherapy, Adoptive/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Middle Aged
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Immunological/economics
- Adult
- Quality-Adjusted Life Years
- Neoplasm Recurrence, Local/drug therapy
- Aged
Collapse
Affiliation(s)
| | | | | | | | - Brett Doble
- Kite, A Gilead Company, Santa Monica, CA, United States
| | - Anik R. Patel
- Kite, A Gilead Company, Santa Monica, CA, United States
| | | |
Collapse
|
9
|
Allen C, Ito S, Butt A, Purcell A, Richmond R, Tormey CA, Krumholz HM, Cuker A, Goshua G. Cost-effectiveness of rapid vs in-house vs send-out ADAMTS13 testing for immune thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2279-2289. [PMID: 38502197 PMCID: PMC11116991 DOI: 10.1182/bloodadvances.2024012608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
ABSTRACT While awaiting confirmatory results, empiric therapy for patients suspected to have immune thrombotic thrombocytopenic purpura (iTTP) provides benefits and also accrues risks and costs. Rapid assays for ADAMTS13 may be able to avoid the cost and risk exposure associated with empiric treatment. We conducted, to our knowledge, the first cost-effectiveness evaluation of testing strategies with rapid vs traditional ADAMTS13 assays in patients with intermediate- to high-risk PLASMIC scores, with and without caplacizumab use. We built a Markov cohort simulation with 4 clinical base-case analyses: (1) intermediate-risk PLASMIC score with caplacizumab; (2) intermediate-risk PLASMIC score without caplacizumab; (3) high-risk PLASMIC score with caplacizumab; and (4) high-risk PLASMIC score without caplacizumab. Each of these evaluated 3 testing strategies: (1) rapid assay (<1-hour turnaround); (2) in-house fluorescence resonance energy transfer (FRET)-based assay (24-hour turnaround); and (3) send-out FRET-based assay (72-hour turnaround). The primary outcome was the incremental net monetary benefit reported over a 3-day time horizon and across accepted willingness-to-pay thresholds in US dollars per quality-adjusted life-year (QALY). While accruing the same amount of QALYs, the rapid assay strategy saved up to $46 820 (95% CI, $41 961-$52 486) per patient tested. No parameter variation changed the outcome. In probabilistic sensitivity analyses, the rapid assay strategy was favored in 100% (3 base cases and scenario analyses) and 99% (1 base-case and scenario analysis) across 100 000 Monte Carlo iterations within each. Rapid ADAMTS13 testing for patients with intermediate- or high-risk PLASMIC scores yields significant per patient cost savings, achieved by reducing the costs associated with unnecessary therapeutic plasma exchange and caplacizumab therapy in patients without iTTP.
Collapse
Affiliation(s)
- Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Ayesha Butt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | | | | | - Christopher A. Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| |
Collapse
|
10
|
Paulden M. Reply to Comment on "A Framework for Fair Pricing of Medicines". PHARMACOECONOMICS 2024; 42:607-609. [PMID: 38478252 DOI: 10.1007/s40273-024-01369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 04/24/2024]
Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, 11405 87 Ave, Edmonton, AB, T6G 1C9, Canada.
| |
Collapse
|
11
|
Majumder MA, Fasipe T. Translational Research and Health Equity: Gene Therapies for Sickle Cell Disease as a Case Study. Ethics Hum Res 2024; 46:34-39. [PMID: 38629220 DOI: 10.1002/eahr.500211] [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: 04/19/2024]
Abstract
In August of 2023, the National Academies of Science, Engineering, and Medicine published a timely report titled "Toward Equitable Innovation in Health and Medicine: A Framework." Here, we review some of the key contributions of the report, focusing on two dimensions of equity: input equity and deployment equity. We then use the example of new gene therapies to treat sickle cell disease (SCD) as a case study of input and deployment equity in translational research. The SCD case study illustrates the need for a kind of translational bioethics with deep understanding of lived experiences and clinical realities as well as a high degree of economic and policy sophistication.
Collapse
Affiliation(s)
- Mary A Majumder
- Dalton Tomlin Professor of Medical Ethics and Health Policy in the Center for Medical Ethics and Health Policy at the Baylor College of Medicine
| | - Titilope Fasipe
- Assistant professor in the Division of Hematology/Oncology in the Department of Pediatrics at Baylor College of Medicine and the codirector of the Sickle Cell and Thalassemia Program at Texas Children's Hospital
| |
Collapse
|
12
|
Dong S, Jutkowitz E, Giardina J, Bilinski A. Screening Strategies to Reduce COVID-19 Mortality in Nursing Homes. JAMA HEALTH FORUM 2024; 5:e240688. [PMID: 38669030 PMCID: PMC11065177 DOI: 10.1001/jamahealthforum.2024.0688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 05/01/2024] Open
Abstract
Importance Nursing home residents continue to bear a disproportionate share of COVID-19 morbidity and mortality, accounting for 9% of all US COVID-19 deaths in 2023, despite comprising only 0.4% of the population. Objective To evaluate the cost-effectiveness of screening strategies in reducing COVID-19 mortality in nursing homes. Design and Setting An agent-based model was developed to simulate SARS-CoV-2 transmission in the nursing home setting. Parameters were determined using SARS-CoV-2 virus data and COVID-19 data from the Centers for Medicare & Medicaid Services and US Centers for Disease Control and Prevention that were published between 2020 and 2023, as well as data on nursing homes published between 2010 and 2023. The model used in this study simulated interactions and SARS-CoV-2 transmission between residents, staff, and visitors in a nursing home setting. The population used in the simulation model was based on the size of the average US nursing home and recommended staffing levels, with 90 residents, 90 visitors (1 per resident), and 83 nursing staff members. Exposure Screening frequency (none, weekly, and twice weekly) was varied over 30 days against varying levels of COVID-19 community incidence, booster uptake, and antiviral use. Main Outcomes and Measures The main outcomes were SARS-CoV-2 infections, detected cases per 1000 tests, and incremental cost of screening per life-year gained. Results Nursing home interactions were modeled between 90 residents, 90 visitors, and 83 nursing staff over 30 days, completing 4000 to 8000 simulations per parameter combination. The incremental cost-effectiveness ratios of weekly and twice-weekly screening were less than $150 000 per resident life-year with moderate (50 cases per 100 000) and high (100 cases per 100 000) COVID-19 community incidence across low-booster uptake and high-booster uptake levels. When COVID-19 antiviral use reached 100%, screening incremental cost-effectiveness ratios increased to more than $150 000 per life-year when booster uptake was low and community incidence was high. Conclusions and Relevance The results of this cost-effectiveness analysis suggest that screening may be effective for reducing COVID-19 mortality in nursing homes when COVID-19 community incidence is high and/or booster uptake is low. Nursing home administrators can use these findings to guide planning in the context of widely varying levels of SARS-CoV-2 transmission and intervention measures across the US.
Collapse
Affiliation(s)
- Shirley Dong
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Eric Jutkowitz
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island
| | - John Giardina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Alyssa Bilinski
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
13
|
Paulden M, Sampson C, O'Mahony JF, Spackman E, McCabe C, Round J, Snowsill T. Logical Inconsistencies in the Health Years in Total and Equal Value of Life-Years Gained. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:356-366. [PMID: 38048985 DOI: 10.1016/j.jval.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/07/2023] [Accepted: 11/08/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVES This study aimed to assess whether recently proposed alternatives to the quality-adjusted life-year (QALY), intended to address concerns about discrimination, are suitable for informing resource allocation decisions. METHODS We consider 2 alternatives to the QALY: the health years in total (HYT), recently proposed by Basu et al, and the equal value of life-years gained (evLYG), currently used by the Institute for Clinical and Economic Review. For completeness we also consider unweighted life-years (LYs). Using a hypothetical example comparing 3 mutually exclusive treatment options, we consider how calculations are performed under each approach and whether the resulting rankings are logically consistent. We also explore some further challenges that arise from the unique properties of the HYT approach. RESULTS The HYT and evLYG approaches can result in logical inconsistencies that do not arise under the QALY or LY approaches. HYT can violate the independence of irrelevant alternatives axiom, whereas the evLYG can produce an unstable ranking of treatment options. HYT have additional issues, including an implausible assumption that the utilities associated with health-related quality of life and LYs are "separable," and a consideration of "counterfactual" health-related quality of life for patients who are dead. CONCLUSIONS The HYT and evLYG approaches can result in logically inconsistent decisions. We recommend that decision makers avoid these approaches and that the logical consistency of any approaches proposed in future be thoroughly explored before considering their use in practice.
Collapse
Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | | | | | - Eldon Spackman
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christopher McCabe
- Centre for Public Health and Queens Management School, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tristan Snowsill
- Health Economics Group, University of Exeter, Exeter, England, UK
| |
Collapse
|
14
|
Thaliffdeen R, Yu A, Rascati K. Cost-Effectiveness Evaluation of Oral CGRP Antagonists, Atogepant and Rimegepant, for the Preventative Treatment of Episodic Migraine: Results from a US Societal Perspective Model. Clin Drug Investig 2024; 44:209-217. [PMID: 38381352 DOI: 10.1007/s40261-024-01345-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND AND OBJECTIVES Two oral calcitonin gene-related peptide (CGRP) antagonists, atogepant and rimegepant, were approved in 2021 for the preventive treatment of episodic migraine (EM), yet no formal cost-effectiveness analysis has been published. The objective of this study was to evaluate the cost-effectiveness of atogepant 60 mg and rimegepant 75 mg compared with placebo. METHODS A decision tree model was constructed over a 1-year time horizon from a US societal perspective. Patient cohorts were simulated using baseline and change from baseline monthly migraine days (MMDs) reported in the trials to incorporate responder rates and within patient response into the model. Due to heterogeneity between the trial populations, each medication was compared with its respective trial's placebo group. Direct healthcare resource costs, productivity costs, acute medication costs, and quality-of-life values were obtained from the literature. RESULTS The atogepant cohort experienced an incremental increase in healthcare plus productivity costs of $11,978 when compared with placebo, with a gain of 0.026 quality-adjusted life-years (QALYs). This yielded an incremental cost-effectiveness ratio (ICER) of more than $450,000/QALY. The rimegepant cohort experienced an incremental increase of $21,692 when compared with placebo, with a gain of 0.024 QALYs. This yields an ICER of more than $890,000/QALY when comparing rimegepant with placebo. Cost savings between atogepant and atogepant placebo were greatest with respect to acute medication costs at $735 of savings over 1 year, followed by savings of $135 for healthcare resource utilization and $34 for productivity costs. A similar relationship was seen between rimegepant and rimegepant placebo. One-way deterministic sensitivity analysis found that monthly acquisition costs of atogepant and rimegepant had the largest impact on the ICER, respectively. CONCLUSIONS Atogepant and rimegepant were both unable to meet generally accepted cost-effectiveness thresholds < 150,0000/QALY. Additional studies are needed to better guide decision making regarding oral CGRPs' place in therapy.
Collapse
Affiliation(s)
- Ryan Thaliffdeen
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, 2409 University Ave. Stop A 1930, Austin, TX, 78712, USA.
| | - Anthony Yu
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, 2409 University Ave. Stop A 1930, Austin, TX, 78712, USA
| | - Karen Rascati
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, 2409 University Ave. Stop A 1930, Austin, TX, 78712, USA
| |
Collapse
|
15
|
Padula WV, Crawford SA, Kennerly SM, Yap TL. Estimating the value of repositioning timing to streamline pressure injury prevention efforts in nursing homes: A cost-effectiveness analysis of the 'TEAM-UP' clinical trial. Int Wound J 2024; 21:e14452. [PMID: 37909183 PMCID: PMC10895199 DOI: 10.1111/iwj.14452] [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: 07/21/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023] Open
Abstract
Pressure injury (PrI) prevention guidelines recommend 2-h repositioning intervals in healthcare settings, requiring significant nursing time investment. We analysed the cost-effectiveness of PrI prevention protocols with 2-, 3- and 4-h repositioning intervals in US nursing homes according to 'Turn Everyone and Move for Ulcer Prevention' (TEAM-UP) randomized controlled trial findings. Markov modelling compared 2-, 3- and 4-h repositioning intervals, controlling for other practice guidelines, to prevent PrIs in nursing home residents from a US health sector perspective over one year using TEAM-UP trial data for model structure, sampling and parameterization. Costs, captured in 2020 US dollars, and quality-adjusted life years (QALYs) were used to derive an incremental cost-effectiveness ratio and net monetary benefit (NMB) at $50 000/QALY-$150 000/QALY cost-effectiveness thresholds. Sensitivity analyses tested model uncertainty. Repositioning intervals between 3 and 4 h were cost-effective based on reduced costs at slightly lower QALYs than 2 h at a $50 000/QALY threshold, and the NMB of 4-h repositioning was also more efficient than at 3 h ($9610). Repositioning labour cost and prevention routines were among the most sensitive parameters. Sensitivity analyses demonstrated that 3- and 4-h intervals were cost-effective in over 65% of simulations at any cost-effectiveness threshold. Repositioning intervals of 3 to 4 h have potential to reduce nursing time costs without significant decrements in clinical benefits to nursing home residents. Clinical guidelines for PrI prevention should be updated to reflect TEAM-UP clinical and economic findings. Facilities can use cost-savings recuperated from nursing time to deploy to other patient safety priorities without seriously jeopardizing PrI safety.
Collapse
Affiliation(s)
- William V. Padula
- Department of Pharmaceutical & Health Economics, School of PharmacyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Leonard D. Schaeffer Center for Health Policy & EconomicsUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Acute & Chronic Care, School of NursingJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Samuel A. Crawford
- Department of Pharmaceutical & Health Economics, School of PharmacyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Leonard D. Schaeffer Center for Health Policy & EconomicsUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Susan M. Kennerly
- College of NursingEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Tracey L. Yap
- School of NursingDuke UniversityDurhamNorth CarolinaUSA
| |
Collapse
|
16
|
Paulden M. A Framework for the Fair Pricing of Medicines. PHARMACOECONOMICS 2024; 42:145-164. [PMID: 38066357 PMCID: PMC10810971 DOI: 10.1007/s40273-023-01325-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 01/26/2024]
Abstract
As high-cost medicines put increasing pressure on public health care budgets, the need to identify 'fair' prices for medicines has never been greater. This paper proposes a framework, built upon fundamental economic principles, that allows for the consideration of 'fair' prices for medicines. The framework incorporates key considerations from conventional supply-side and demand-side approaches for specifying a cost-effectiveness 'threshold', including the health opportunity cost borne by other patients ([Formula: see text]) and society's willingness to pay for marginal improvements in population health ([Formula: see text]). The costs incurred by manufacturers in developing and supplying new medicines are also considered, as are the incentives for manufacturers to strategically price up to any common price per unit of benefit (cost-effectiveness 'threshold') specified by the payer. The framework finds that, at any 'fair' price, a medicine's dynamically calculated incremental cost-effectiveness ratio (ICER) lies below [Formula: see text]. When pricing medicines collectively, the framework finds that a common price below [Formula: see text] is required to maximize population health (consumer surplus) or to maximize total welfare (consumer and producer surplus). This framework has important policy implications for payers who wish to improve population health outcomes from constrained health care budgets. In particular, existing approaches to 'value-based pricing' should be reconsidered to ensure that patients receive a 'fair' share of the resulting economic surplus.
Collapse
Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, Edmonton, Canada.
| |
Collapse
|
17
|
Basu A, Winn AN, Johnson KM, Jiao B, Devine B, Hankins JS, Arnold SD, Bender MA, Ramsey SD. Gene Therapy Versus Common Care for Eligible Individuals With Sickle Cell Disease in the United States : A Cost-Effectiveness Analysis. Ann Intern Med 2024; 177:155-164. [PMID: 38252942 DOI: 10.7326/m23-1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Sickle cell disease (SCD) and its complications contribute to high rates of morbidity and early mortality and high cost in the United States and African heritage community. OBJECTIVE To evaluate the cost-effectiveness of gene therapy for SCD and its value-based prices (VBPs). DESIGN Comparative modeling analysis across 2 independently developed simulation models (University of Washington Model for Economic Analysis of Sickle Cell Cure [UW-MEASURE] and Fred Hutchinson Institute Sickle Cell Disease Outcomes Research and Economics Model [FH-HISCORE]) using the same databases. DATA SOURCES Centers for Medicare & Medicaid Services claims data, 2008 to 2016; published literature. TARGET POPULATION Persons eligible for gene therapy. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care sector and societal. INTERVENTION Gene therapy versus common care. OUTCOME MEASURES Incremental cost-effectiveness ratios (ICERs), equity-informed VBPs, and price acceptability curves. RESULTS OF BASE-CASE ANALYSIS At an assumed $2 million price for gene therapy, UW-MEASURE and FH-HISCORE estimated ICERs of $193 000 per QALY and $427 000 per QALY, respectively, under the health care sector perspective. Corresponding estimates from the societal perspective were $126 000 per QALY and $281 000 per QALY. The difference in results between models stemmed primarily from considering a slightly different target population and incorporating the quality-of-life (QOL) effects of splenic sequestration, priapism, and acute chest syndrome in the UW model. From a societal perspective, acceptable (>90% confidence) VBPs ranged from $1 million to $2.5 million depending on the use of alternative effective metrics or equity-informed threshold values. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to the costs of myeloablative conditioning before gene therapy, effect on caregiver QOL, and effect of gene therapy on long-term survival. LIMITATION The short-term effects of gene therapy on vaso-occlusive events were extrapolated from 1 study. CONCLUSION Gene therapy for SCD below a $2 million price tag is likely to be cost-effective when applying a societal perspective at an equity-informed threshold for cost-effectiveness analysis. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
Collapse
Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy; Department of Health Systems and Population Health; and Department of Economics, University of Washington, Seattle, Washington (A.B.)
| | - Aaron N Winn
- Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - Kate M Johnson
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Faculty of Pharmaceutical Sciences and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (K.M.J.)
| | - Boshen Jiao
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (B.J.)
| | - Beth Devine
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, and Department of Health Systems and Population Health, University of Washington, Seattle, Washington (B.D.)
| | - Jane S Hankins
- Department of Global Pediatric Medicine and Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee (J.S.H.)
| | - Staci D Arnold
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia (S.D.A.)
| | - M A Bender
- Department of Pediatrics, University of Washington, and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (M.A.B.)
| | - Scott D Ramsey
- Division of Public Health Sciences and Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and the Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (S.D.R.)
| |
Collapse
|
18
|
Tahami Monfared AA, Khachatryan A, Hummel N, Kopiec A, Martinez M, Zhang R, Zhang Q. Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys. J Alzheimers Dis 2024; 99:191-206. [PMID: 38640156 DOI: 10.3233/jad-231259] [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: 04/21/2024]
Abstract
Background Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD. Objective To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity. Methods An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics. Results One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01). Conclusions Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.
Collapse
|
19
|
Wu C, Li W, Tao H, Zhang X, Xin Y, Song R, Wang K, Zuo L, Cai Y, Wu H, Hui W. Cost-effectiveness of first-line immunotherapy for advanced non-small cell lung cancer with different PD-L1 expression levels: A comprehensive overview. Crit Rev Oncol Hematol 2024; 193:104195. [PMID: 37931769 DOI: 10.1016/j.critrevonc.2023.104195] [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] [Received: 07/20/2023] [Revised: 10/15/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Immunotherapies can substantially improve treatment efficacy, despite their high cost. A comprehensive overview of the cost-effectiveness analysis (CEA) of immune checkpoint inhibitors (ICIs) in patients with non-small cell lung cancer based on different tumor proportion scores (TPSs) was conducted. METHODS PubMed, Embase, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, and NHS Economic Evaluation databases were searched from their inception until August 24, 2022. Data relevant to the CEA results were recorded, and quality assessments conducted based on the Quality of Health Economic Studies (QHES) process. FINDINGS Fifty-one original studies from seven countries were included. The mean QHES score was 77.0 (range: 53-95). Twenty-seven studies were classified as high-quality, and the rest as fair quality. Pembrolizumab, nivolumab, ipilimumab, atezolizumab, camrelizumab, cemiplimab, sintilimab, tislelizumab, and durvalumab were identified using three TPS categories. While nivolumab plus ipilimumab and pembrolizumab plus chemotherapy were unlikely to be cost-effective in China, the results for the US were uncertain. Atezolizumab combinations were not cost-effective in China or the US, and tislelizumab and sintilimab were cost-effective in China. For TPSs ≥ 50%, the pembrolizumab monotherapy could be cost-effective in some developed countries. Cemiplimab was more cost-effective than chemotherapy, pembrolizumab, and atezolizumab in the US. For TPSs ≥ 1%, the cost-effectiveness of pembrolizumab was controversial due to the different willingness-to-pay thresholds. CONCLUSIONS None of the atezolizumab combination regimens were found to be cost-effective in any perspective of evaluations. Camrelizumab, tislelizumab, and sintilimab have lower ICERs compared to atezolizumab, pembrolizumab, and nivolumab in China. Cemiplimab may be a more affordable alternative to pembrolizumab or atezolizumab. However, it remains unclear which ICIs are the best choices for each country. Future CEAs are required to select comprehensive regimens alongside randomized trials and real-world studies to help verify the economics of ICIs in specific decision-making settings.
Collapse
Affiliation(s)
- Changjin Wu
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Wentan Li
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Hongyu Tao
- Laboratory of Oncology, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiyan Zhang
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Yu Xin
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruomeng Song
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Kaige Wang
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ling Zuo
- Department of Pulmonary and Critical Care Medicine, West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China; Integrated Care Management Center, Outpatient Department, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuanyi Cai
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Huazhang Wu
- School of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Wen Hui
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
20
|
Kenney EL, Lee MM, Barrett JL, Ward ZJ, Long MW, Cradock AL, Williams DR, Gortmaker SL. Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity. Pediatrics 2024; 153:e2023063182. [PMID: 38258385 PMCID: PMC10827651 DOI: 10.1542/peds.2023-063182] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities. METHODS We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained. RESULTS An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented. CONCLUSIONS Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.
Collapse
Affiliation(s)
- Erica L. Kenney
- Department of Nutrition
- Department of Social and Behavioral Sciences
| | | | | | - Zachary J. Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Michael W. Long
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | | | | |
Collapse
|
21
|
Zhao Z, Yang Y, Wu W, Dong H. Willingness to pay for cancer prevention versus treatment in China: implications for cost-effectiveness threshold. Expert Rev Pharmacoecon Outcomes Res 2024; 24:155-160. [PMID: 37754783 DOI: 10.1080/14737167.2023.2262141] [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] [Received: 06/14/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Zixuan Zhao
- Department of Public Administration, School of Health Economics and Management, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yi Yang
- Department of Science and Education of the Fourth Affiliated Hospital, and Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Weijia Wu
- Department of Science and Education of the Fourth Affiliated Hospital, and Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| | - Hengjin Dong
- Department of Science and Education of the Fourth Affiliated Hospital, and Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
22
|
Ackerman M, Holmes CS, Antigua JR, Riback LR, Zhang C, Walker JG, Vickerman P, Travers A, Linder M, Day R, Fox AD, Cunningham CO, Akiyama MJ. Mitigation through on-site testing & education among formerly incarcerated individuals against Covid-19 - The MOSAIC study: Design and rationale. Contemp Clin Trials 2024; 136:107406. [PMID: 38097063 PMCID: PMC11055630 DOI: 10.1016/j.cct.2023.107406] [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: 08/31/2023] [Revised: 11/29/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care post-release. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care. METHODS We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention. DISCUSSION The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations.
Collapse
Affiliation(s)
- Maxwell Ackerman
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Connor S Holmes
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Jordy Rojas Antigua
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Lindsey R Riback
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Chenshu Zhang
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Josephine G Walker
- Bristol Medical School, Population Health Sciences, University of Bristol, Queens Road, Bristol BS8 1QU, UK
| | - Peter Vickerman
- Bristol Medical School, Population Health Sciences, University of Bristol, Queens Road, Bristol BS8 1QU, UK
| | - Ann Travers
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Micaela Linder
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Ronald Day
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Aaron D Fox
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Matthew J Akiyama
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America.
| |
Collapse
|
23
|
Jansen JP, Ragavan MV, Chen C, Douglas MP, Phillips KA. The Health Inequality Impact of Liquid Biopsy to Inform First-Line Treatment of Advanced Non-Small Cell Lung Cancer: A Distributional Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1697-1710. [PMID: 37741446 PMCID: PMC10859998 DOI: 10.1016/j.jval.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES To perform a distributional cost-effectiveness analysis of liquid biopsy (LB) followed by, if needed, tissue biopsy (TB) (LB-first strategy) relative to a TB-only strategy to inform first-line treatment of advanced non-small cell lung cancer (aNSCLC) from a US payer perspective by which we quantify the impact of LB-first on population health inequality according to race and ethnicity. METHODS With a health economic model, quality-adjusted life-years (QALYs) and costs per patient were estimated for each subgroup. Given the lifetime risk of aNSCLC, and assuming equally distributed opportunity costs, the incremental net health benefits of LB-first were calculated, which were used to estimate general population quality-adjusted life expectancy at birth (QALE) by race and ethnicity with and without LB-first. The degree of QALYs and QALE differences with the strategies was expressed with inequality indices. Their differences were defined as the inequality impact of LB-first. RESULTS LB-first resulted in an additional 0.21 (95% uncertainty interval: 0.07-0.39) QALYs among treated patients, with the greatest gain observed among Asian patients (0.31 QALYs [0.09-0.61]). LB-first resulted in an increase in relative inequality in QALYs among patients, but a minor decrease in relative inequality in QALE. CONCLUSIONS LB-first to inform first-line aNSCLC therapy can improve health outcomes. With current diagnostic performance, the benefit is the greatest among Asian patients, thereby potentially widening racial and ethnic differences in survival among patients with aNSCLC. Assuming equally distributed opportunity costs and access, LB-first does not worsen and, in fact, may reduce inequality in general population health according to race and ethnicity.
Collapse
Affiliation(s)
- Jeroen P Jansen
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA; UCSF Philip R. Lee Institute for Health Policy, San Francisco, CA, USA.
| | - Meera V Ragavan
- Division of Hematology and Oncology, UCSF Department of Medicine, San Francisco, CA, USA
| | - Cheng Chen
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA; UCSF Philip R. Lee Institute for Health Policy, San Francisco, CA, USA
| |
Collapse
|
24
|
Chew DS, Li Y, Bigelow R, Cowper PA, Anstrom KJ, Daniels MR, Davidson-Ray L, Hernandez AF, O'Connor CM, Armstrong PW, Mark DB. Cost-Effectiveness of Vericiguat in Patients With Heart Failure With Reduced Ejection Fraction: The VICTORIA Randomized Clinical Trial. Circulation 2023; 148:1087-1098. [PMID: 37671551 DOI: 10.1161/circulationaha.122.063602] [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: 12/09/2022] [Accepted: 08/10/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND The VICTORIA trial (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) demonstrated that, in patients with high-risk heart failure, vericiguat reduced the primary composite outcome of cardiovascular death or heart failure hospitalization relative to placebo. The hazard ratio for all-cause mortality was 0.95 (95% CI, 0.84-1.07). In a prespecified analysis, treatment effects varied substantially as a function of baseline NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, with survival benefit for vericiguat in the lower NT-proBNP quartiles (hazard ratio, 0.82 [95% CI, 0.69-0.97]) and no benefit in the highest NT-proBNP quartile (hazard ratio, 1.14 [95% CI, 0.95-1.38]). An economic analysis was a major secondary objective of the VICTORIA research program. METHODS Medical resource use data were collected for all VICTORIA patients (N=5050). Costs were estimated by applying externally derived US cost weights to resource use counts. Life expectancy was projected from patient-level empirical trial survival results with the use of age-based survival modeling methods. Quality-of-life adjustments were based on prospectively collected EQ-5D-based utilities. The primary outcome was the incremental cost-effectiveness ratio, comparing vericiguat with placebo, assessed from the US health care sector perspective over a lifetime horizon. Cost-effectiveness was estimated using the total VICTORIA cohort, both with and without interaction between treatment and baseline NT-proBNP. RESULTS Life expectancy modeling results varied according to whether the observed heterogeneity of treatment effect by baseline NT-proBNP values was incorporated into the modeling. Including the interaction term, the vericiguat arm had an estimated quality-adjusted life expectancy of 4.56 quality-adjusted life-years (QALYs) compared with 4.13 QALYs for placebo (incremental discounted QALY, 0.43). Without the treatment heterogeneity/interaction term, vericiguat had 4.50 QALYs compared with 4.33 QALYs for placebo (incremental discounted QALY, 0.17). Incremental discounted costs (vericiguat minus placebo) were $28 546 with the treatment interaction and $20 948 without it. Corresponding incremental cost-effectiveness ratios were $66 509 per QALY allowing for treatment heterogeneity and $124 512 without heterogeneity. CONCLUSIONS Vericiguat use in the VICTORIA trial met criteria for intermediate value, but the incremental cost-effectiveness ratio estimates were sensitive to whether the analysis accounted for observed NT-proBNP treatment effect heterogeneity. The cost-effectiveness of vericiguat was driven by the projected incremental life expectancy among patients in the lowest 3 quartiles of NT-proBNP. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
Collapse
Affiliation(s)
- Derek S Chew
- Libin Cardiovascular Institute and O'Brien Institute for Public Health, University of Calgary, AB, Canada (D.S.C.)
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Yanhong Li
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Robert Bigelow
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill (K.J.A.)
| | - Melanie R Daniels
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Linda Davidson-Ray
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
| | - Christopher M O'Connor
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
- Inova Heart and Vascular Institute, Falls Church, VA (C.M.O.)
| | - Paul W Armstrong
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Canada (P.W.A.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
| |
Collapse
|
25
|
Rane A, Nechi RN, Imam M, Zoni CR, Ndikumukiza C, Karaye IM, Yunusa I, Alanzi A. Comparative value of dapagliflozin vs empagliflozin in patients with heart failure and preserved ejection fraction: A cost-effectiveness analysis. J Manag Care Spec Pharm 2023; 29:1045-1053. [PMID: 37610112 PMCID: PMC10508839 DOI: 10.18553/jmcp.2023.29.9.1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) imposes a high disease burden on patients, primarily because of multimorbidity and frequent hospitalizations. Recently, the American College of Cardiology Expert Consensus recommended treating all patients diagnosed with HFpEF with a sodium-glucose cotransporter 2 inhibitor, such as dapagliflozin or empagliflozin, to reduce the risk of cardiovascular death and hospitalization and improve health status. However, managing HFpEF can be expensive, highlighting the need to assess therapeutic alternatives that can minimize health care costs while optimizing patient outcomes. OBJECTIVE: To compare the cost-effectiveness of dapagliflozin vs empagliflozin in managing patients with HFpEF from the US health care system perspective. METHODS: We developed a Markov model to simulate a cohort of patients with HFpEF (defined as having a left ventricular ejection fraction ≥ 50%) treated with dapagliflozin or empagliflozin. Transition probabilities between 3 health states (HFpEF, hospitalization for heart failure, and death), costs, and quality of life weight input variables were obtained from the literature. In the base-case analysis, we estimated total expected costs, quality-adjusted life-years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) over a lifetime horizon. All future expected costs and QALYs were discounted at the annual rate of 3%. We conducted sensitivity analyses to demonstrate the robustness of the cost-effectiveness model findings. RESULTS: Dapagliflozin had an incremental expected lifetime cost of $29,896 compared with empagliflozin, resulting in an ICER of $36,902/QALY. Value-based price threshold analysis suggested that for empagliflozin to be cost-effective, it would need a 29% discount on its annual price. In a probabilistic sensitivity analysis, dapagliflozin would be the most preferred cost-effective option at willingness-to-pay thresholds of $50,000/QALY about 72% of the time. CONCLUSIONS: This cost-effectiveness analysis showed that, from the US health care system perspective, dapagliflozin was more cost-effective than empagliflozin, and its uptake may enhance long-term outcomes in patients with HFpEF.
Collapse
Affiliation(s)
- Amey Rane
- Massachusetts College of Pharmacy and Health Sciences, Boston
| | | | | | | | | | | | - Ismaeel Yunusa
- Department of Clinical Pharmacy and Outcomes Sciences and Center for Outcomes Research and Evaluation, University of South Carolina College of Pharmacy, Columbia
| | - Abdullah Alanzi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Al-Jouf Province, Saudi Arabia
| |
Collapse
|
26
|
Kim DD. Accounting for Nonhealth and Future Costs in Cost-Effectiveness Analysis: Distributional Impacts of a US Cancer Prevention Strategy. PHARMACOECONOMICS 2023; 41:1151-1164. [PMID: 37195368 PMCID: PMC10189225 DOI: 10.1007/s40273-023-01275-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE To provide up-to-date and comprehensive US data tables to estimate future net resource use, including nonlabor market production, and examine distributional impacts of including nonhealth and future costs in cost-effectiveness results. METHODS Using a published US cancer prevention simulation model, the paper evaluated the lifetime cost effectiveness of implementing a 10% excise tax on processed meats across age- and sex-specific population subgroups. The model examined multiple scenarios accounting for cancer-related healthcare expenditure (HCE) only, cancer-related and unrelated background HCE, adding productivity benefits (i.e., patient time, cancer-related productivity loss, and background labor and nonlabor market production), and with nonhealth consumption costs, adjusted for household economies of scale. Additional analyses include using population-average versus age-sex-specific estimates for quantifying production and consumption value, as well as comparing direct model estimation versus postcorrections with Meltzer's approximation for incorporating future resource use. RESULTS Accounting for nonhealth and future costs impacted cost-effectiveness results across population subgroups, often leading to changes in "cost-saving" determination. Including nonlabor market production had a noticeable impact on estimating future resource use and reduced the bias toward undervaluing productivity among females and older populations. The use of age-sex-specific estimates resulted in less favorable cost-effectiveness results compared with population-average estimates. Meltzer's approximation provided reasonable corrections among the middle-aged population for re-engineering cost-effectiveness ratios from a healthcare sector to a societal perspective. CONCLUSION With updated US data tables, this paper can help researchers conduct a comprehensive value assessment to reflect net resource use (health and nonhealth resource use minus production value) from a societal perspective.
Collapse
Affiliation(s)
- David D Kim
- Department of Medicine, Section of Hospital Medicine, The University of Chicago, 5841 South Maryland Ave., MC 5000, Chicago, IL, 60637, USA.
| |
Collapse
|
27
|
Ulfsdottir H, Bäck M, Cider Å, Jivegård L, Sandberg A, Nordanstig J, Svensson M. Cost-Effectiveness of Exercise Therapy in Patients with Intermittent Claudication-A Comparison of Supervised Exercise, Home-Based Structured Exercise, and Walk Advice from the SUNFIT Trial. J Clin Med 2023; 12:5277. [PMID: 37629318 PMCID: PMC10455939 DOI: 10.3390/jcm12165277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/19/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Hospital-based supervised exercise (SEP) is a guideline-recommended intervention for patients with intermittent claudication (IC). However, due to the limited availability of SEP, home-based structured exercise programs (HSEP) have become increasingly popular alongside the "go home and walk" advice. We evaluated the cost-effectiveness of walk advice (WA) with Nordic pole walking vs. SEP combined with WA or HSEP combined with WA. We used data from the SUNFIT RCT (NCT02341716) to measure quality-adjusted life-years (QALYs) over a 12-month follow-up, and economic costs were obtained from a hospital cost-per-patient accounting system. Incremental cost-effectiveness ratios (ICERs) were calculated, and uncertainty was assessed using nonparametric bootstrapping. The average health-care-cost per patient was similar in the WA (EUR 1781, n = 51) and HSEP (EUR 1820, n = 48) groups but higher in the SEP group (EUR 4619, n = 50, p-value < 0.01). Mean QALYs per patient during the follow-up were similar with no statistically significant differences. The findings do not support SEP as a cost-effective treatment for IC, as it incurred significantly higher costs without providing additional health improvements over WA with or without HSEP during the one-year observation period. The analysis also suggested that HSEP may be cost-effective compared to WA, but only with a 64% probability.
Collapse
Affiliation(s)
- Hildigunnur Ulfsdottir
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Sidekick Health, 413 90 Gothenburg, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Åsa Cider
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Lennart Jivegård
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Health Technology Assessment Centre Region Västra Götaland, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Anna Sandberg
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden; (M.B.); (Å.C.); (A.S.)
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Department of Vascular Surgery, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL 32610, USA
| |
Collapse
|
28
|
Berkowitz SA, Basu S, Hanmer J. Eliminating Food Insecurity in the USA: a Target Trial Emulation Using Observational Data to Estimate Effects on Health-Related Quality of Life. J Gen Intern Med 2023; 38:2308-2317. [PMID: 36814050 PMCID: PMC10406772 DOI: 10.1007/s11606-023-08095-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Food insecurity is associated with many aspects of poor health. However, trials of food insecurity interventions typically focus on outcomes of interest to funders, such as healthcare use, cost, or clinical performance metrics, rather than quality of life outcomes that may be prioritized by individuals who experience food insecurity. OBJECTIVE To emulate a trial of a food insecurity elimination intervention, and quantify its estimated effects on health utility, health-related quality of life, and mental health. DESIGN Target trial emulation using longitudinal, nationally representative data, from the USA, 2016-2017. PARTICIPANTS A total of 2013 adults in the Medical Expenditure Panel Survey screened positive for food insecurity, representing 32 million individuals. MAIN MEASURES Food insecurity was assessed using the Adult Food Security Survey Module. The primary outcome was the SF-6D (Short-Form Six Dimension) measure of health utility. Secondary outcomes were mental component score (MCS) and physical component score (PCS) of the Veterans RAND 12-Item Health Survey (a measure of health-related quality of life), Kessler 6 (K6) psychological distress, and Patient Health Questionnaire 2-item (PHQ2) depressive symptoms. KEY RESULTS We estimated that food insecurity elimination would improve health utility by 80 QALYs per 100,000 person-years, or 0.008 QALYs per person per year (95% CI 0.002 to 0.014, p = 0.005), relative to the status quo. We also estimated that food insecurity elimination would improve mental health (difference in MCS [95% CI]: 0.55 [0.14 to 0.96]), physical health (difference in PCS: 0.44 [0.06 to 0.82]), psychological distress (difference in K6: -0.30 [-0.51 to -0.09]), and depressive symptoms (difference in PHQ-2: -0.13 [-0.20 to -0.07]). CONCLUSIONS Food insecurity elimination may improve important, but understudied, aspects of health. Evaluations of food insecurity interventions should holistically investigate their potential to improve many different aspects of health.
Collapse
Affiliation(s)
- Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Sanjay Basu
- Research and Development, Waymark, San Francisco, CA, USA
| | - Janel Hanmer
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
29
|
Lim F, Bellows BK, Tan SX, Aziz Z, Woo Baidal JA, Kelly AS, Hur C. Cost-Effectiveness of Pharmacotherapy for the Treatment of Obesity in Adolescents. JAMA Netw Open 2023; 6:e2329178. [PMID: 37651143 PMCID: PMC10472196 DOI: 10.1001/jamanetworkopen.2023.29178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/09/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Antiobesity pharmacotherapy is recommended for adolescents ages 12 years and older with obesity. Several medications have been approved by the US Food and Drug Administration for adolescent use, but the most cost-effective medication remains unclear. Objective To estimate the cost-effectiveness of lifestyle counseling alone and as adjunct to liraglutide, mid-dose phentermine and topiramate (7.5 mg phentermine and 46 mg topiramate), top-dose phentermine and topiramate (15 mg phentermine and 92 mg topiramate), or semaglutide among adolescent patients with obesity. Design, Setting, and Participants This economic evaluation used a microsimulation model to project health and cost outcomes of lifestyle counseling alone and adjunct to liraglutide, mid-dose phentermine and topiramate, top-dose phentermine and topiramate, or semaglutide over 13 months, 2 years, and 5 years among a hypothetical cohort of 100 000 adolescents with obesity, defined as an initial body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 37. Model inputs were derived from clinical trials, published literature, and national sources. Data were analyzed from April 2022 to July 2023. Exposures Lifestyle counseling alone and as adjunct to liraglutide, mid-dose phentermine and topiramate, top-dose phentermine and topiramate, or semaglutide. Main Outcomes and Measures The main outcome was quality-adjusted life years (QALYs), costs (2022 US dollars), and incremental cost-effectiveness ratios (ICERs), with future costs and QALYs discounted 3.0% annually. A strategy was considered cost-effective if the ICER was less than $100 000 per QALY gained. The preferred strategy was determined as the strategy with the greatest increase in QALYs while being cost-effective. One-way and probabilistic sensitivity analyses were used to assess parameter uncertainty. Results The model simulated 100 000 adolescents at age 15 with an initial BMI of 37, of whom 58 000 (58%) were female. At 13 months and 2 years, lifestyle counseling was estimated to be the preferred strategy. At 5 years, top-dose phentermine and topiramate was projected to be the preferred strategy with an ICER of $56 876 per QALY gained vs lifestyle counseling. Semaglutide was projected to yield the most QALYs, but with an unfavorable ICER of $1.1 million per QALY gained compared with top-dose phentermine and topiramate. Model results were most sensitive to utility of weight reduction and weight loss of lifestyle counseling and top-dose phentermine and topiramate. Conclusions and Relevance In this economic evaluation of pharmacotherapy for adolescents with obesity, top-dose phentermine and topiramate as adjunct to lifestyle counseling was estimated to be cost-effective after 5 years. Long-term clinical trials in adolescents are needed to fully evaluate the outcomes of pharmacotherapy, especially into adulthood.
Collapse
Affiliation(s)
- Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Brandon K. Bellows
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sarah Xinhui Tan
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
| | - Zainab Aziz
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | | | - Aaron S. Kelly
- Department of Pediatrics and Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
30
|
Thepsuwan A, Tontisirin N, Euasobhon P, Pannangpetch P, Leerapan B, Pattanaprateep O, Cohen SP. Cost-Effectiveness and Cost-Utility Analyses in Thailand of Continuous Intrathecal Morphine Infusion Compared with Conventional Therapy in Cancer Pain: A 10-year Multicenter Retrospective Study. Can J Pain 2023; 7:2225564. [PMID: 37533506 PMCID: PMC10392764 DOI: 10.1080/24740527.2023.2225564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023]
Abstract
Background Because of the high initial cost of intrathecal drug delivery (ITDD) therapy, this study investigated the cost-effectiveness and cost-utility of ITDD therapy in refractory cancer pain management in Thailand over the past 10 years. Methods The retrospective study was conducted in patients with cancer pain who underwent ITDD therapy from January 2011 to 2021 at three university hospitals. Clinical outcomes included the numerical rating scale (NRS), Palliative Performance Scale, and the EQ-5D. The direct medical and nonmedical as well as indirect costs were also recorded. Cost-effectiveness and cost-utility analyses were performed comparing ITDD therapy with conventional therapy (extrapolated from costs of the same patient before ITDD therapy) from a societally oriented economic evaluation. Results Twenty patients (F:M: 10:10) aged 60 ± 15 years who underwent implantation of an intrathecal percutaneous port (IT port; n = 15) or programmable intrathecal pump (IT pump; n = 5) were included. The median survival time was 78 (interquartile range = 121-54) days after ITDD therapy. At 2-month follow-up, the incremental cost-effectiveness ratio (ICER)/pain reduction of an IT port (US$2065.36 (CA$2829.54)/2-point NRS reduction/lifetime) was lower than for patients with an IT pump (US$5479.26 (CA$7506.58)/2-point NRS reduction/lifetime) compared with continued conventional therapy. The ICER/quality-adjusted life years (QALYs) gained for an IT port compared with conventional treatment was US$93,999.31(CA$128,799.06)/QALY gained, which is above the cost-effectiveness threshold for Thailand. Conclusion The cost-effectiveness and cost-utility of IT port therapy for cancer pain was high relative to the cost of living in Thailand, above the cost-effectiveness threshold. Prospective cost analysis studies enrolling more patients with diverse cancers that investigate the benefit of early ITDD therapy with devices over a range of prices are warranted.
Collapse
Affiliation(s)
- Arpawan Thepsuwan
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nuj Tontisirin
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pramote Euasobhon
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patt Pannangpetch
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Borwornsom Leerapan
- Chakri Naruebodindra Medical Institute, Mahidol University, Samut Prakan, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Steven P. Cohen
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Departments of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| |
Collapse
|
31
|
Nechi RN, Rane A, Karaye RM, Ndikumukiza C, Alsahali S, Jatau AI, Zoni CR, Alanzi A, Karaye IM, Yunusa I. Cost-Effectiveness of Dapagliflozin vs Empagliflozin for Treating Heart Failure With Reduced Ejection Fraction in the United States. Clin Ther 2023; 45:627-632. [PMID: 37270374 DOI: 10.1016/j.clinthera.2023.05.002] [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] [Received: 01/31/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Evidence suggests that adding dapagliflozin to the prior standard of care is cost-effective compared with the standard of care alone. The latest guideline by the American Heart Association/American College of Cardiology/Heart Failure Society of America now recommends the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with heart failure with reduced ejection fraction (HFrEF). However, the relative cost-effectiveness of different SGLT2 inhibitors, including dapagliflozin and empagliflozin, has not been fully characterized. Therefore, we conducted a cost-effectiveness analysis to compare dapagliflozin and empagliflozin in patients with HFrEF from the US health care perspective. METHODS To compare the cost-effectiveness of dapagliflozin and empagliflozin in treating HFrEF, we used a state-transition Markov model. This model was used to estimate the expected lifetime costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) for both medications. The model incorporated patients who were 65 years of age at entry and simulated their health outcomes over a lifetime horizon. The perspective of the analysis was based on the US health care system. To determine the health state transition probabilities, we used a network meta-analysis. All future costs and QALYs were discounted at an annual rate of 3%, and the costs were presented in 2022 US dollars. FINDINGS The base case analysis found that the incremental expected lifetime cost of treating patients with dapagliflozin vs empagliflozin was $37,684, resulting in an ICER of $44,763 per QALY. A price threshold analysis indicated that for empagliflozin to be the most cost-effective SGLT2 inhibitor at a willingness-to-pay threshold of $50,000 per QALY, it may require a 12% discount on its current annual prices. IMPLICATIONS The findings of this study indicate that dapagliflozin may offer greater lifetime economic value when compared with empagliflozin. Given that the current clinical practice guideline does not recommend one SGLT2 inhibitor over the other, it is essential to implement scalable strategies to ensure affordable access to both medications. By doing so, patients and health care practitioners can make informed decisions about their treatment options without being constrained by financial barriers.
Collapse
Affiliation(s)
- Regina Nwamaka Nechi
- Penn State College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Amey Rane
- Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts
| | | | - Cyrille Ndikumukiza
- Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts
| | - Saud Alsahali
- Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | - Abubakar I Jatau
- School of Pharmacy and Pharmacology, University of Tasmania, Australia
| | | | - Abdullah Alanzi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Al-Jouf Province, Saudi Arabia
| | | | - Ismaeel Yunusa
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, South Carolina; Center for Outcomes Research and Evaluation, University of South Carolina College of Pharmacy, Columbia, South Carolina.
| |
Collapse
|
32
|
Borre ED, Johri M, Dubno JR, Myers ER, Emmett SD, Pavon JM, Francis HW, Ogbuoji O, Sanders Schmidler GD. Potential Clinical and Economic Outcomes of Over-the-Counter Hearing Aids in the US. JAMA Otolaryngol Head Neck Surg 2023; 149:607-614. [PMID: 37200042 PMCID: PMC10196927 DOI: 10.1001/jamaoto.2023.0949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/28/2023] [Indexed: 05/19/2023]
Abstract
Importance Over-the-counter (OTC) hearing aids are now available in the US; however, their clinical and economic outcomes are unknown. Objective To project the clinical and economic outcomes of traditional hearing aid provision compared with OTC hearing aid provision. Design, Setting, and Participants This cost-effectiveness analysis used a previously validated decision model of hearing loss (HL) to simulate US adults aged 40 years and older across their lifetime in US primary care offices who experienced yearly probabilities of acquiring HL (0.1%-10.4%), worsening of their HL, and traditional hearing aid uptake (0.5%-8.1%/y at a fixed uptake cost of $3690) and utility benefits (0.11 additional utils/y). For OTC hearing aid provision, persons with perceived mild to moderate HL experienced increased OTC hearing aid uptake (1%-16%/y) based on estimates of time to first HL diagnosis. In the base case, OTC hearing aid utility benefits ranged from 0.05 to 0.11 additional utils/y (45%-100% of traditional hearing aids), and costs were $200 to $1400 (5%-38% of traditional hearing aids). Distributions were assigned to parameters to conduct probabilistic uncertainty analysis. Intervention Provision of OTC hearing aids, at increased uptake rates, across a range of effectiveness and costs. Main Outcomes and Measures Lifetime undiscounted and discounted (3%/y) costs and quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results Traditional hearing aid provision resulted in 18.162 QALYs, compared with 18.162 to 18.186 for OTC hearing aids varying with OTC hearing aid utility benefit (45%-100% that of traditional hearing aids). Provision of OTC hearing aids was associated with greater lifetime discounted costs by $70 to $200 along with OTC device cost ($200-$1000/pair; 5%-38% traditional hearing aid cost) due to increased hearing aid uptake. Provision of OTC hearing aids was considered cost-effective (ICER<$100 000/QALY) if the OTC utility benefit was 0.06 or greater (55% of the traditional hearing aid effectiveness). In probabilistic uncertainty analysis, OTC hearing aid provision was cost-effective in 53% of simulations. Conclusions and Relevance In this cost-effectiveness analysis, provision of OTC hearing aids was associated with greater uptake of hearing intervention and was cost-effective over a range of prices so long as OTC hearing aids were greater than 55% as beneficial to patient quality of life as traditional hearing aids.
Collapse
Affiliation(s)
- Ethan D. Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Mohini Johri
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Judy R. Dubno
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Evan R. Myers
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Division of Women’s Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Susan D. Emmett
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock
| | - Juliessa M. Pavon
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, North Carolina
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Howard W. Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Osondu Ogbuoji
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, North Carolina
| | - Gillian D. Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
33
|
Harris A, Hinman RS, Lawford BJ, Egerton T, Keating C, Brown C, Metcalf B, Spiers L, Sumithran P, Quicke JG, Bennell KL. Cost-Effectiveness of Telehealth-Delivered Exercise and Dietary Weight Loss Programs for Knee Osteoarthritis Within a Twelve-Month Randomized Trial. Arthritis Care Res (Hoboken) 2023; 75:1311-1319. [PMID: 36106928 PMCID: PMC10953202 DOI: 10.1002/acr.25022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/23/2022] [Accepted: 09/13/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of telehealth-delivered exercise and diet-plus-exercise programs within 12 months. METHODS An economic evaluation within a 12-month, 3-arm, parallel randomized trial of two 6-month telehealth-delivered exercise programs, with and without a dietary component. A total of 415 people with knee osteoarthritis ages 45-80 years and body mass index of 28-40 kg/m2 were assigned to 1 of 2 telehealth-delivered exercise programs, 1 without (n = 172) and 1 with (n = 175) a dietary component (ketogenic very low calorie diet), or to an education control (n = 67), for 6 months, with 6 months follow-up. The primary economic outcomes were quality-adjusted life years (QALYs) and health system costs. Measured costs were the direct intervention (consultations, equipment/resources, and meal replacements) and health care use in 2020 Australian dollars ($AU1.5 = $US1). Secondary analysis included weight loss and work productivity gains. RESULTS The clinical trial demonstrated greater improvements in pain and function compared to information only for individuals with knee osteoarthritis and overweight/obesity. We can be 88% confident that diet plus exercise is cost effective ($45,500 per QALY), 53% confident that exercise is cost-effective ($67,600 per QALY) compared to the control, and 86% confident that augmenting exercise with the diet program is cost effective ($21,100 per QALY). CONCLUSION Telehealth-delivered programs targeting exercise with dietary intervention for people with knee osteoarthritis who have overweight/obesity are likely to be cost-effective, particularly if potential long-term gains from weight loss and work productivity are realized.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Ben Metcalf
- University of MelbourneMelbourneVictoriaAustralia
| | - Libby Spiers
- University of MelbourneMelbourneVictoriaAustralia
| | | | | | | |
Collapse
|
34
|
Oliva-Moreno J. Response letter for the comment made on our article entitled "Does the inclusion of societal costs change the economic evaluations recommendations? A systematic review for multiple sclerosis disease", published online last May in the European Journal of Health Economics, doi: 10.1007/s10198-022-01471-9. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:663-672. [PMID: 37000338 DOI: 10.1007/s10198-023-01564-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Juan Oliva-Moreno
- Faculty of Law and Social Sciences, University of Castilla la Mancha, Toledo, Spain.
| |
Collapse
|
35
|
Ethgen O, Murugan R, Echeverri J, Blackowicz M, Harenski K, Ostermann M. Economic Analysis of Renal Replacement Therapy Modality in Acute Kidney Injury Patients With Fluid Overload. Crit Care Explor 2023; 5:e0921. [PMID: 37637357 PMCID: PMC10456980 DOI: 10.1097/cce.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Acute kidney injury (AKI) and fluid overload (FO) are among the top reasons to initiate intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Prior research suggests CRRT provides more precise volume control, but whether CRRT is cost-effective remains unclear. We assessed the cost-effectiveness of CRRT for volume control compared with IHD from a U.S. healthcare payer perspective. DESIGN Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty. SETTING ICU. PATIENTS OR SUBJECTS AKI patients with FO. INTERVENTIONS IHD or CRRT. MEASUREMENTS AND MAIN RESULTS The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (-$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses. CONCLUSIONS Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.
Collapse
Affiliation(s)
- Olivier Ethgen
- Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium
- SERFAN Innovation, Namur, Belgium
| | - Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael Blackowicz
- Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium
- Baxter Healthcare Corporation, Deerfield, IL
| | - Kai Harenski
- Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| |
Collapse
|
36
|
Goshua G, Calhoun C, Ito S, James LP, Luviano A, Krishnamurti L, Pandya A. Distributional Cost-Effectiveness of Equity-Enhancing Gene Therapy in Sickle Cell Disease in the United States. Ann Intern Med 2023; 176:779-787. [PMID: 37247420 PMCID: PMC10370480 DOI: 10.7326/m22-3272] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Gene therapy is a potential cure for sickle cell disease (SCD). Conventional cost-effectiveness analysis (CEA) does not capture the effects of treatments on disparities in SCD, but distributional CEA (DCEA) uses equity weights to incorporate these considerations. OBJECTIVE To compare gene therapy versus standard of care (SOC) in patients with SCD by using conventional CEA and DCEA. DESIGN Markov model. DATA SOURCES Claims data and other published sources. TARGET POPULATION Birth cohort of patients with SCD. TIME HORIZON Lifetime. PERSPECTIVE U.S. health system. INTERVENTION Gene therapy at age 12 years versus SOC. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) (in dollars per quality-adjusted life-years [QALYs] gained) and threshold inequality aversion parameter (equity weight). RESULTS OF BASE-CASE ANALYSIS Gene therapy versus SOC for females yielded 25.5 versus 15.7 (males: 24.4 vs. 15.5) discounted lifetime QALYs at costs of $2.8 million and $1.0 million (males: $2.8 million and $1.2 million), respectively, with an ICER of $176 000 per QALY (full SCD population). The inequality aversion parameter would need to be 0.90 for the full SCD population for gene therapy to be preferred per DCEA standards. RESULTS OF SENSITIVITY ANALYSIS SOC was favored in 100.0% (females) and 87.1% (males) of 10 000 probabilistic iterations at a willingness-to-pay threshold of $100 000 per QALY. Gene therapy would need to cost less than $1.79 million to meet conventional CEA standards. LIMITATION Benchmark equity weights (as opposed to SCD-specific weights) were used to interpret DCEA results. CONCLUSION Gene therapy is cost-ineffective per conventional CEA standards but can be an equitable therapeutic strategy for persons living with SCD in the United States per DCEA standards. PRIMARY FUNDING SOURCE Yale Bernard G. Forget Scholars Program and Bunker Endowment.
Collapse
Affiliation(s)
- George Goshua
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut (G.G., C.C., S.I.)
| | - Cecelia Calhoun
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut (G.G., C.C., S.I.)
| | - Satoko Ito
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut (G.G., C.C., S.I.)
| | - Lyndon P James
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts (L.P.J., A.L.)
| | - Andrea Luviano
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts (L.P.J., A.L.)
| | - Lakshmanan Krishnamurti
- Section of Pediatric Hematology, Oncology and Bone Marrow Transplant, Yale University School of Medicine, New Haven, Connecticut (L.K.)
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (A.P.)
| |
Collapse
|
37
|
Cusick MM, Tisdale RL, Chertow GM, Owens DK, Goldhaber-Fiebert JD. Population-Wide Screening for Chronic Kidney Disease : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:788-797. [PMID: 37216661 PMCID: PMC11091494 DOI: 10.7326/m22-3228] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors have the potential to alter the natural history of chronic kidney disease (CKD), and they should be included in cost-effectiveness analyses of screening for CKD. OBJECTIVE To determine the cost-effectiveness of adding population-wide screening for CKD. DESIGN Markov cohort model. DATA SOURCES NHANES (National Health and Nutrition Examination Survey), U.S. Centers for Medicare & Medicaid Services data, cohort studies, and randomized clinical trials, including the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial. TARGET POPULATION Adults. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Screening for albuminuria with and without adding SGLT2 inhibitors to the current standard of care for CKD. OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually. RESULTS OF BASE-CASE ANALYSIS One-time CKD screening at age 55 years had an ICER of $86 300 per QALY gained by increasing costs from $249 800 to $259 000 and increasing QALYs from 12.61 to 12.72; this was accompanied by a decrease in the incidence of kidney failure requiring dialysis or kidney transplant of 0.29 percentage points and an increase in life expectancy from 17.29 to 17.45 years. Other options were also cost-effective. During ages 35 to 75 years, screening once prevented dialysis or transplant in 398 000 people and screening every 10 years until age 75 years cost less than $100 000 per QALY gained. RESULTS OF SENSITIVITY ANALYSIS When SGLT2 inhibitors were 30% less effective, screening every 10 years during ages 35 to 75 years cost between $145 400 and $182 600 per QALY gained, and price reductions would be required for screening to be cost-effective. LIMITATION The efficacy of SGLT2 inhibitors was derived from a single randomized controlled trial. CONCLUSION Screening adults for albuminuria to identify CKD could be cost-effective in the United States. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality, Veterans Affairs Office of Academic Affiliations, and National Institute of Diabetes and Digestive and Kidney Diseases.
Collapse
Affiliation(s)
- Marika M. Cusick
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Rebecca L. Tisdale
- VA Palo Alto Health Care System, Center for Innovation to
Implementation (Ci2i), Menlo Park, CA, USA
| | - Glenn M. Chertow
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford
University School of Medicine, Stanford, CA, USA
- Division of Nephrology, Department of Medicine, Stanford
University School of Medicine, Stanford, CA, USA
| | - Douglas K. Owens
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| | - Jeremy D. Goldhaber-Fiebert
- Department of Health Policy, School of Medicine, and
Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford
University, Stanford, CA, USA
| |
Collapse
|
38
|
Vallejo-Torres L. The Broader Opportunity Costs in the Broader Cost-Effectiveness Analysis Framework. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:373-384. [PMID: 37043159 PMCID: PMC10119227 DOI: 10.1007/s40258-023-00801-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The traditional cost-effectiveness analysis framework usually takes a healthcare system perspective, where the aim is to maximise population health from a fixed budget allocated to healthcare. Extensions to this framework have been suggested, including: (i) incorporating impacts that fall outside the healthcare sector; (ii) accounting for outcomes beyond health; and (iii) assessing equity considerations. Several alternatives have been proposed that serve these purposes, for example, the extended "impact inventory", the "beyond-the-QALY" approach and the distributional cost-effectiveness analysis. OBJECTIVE This paper aims to develop a comprehensive framework that incorporates into the cost-effectiveness analysis framework some of its most advocated extensions and provides a means of arriving at a unidimensional cost-effectiveness analysis result measure. METHODS Building on previous work, I proposed a framework that explicitly incorporates the full extent of the opportunity costs that arise when new dimensions and distributional concerns are included in cost-effectiveness analyses. A hypothetical example is provided as a way of illustration. RESULTS Operationalising the proposed framework requires system-wide representative values and/or robust estimates concerning: (i) selecting dimensions; (ii) measuring opportunity costs associated with each dimension; (iii) quantifying equity weights and percentages of beneficiaries and losers meeting equity considerations; and (iv) attaching monetary values to dimensions measured using a non-monetary metric. CONCLUSIONS Extending the cost-effectiveness analysis framework entails extending the measurement of the opportunity costs of funding decisions. This implies populating an ambitious puzzle that in some cases poses fundamental conceptual and empirical questions. Potential routes of further research that might facilitate such undertaking are proposed.
Collapse
Affiliation(s)
- Laura Vallejo-Torres
- Department of Quantitative Methods in Economics and Management, Universidad de Las Palmas de Gran Canaria, Edificio de Ciencias Económicas y Empresariales. Mȯdulo D. Campus de Tafira, Las Palmas de Gran Canaria, 35017, Spain.
| |
Collapse
|
39
|
Neumann PJ, Kim DD. Cost-effectiveness Thresholds Used by Study Authors, 1990-2021. JAMA 2023; 329:1312-1314. [PMID: 37071104 PMCID: PMC10114019 DOI: 10.1001/jama.2023.1792] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/02/2023] [Indexed: 04/19/2023]
Abstract
This study examines what study authors consider to be appropriate cost-effectiveness analysis thresholds as reflected in the referenced thresholds in their published cost-effectiveness analyses.
Collapse
Affiliation(s)
- Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - David D. Kim
- Department of Medicine, University of Chicago, Chicago, Illinois
| |
Collapse
|
40
|
Egan RC, Chaiken SR, Derrah K, Doshi U, Hersh A, Packer CH, Caughey AB. Universal Tetanus-Diphtheria-Pertussis Vaccination During Pregnancy: A Cost-Effectiveness Analysis. Obstet Gynecol 2023; 141:837-844. [PMID: 36897561 DOI: 10.1097/aog.0000000000005103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/15/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To assess the cost effectiveness of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination in pregnant patients in the United States. METHODS A decision-analytic model in TreeAge was developed to compare universal Tdap vaccination in pregnancy with no Tdap vaccination in pregnancy using a theoretical cohort of 3.66 million pregnant individuals, the approximate number of deliveries per year in the United States. Outcomes included infant pertussis infections, infant hospitalizations, infant encephalopathy cases, infant deaths, and maternal pertussis infections. All probabilities and costs were derived from the literature. Utilities were applied to discounted life expectancies at a rate of 3% to generate quality-adjusted life-years (QALYs). A strategy was considered cost effective if it had an incremental cost-effectiveness ratio of less than $100,000 per QALY. Univariable and multivariable sensitivity analyses were performed to assess the robustness of the model to changes in the baseline assumptions. RESULTS With a baseline assumption of vaccine cost at $47.75, Tdap vaccination was cost effective at $7,601 per QALY. The vaccination strategy was associated with a decrease of 22 infant deaths, 11 infant encephalopathy cases, 2,018 infant hospitalizations, 6,164 infant pertussis infections, and 8,585 maternal pertussis infections, with an increase of 19,489 QALYs. In sensitivity analyses, the strategy was cost effective until the incidence of maternal pertussis became lower than 1.6 cases per 10,000 individuals, the cost of the Tdap vaccine was greater than $540, or previous pertussis immunity was present in more than 92.1% of pregnant individuals. CONCLUSION In a theoretical U.S. cohort of 3.66 million pregnant individuals, Tdap vaccination during pregnancy is cost effective and reduces infant morbidity and mortality compared with no vaccination during pregnancy. These findings are especially relevant given that approximately half of individuals are not vaccinated during pregnancy and recent data have shown that postpartum maternal vaccination and cocooning strategies are ineffective. Public health strategies to encourage greater uptake of Tdap vaccination should be used to reduce the morbidity and mortality of pertussis infection.
Collapse
Affiliation(s)
- Rachel C Egan
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | | | | | | | | | | | | |
Collapse
|
41
|
Yunusa I, Love BL. Cost-Effectiveness of Vonoprazan-Based and Rifabutin-Based vs Other Regimens as First-Line Treatment of Helicobacter pylori Infection in the United States. Am J Gastroenterol 2023; 118:635-644. [PMID: 36693030 DOI: 10.14309/ajg.0000000000002146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/30/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The economic and clinical implications of eradicating Helicobacter pylori ( H. pylori ) with vonoprazan-based and rifabutin-based regimens vs other existing prepackaged first-line treatment options in the United States are unknown. Therefore, we evaluated the cost-effectiveness of vonoprazan-based and rifabutin-based and other prepackaged regimens for the first-line treatment of H. pylori from the perspective of US healthcare payers. METHODS We used the state-transition Markov model to conduct a cost-effectiveness analysis of H. pylori eradication with clarithromycin triple, bismuth quadruple, vonoprazan dual, vonoprazan triple, and rifabutin triple regimens. In a cycle length of 2 months, the model estimated the expected costs (expressed in 2022 US$), expected quality-adjusted life-years (QALY), incremental cost-effectiveness ratios, and expected net monetary benefit over 20 years. In addition, we accounted for the present value of future costs and QALY by applying a 3% discounting rate. RESULTS In this study, rifabutin triple therapy had a lower expected cost but was more effective than clarithromycin triple, bismuth quadruple, and vonoprazan dual regimens; hence, it dominated them. Vonoprazan triple therapy had a higher expected cost (US$ 1,172 vs US$ 1,048) and expected QALY (14.262 vs 14.256) than rifabutin triple therapy, yielding an estimated incremental cost-effectiveness ratio of US$ 22,573/QALY. The study suggested that vonoprazan triple treatment had the highest expected net monetary benefit and was the most cost-effective at willingness-to-pay thresholds between US$50,000 and US$150,000 per QALY, followed by rifabutin triple therapy. DISCUSSION H. pylori infection eradication with vonoprazan triple therapy would provide the greatest net health and monetary benefit from the perspective of US healthcare payers.
Collapse
Affiliation(s)
- Ismaeel Yunusa
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
- Center for Outcomes Research and Evaluation, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
| | - Bryan L Love
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
- Center for Outcomes Research and Evaluation, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
| |
Collapse
|
42
|
Rand LZ, Melendez‐Torres GJ, Kesselheim AS. Alternatives to the quality-adjusted life year: How well do they address common criticisms? Health Serv Res 2023; 58:433-444. [PMID: 36537647 PMCID: PMC10012222 DOI: 10.1111/1475-6773.14116] [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] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze whether other outcome measures used in health technology assessment (HTA) address the criticisms of quality-adjusted life years (QALYs). DATA SOURCES AND STUDY SETTING HTA methods guidance from 11 US comparator countries (the G10 and Australia) and six value frameworks from US organizations were reviewed to identify health outcome measures currently used to evaluate the benefits of a drug. STUDY DESIGN The study involved a documentary analysis of guidelines to identify outcome measures used by the sampled HTA organizations. Similar outcomes were grouped together into outcome types. Each type was analyzed to determine the extent to which it replicates key advantages and responds to criticisms of QALYs extracted from the literature. EXTRACTION METHODS Outcomes were included if guidance from at least one HTA organization identified the outcome as acceptable for HTA. Outcomes measuring or evaluating the benefit, clinical effect, or impact of a drug or health technology was included; methods of calculating costs were excluded. PRINCIPAL FINDINGS Seven types of outcome measures were identified falling into three groups: preference-based, single-dimension outcomes, and outcomes using non-health perspectives. Among the seven QALY alternative outcome measures currently used for HTA by the sampled countries, no one outcome measure addresses all the QALY criticisms while retaining the advantageous features of the QALY. CONCLUSIONS Proposals to adopt health technology assessment (HTA) to support value-based pricing of prescription drugs in the US have faced pushback over the use of the QALY. There is no single "right" outcome measure, and the criticisms of QALYs apply to other outcome measures used to evaluate health. The measures identified have different features and strengths, which may be appropriate for specific decision making goals, but the QALY remains the best option for decision making that requires comparisons of the overall societal value of health gains.
Collapse
Affiliation(s)
- Leah Z. Rand
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
| | - G. J. Melendez‐Torres
- Peninsula Technology Assessment Group (PenTAG), Faculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Aaron S. Kesselheim
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
43
|
Borre ED, Dubno JR, Myers ER, Emmett SD, Pavon JM, Francis HW, Ogbuoji O, Sanders Schmidler GD. Model-Projected Cost-Effectiveness of Adult Hearing Screening in the USA. J Gen Intern Med 2023; 38:978-985. [PMID: 35931909 PMCID: PMC10039166 DOI: 10.1007/s11606-022-07735-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/28/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND While 60% of older adults have hearing loss (HL), the majority have never had their hearing tested. OBJECTIVE We sought to estimate long-term clinical and economic effects of alternative adult hearing screening schedules in the USA. DESIGN Model-based cost-effectiveness analysis simulating Current Detection (CD) and linkage of persons with HL to hearing healthcare, compared to alternative screening schedules varying by age at first screen (45 to 75 years) and screening frequency (every 1 or 5 years). Simulated persons experience yearly age- and sex-specific probabilities of acquiring HL, and subsequent hearing aid uptake (0.5-8%/year) and discontinuation (13-4%). Quality-adjusted life-years (QALYs) were estimated according to hearing level and treatment status. Costs from a health system perspective include screening ($30-120; 2020 USD), HL diagnosis ($300), and hearing aid devices ($3690 year 1, $910/subsequent year). Data sources were published estimates from NHANES and clinical trials of adult hearing screening. PARTICIPANTS Forty-year-old persons in US primary care across their lifetime. INTERVENTION Alternative screening schedules that increase baseline probabilities of hearing aid uptake (base-case 1.62-fold; range 1.05-2.25-fold). MAIN MEASURES Lifetime undiscounted and discounted (3%/year) costs and QALYs and incremental cost-effectiveness ratios (ICERs). KEY RESULTS CD resulted in 1.20 average person-years of hearing aid use compared to 1.27-1.68 with the screening schedules. Lifetime total per-person undiscounted costs were $3300 for CD and ranged from $3630 for 5-yearly screening beginning at age 75 to $6490 for yearly screening beginning at age 45. In cost-effectiveness analysis, yearly screening beginning at ages 75, 65, and 55 years had ICERs of $39,100/QALY, $48,900/QALY, and $96,900/QALY, respectively. Results were most sensitive to variations in hearing aid utility benefit and screening effectiveness. LIMITATION Input uncertainty around screening effectiveness. CONCLUSIONS We project that yearly hearing screening beginning at age 55+ is cost-effective by US standards.
Collapse
Affiliation(s)
- Ethan D Borre
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Judy R Dubno
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Evan R Myers
- Division of Women's Community and Population Health, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Susan D Emmett
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Juliessa M Pavon
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
| | - Howard W Francis
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Osondu Ogbuoji
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Center for Policy Impact in Global Health, Duke Global Health Institute, Durham, NC, USA
| | - Gillian D Sanders Schmidler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
44
|
Toumazis I, Cao P, de Nijs K, Bastani M, Munshi V, Hemmati M, Ten Haaf K, Jeon J, Tammemägi M, Gazelle GS, Feuer EJ, Kong CY, Meza R, de Koning HJ, Plevritis SK, Han SS. Risk Model-Based Lung Cancer Screening : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:320-332. [PMID: 36745885 PMCID: PMC11025620 DOI: 10.7326/m22-2216] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening. OBJECTIVE To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. DESIGN Comparative modeling analysis. DATA SOURCES National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. TARGET POPULATION 1960 U.S. birth cohort. TIME HORIZON 45 years. PERSPECTIVE U.S. health care sector. INTERVENTION Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. RESULTS OF BASE-CASE ANALYSIS Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). RESULTS OF SENSITIVITY ANALYSES Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. LIMITATION Risk models were restricted to age, sex, and smoking-related risk predictors. CONCLUSION Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. PRIMARY FUNDING SOURCE National Cancer Institute (NCI).
Collapse
Affiliation(s)
- Iakovos Toumazis
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (I.T., M.H.)
| | - Pianpian Cao
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan (P.C., J.J.)
| | - Koen de Nijs
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Mehrad Bastani
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York (M.B.)
| | - Vidit Munshi
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts (V.M., G.S.G.)
| | - Mehdi Hemmati
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas (I.T., M.H.)
| | - Kevin Ten Haaf
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan (P.C., J.J.)
| | - Martin Tammemägi
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada (M.T.)
| | - G Scott Gazelle
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts (V.M., G.S.G.)
| | - Eric J Feuer
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (E.J.F.)
| | - Chung Yin Kong
- Division of General Internal Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York (C.Y.K.)
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, and Department of Integrative Oncology, BC Cancer Research Institute, British Columbia, Canada (R.M.)
| | - Harry J de Koning
- Erasmus MC-University Medical Center, Rotterdam, the Netherlands (K. de N., K. ten H., H.J. de K.)
| | - Sylvia K Plevritis
- Department of Biomedical Data Sciences, Stanford University, Stanford, California (S.K.P.)
| | - Summer S Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California (S.S.H.)
| |
Collapse
|
45
|
Boltri JM, Tracer H, Strogatz D, Idzik S, Schumacher P, Fukagawa N, Leake E, Powell C, Shell D, Wu S, Herman WH. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes. Diabetes Care 2023; 46:e39-e50. [PMID: 36701590 PMCID: PMC9887613 DOI: 10.2337/dc22-0620] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/03/2022] [Indexed: 01/27/2023]
Abstract
Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.
Collapse
Affiliation(s)
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | | | - Shannon Idzik
- School of Nursing, University of Maryland, Baltimore, MD
| | - Pat Schumacher
- Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, GA
| | | | - Ellen Leake
- Juvenile Diabetes Research Foundation, Jackson, MS
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | | | - Samuel Wu
- U.S. Office of Minority Health, Rockville, MD
| | | |
Collapse
|
46
|
Woon TK, Zhou K, Tan BS, Matchar DB. High-Suspicion Subcentimeter Thyroid Nodules: Cost Effectiveness of Active Surveillance versus Fine Needle Aspiration. J Vasc Interv Radiol 2023; 34:173-181. [PMID: 36400119 DOI: 10.1016/j.jvir.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/23/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To compare the cost-benefit of active surveillance (AS) against immediate fine needle aspiration (FNA) of sonographically suspicious subcentimeter thyroid nodules. MATERIALS AND METHODS A Markov model was constructed to compare the cost-benefit of 3 strategies from the point of discovery until death: (a) Surveillance of all nodules, (b) Surveillance of nodules with positive cytology, and (c) Surgery of nodules with positive cytology. The reference case was a 40-year-old woman with a sonographically suspicious subcentimeter thyroid nodule. Transition probabilities, costs, and health state utilities were derived from the literature. Sensitivity analyses were performed to evaluate model uncertainty. Willingness-to-pay threshold was set at $100,000/quality-adjusted life year. RESULTS Surveillance of nodules with positive cytology dominated in the reference scenario and was cost-beneficial over Surveillance of all nodules, independent of the utility of AS. Surveillance of all nodules was cost-beneficial only at a life expectancy of <2.6 years or surveillance duration of <4 years. CONCLUSIONS While current guidelines recommend AS of sonographically suspicious subcentimeter nodules, the results of this study suggest that immediate FNA (Surveillance of nodules with positive cytology) is more cost-beneficial than AS (Surveillance of all nodules). Patients with positive cytology on FNA may subsequently opt for AS (Surveillance of nodules with positive cytology) or surgery (Surgery of nodules with positive cytology) according to their level of comfort (ie, utility) with AS.
Collapse
Affiliation(s)
- Tian Kai Woon
- Diagnostic Radiology, Singapore Health Services (SingHealth), Singapore.
| | - Ke Zhou
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Bien Soo Tan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - David B Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Medicine (General Internal Medicine), Duke University, Durham, North Carolina
| |
Collapse
|
47
|
Murray B, Miles-Thomas J, Park AJ, Nguyen VB, Tung A, Gillard P, Lalla A, Nitti VW, Chermansky CJ. Cost-effectiveness of overactive bladder treatments from a US commercial and payer perspective. J Comp Eff Res 2023; 12:e220089. [PMID: 36655745 PMCID: PMC10288955 DOI: 10.2217/cer-2022-0089] [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: 05/17/2022] [Accepted: 11/10/2022] [Indexed: 01/20/2023] Open
Abstract
Aim: The cost-effectiveness of treatment options (anticholinergics, β3-adrenoceptor agonists, onabotulinumtoxinA, sacral nerve stimulation and percutaneous tibial stimulation [the latter two including new rechargeable neurostimulators]) for the management of overactive bladder (OAB) were compared with best supportive care (BSC) using a previously published Markov model. Materials & methods: Cost-effectiveness was evaluated over a 15-year time horizon, and sensitivity analyses were performed using 2- and 5-year horizons. Discontinuation rates, resource utilization, and costs were derived from published sources. Results: Using Medicare and commercial costs over a 15-year time period, onabotulinumtoxinA 100U had incremental cost-effectiveness ratios (ICERs) gained of $39,591/quality-adjusted life-year (QALY) and $42,255/QALY, respectively, versus BSC, which were the lowest ICERs of all assessed treatments. The sensitivity analyses at 2- and 5-year horizons also showed onabotulinumtoxinA to be the most cost-effective of all assessed treatments versus BSC. Conclusion: OnabotulinumtoxinA 100U is currently the most cost-effective treatment for OAB.
Collapse
Affiliation(s)
- Brian Murray
- Capital Region Urological Surgeons, 319 S Manning Blvd #106, Albany, NY 12208, USA
| | | | - Amy J Park
- Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | | | - Amy Tung
- Allergan, an AbbVie company, 2525 Dupont Drive, Irvine, CA 92612, USA
| | - Patrick Gillard
- Allergan, an AbbVie company, 2525 Dupont Drive, Irvine, CA 92612, USA
| | - Anjana Lalla
- Allergan, an AbbVie company, 2525 Dupont Drive, Irvine, CA 92612, USA
| | - Victor W Nitti
- David Geffen School of Medicine at UCLA, 300 Stein Plaza Driveway, Los Angeles, CA 90095, USA
| | - Christopher J Chermansky
- University of Pittsburgh Medical Center Magee Womens Hospital, 300 Halket St, Suite 2541, Pittsburgh, PA 15213, USA
| |
Collapse
|
48
|
Kowal S, Ng CD, Schuldt R, Sheinson D, Cookson R. The Impact of Funding Inpatient Treatments for COVID-19 on Health Equity in the United States: A Distributional Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:216-225. [PMID: 36192293 PMCID: PMC9525218 DOI: 10.1016/j.jval.2022.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/10/2022] [Accepted: 08/18/2022] [Indexed: 05/29/2023]
Abstract
OBJECTIVES We conducted a distributional cost-effectiveness analysis (DCEA) to evaluate how Medicare funding of inpatient COVID-19 treatments affected health equity in the United States. METHODS A DCEA, based on an existing cost-effectiveness analysis model, was conducted from the perspective of a single US payer, Medicare. The US population was divided based on race and ethnicity (Hispanic, non-Hispanic black, and non-Hispanic white) and county-level social vulnerability index (5 quintile groups) into 15 equity-relevant subgroups. The baseline distribution of quality-adjusted life expectancy was estimated across the equity subgroups. Opportunity costs were estimated by converting total spend on COVID-19 inpatient treatments into health losses, expressed as quality-adjusted life-years (QALYs), using base-case assumptions of an opportunity cost threshold of $150 000 per QALY gained and an equal distribution of opportunity costs across equity-relevant subgroups. RESULTS More socially vulnerable populations received larger per capita health benefits due to higher COVID-19 incidence and baseline in-hospital mortality. The total direct medical cost of inpatient COVID-19 interventions in the United States in 2020 was estimated at $25.83 billion with an estimated net benefit of 735 569 QALYs after adjusting for opportunity costs. Funding inpatient COVID-19 treatment reduced the population-level burden of health inequality by 0.234%. Conclusions remained robust across scenario and sensitivity analyses. CONCLUSIONS To the best of our knowledge, this is the first DCEA to quantify the equity implications of funding COVID-19 treatments in the United States. Medicare funding of COVID-19 treatments in the United States could improve overall health while reducing existing health inequalities.
Collapse
Affiliation(s)
| | - Carmen D Ng
- Genentech, Inc, South San Francisco, CA, USA
| | | | | | - Richard Cookson
- Centre for Health Economics, University of York, York, England, UK
| |
Collapse
|
49
|
Gulati S, Eckman MH. Anticoagulant Therapy for Cancer-Associated Thrombosis : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:1-9. [PMID: 36571839 PMCID: PMC10279520 DOI: 10.7326/m22-1258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). OBJECTIVE To determine the cost and effectiveness of DOACs versus LMWH. DESIGN Cohort-state transition decision analytic model. DATA SOURCES Network meta-analysis comparing DOACs versus LMWH. TARGET POPULATION Adult patients with cancer at the time they develop thrombosis. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using "real-world" drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY. RESULTS OF SENSITIVITY ANALYSIS Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective. LIMITATIONS An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled. CONCLUSION The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers. PRIMARY FUNDING SOURCE None.
Collapse
Affiliation(s)
- Shuchi Gulati
- Division of Hematology and Oncology, Department of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California (S.G.)
| | - Mark H Eckman
- University of Cincinnati Medical Center, Cincinnati, and Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio (M.H.E.)
| |
Collapse
|
50
|
Al-Jedai AH, Lomas J, Almudaiheem HY, Al-Ruthia YSH, Alghamdi S, Awad N, Alghamdi A, Alowairdhi MA, Alabdulkarim H, Almadi M, Bunyan RF, Ochalek J. Informing a cost-effectiveness threshold for Saudi Arabia. J Med Econ 2023; 26:128-138. [PMID: 36576804 DOI: 10.1080/13696998.2022.2157141] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Saudi Arabia's Vision 2030 aims to reform health care across the Kingdom, with health technology assessment being adopted as one tool promising to improve the efficiency with which resources are used. An understanding of the opportunity costs of reimbursement decisions is key to fulfilling this promise and can be used to inform a cost-effectiveness threshold. This paper is the first to provide a range of estimates of this using existing evidence extrapolated to the context of Saudi Arabia. METHODS AND MATERIALS We use four approaches to estimate the marginal cost per unit of health produced by the healthcare system; drawing from existing evidence provided by a cross-country analysis, two alternative estimates from the UK context, and based on extrapolating a UK estimate using evidence on the income elasticity of the value of health. Consequences of estimation error are explored. RESULTS Based on the four approaches, we find a range of SAR 42,046 per QALY gained (48% of GDP per capita) to SAR 215,120 per QALY gained (246% of GDP per capita). Calculated potential central estimates from the average of estimated health gains based on each source gives a range of SAR 50,000-75,000. The results are in line with estimates from the emerging literature from across the world. CONCLUSION A cost-effectiveness threshold reflecting health opportunity costs can aid decision-making. Applying a cost-effectiveness threshold based on the range SAR 50,000 to 75,000 per QALY gained would ensure that resource allocation decisions in healthcare can in be informed in a way that accounts for health opportunity costs. LIMITATIONS A limitation is that it is not based on a within-country study for Saudi Arabia, which represents a promising line of future work.
Collapse
Affiliation(s)
- Ahmed Hamdan Al-Jedai
- Therapeutic Affairs, Ministry of Health Saudi Arabia, Riyadh, Saudi Arabia
- Colleges of Pharmacy and Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - James Lomas
- Department of Economics and Related Studies, University of York, York, United Kingdom
| | | | | | | | - Nancy Awad
- IQVIA Dubai, Dubai, United Arab Emirates
| | - Ahlam Alghamdi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | | | - Hana Alabdulkarim
- Drug Policy and Economic Center, Ministry of National Guard Health Affairs (MNG-HA), Riyadh, Saudi Arabia
| | - Majid Almadi
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reem F Bunyan
- Center for Improving Value in Health, Ministry of Health, Riyadh, Saudi Arabia
- King Fahad Specialist Hospital, Dammam, Ash Sharqiyah, Saudi Arabia
| | - Jessica Ochalek
- Centre for Health Economics, University of York, York, United Kingdom
| |
Collapse
|