The Allocation of the Economic Value of Second-Generation Antipsychotics Over the Product Life Cycle: The Case of Risperidone in Sweden and the United Kingdom

OBJECTIVE

This article estimates the life-cycle value of risperidone as representative of second-generation antipsychotics (SGA) relative to haloperidol (first-generation antipsychotics).

METHODS

We estimated the number of patients treated with risperidone in Sweden and the United Kingdom, from 1994 to 2017, using data of usage and volume sales. We collected data from the literature on the effectiveness (quality-adjusted life-years per patient per year), direct costs (health services), and indirect costs (productivity) of risperidone and haloperidol. We proxied the incremental value added by the new class (SGA) using a comparator from the inferior class. Next, we modeled the life-cycle uptake of risperidone to estimate the life-cycle incremental cost (ie, direct, indirect, and medicine costs), incremental quality-adjusted life-years, and net monetary benefit of risperidone. We also assessed the life-cycle distribution of the social surplus between the payer (consumer surplus) and the innovator (producer surplus).

RESULTS

For the United Kingdom, consumer surplus represents around 72% of the total surplus before patent expiration and around 95% after patent expiration. For Sweden, the consumer surplus represents around 94% of the total surplus before patent expiration and around 99% after generic competition.

CONCLUSION

These results suggest that the value added by SGAs to the system is higher than the expected value estimated using cost-effectiveness analysis at launch. Pricing and reimbursement decisions could recognize the full life cycle of value of innovative medicines. This not only presents a challenge of estimation but also of assessing the appropriate division of shares of social value.

Cost-Effectiveness Analysis of Pan-Genotypic Sofosbuvir-Based Regimens for Treatment of Chronic Hepatitis C Genotype 1 Infection in China

Background: Hepatitis C virus (HCV) genotype 1 is the most prevalent HCV infection in China. Sofosbuvir-based direct antiviral agent (DAA) regimens are the current mainstays of treatment. Sofosbuvir/velpatasvir (SOF/VEL) and sofosbuvir/ledipasvir (SOF/LDV) regimens became reimbursable in China in 2020. Thus, this study aimed to identify the optimal SOF-based regimen and to inform efficient use of healthcare resources by optimizing DAA use in treating HCV genotype 1. Methods and Models: A modeling-based cost-utility analysis was conducted from the payer's perspective targeting adult Chinese patients with chronic HCV genotype 1 infection. Direct medical costs and health utilities were inputted into a Markov model to simulate lifetime experiences of chronically infected HCV patients after receiving SOF/LDV, SOF/VEL or the traditional strategy of pegylated interferon (pegIFN) + ribavirin (RBV). Discounted lifetime cost and quality adjusted life years (QALYs) were computed and compared to generate the incremental cost utility ratio (ICUR). An ICUR below the threshold of 31,500 $/QALY suggests cost-effectiveness. Deterministic and probabilistic sensitivity analyses were performed to examine the robustness of model findings. Results: Both SOF/LDV and SOF/VEL regimens were dominant to the pegIFN + RBV regimen by creating more QALYs and incurring less cost. SOF/LDV produced 0.542 more QALYs but cost $10,390 less than pegIFN + RBV. Relative to SOF/LDV, SOF/VEL had an ICUR of 168,239 $/QALY which did not meet the cost-effectiveness standard. Therefore SOF/LDV was the optimal strategy. These findings were robust to linear and random variations of model parameters. However, reducing the SOF/VEL price by 40% would make this regimen the most cost-effective option. Conclusions: SOF/LDV was found to be the most cost-effective treatment, and SOF/VEL was also economically dominant to pegIFN + RBV. These findings indicated that replacing pegIFN + RBV with DAA regimens could be a promising strategy.

Adaptive Policies to Balance Health Benefits and Economic Costs of Physical Distancing Interventions during the COVID-19 Pandemic

Policy makers need decision tools to determine when to use physical distancing interventions to maximize the control of COVID-19 while minimizing the economic and social costs of these interventions. We describe a pragmatic decision tool to characterize adaptive policies that combine real-time surveillance data with clear decision rules to guide when to trigger, continue, or stop physical distancing interventions during the current pandemic. In model-based experiments, we find that adaptive policies characterized by our proposed approach prevent more deaths and require a shorter overall duration of physical distancing than alternative physical distancing policies. Our proposed approach can readily be extended to more complex models and interventions.

Cost-utility analysis of stereotactic body radiotherapy plus cetuximab in previously irradiated recurrent squamous cell carcinoma of the head and neck

BACKGROUND

This study aimed to estimate the cost-utility of stereotactic body radiotherapy (SBRT) plus cetuximab for patients with previously irradiated recurrent squamous cell carcinoma of the head and neck.

METHODS

We constructed a Markov health-state transition model to simulate costs and clinical outcomes of recurrent squamous cell carcinoma of the head and neck. Model parameters were derived from the published literature and the National Health Insurance Administration reimbursement price list. Incremental cost-effectiveness ratio and the net monetary benefit were calculated from a health payer perspective. The impact of uncertainty was modeled with one-way and probabilistic sensitivity analyses.

RESULTS

In the base-case, SBRT plus cetuximab compared to SBRT alone resulted in an ICER of NT$ 840,455 per QALY gained. In the one-way sensitivity analysis, the utility of progression-free state for patients treated with SBRT plus cetuximab or SBRT alone and the cost of progression-free survival for SBRT+Cet were the most sensitive parameters in the model. Probabilistic sensitivity analysis showed that the probability of cost-effectiveness at a willingness-to-pay threshold of NT$ 2,252,340 per QALY was 100% for SBRT plus cetuximab but 0% for SBRT alone.

CONCLUSIONS

This study showed that SBRT+Cet was cost-effective and benefited patients with previously irradiated rSCCHN.

Cost-Effectiveness and Net Monetary Benefit of Olaparib Maintenance Therapy Versus No Maintenance Therapy After First-line Platinum-based Chemotherapy in Newly Diagnosed Advanced BRCA1/2-mutated Ovarian Cancer in the Italian National Health Service

PURPOSE

The aim of this study was to evaluate the cost-effectiveness and net monetary benefit of olaparib maintenance therapy compared with no maintenance therapy after first-line platinum-based chemotherapy in newly diagnosed advanced BRCA1/2-mutated ovarian cancer from the Italian National Health Service (NHS) perspective.

METHODS

We developed a lifetime Markov model in which a cohort of patients with newly diagnosed advanced BRCA1/2-mutated ovarian cancer was assigned to receive either olaparib maintenance therapy or active surveillance (Italian standard of care) after first-line platinum-based chemotherapy to compare cost-effectiveness and net monetary benefit of the 2 strategies. Data on clinical outcomes were obtained from related clinical trial literature and extrapolated using parametric survival analyses. Data on costs were derived from Italian official sources and relevant real-world studies. The incremental cost-effectiveness ratio (ICER), incremental cost-utility ratio (ICUR), and incremental net monetary benefit (INMB) were computed and compared against an incremental cost per quality-adjusted life-year (QALY) gained of €16,372 willingness-to-pay (WTP) threshold. We used deterministic sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) to assess how uncertainty affects results; we also performed scenario analyses to compare results under different pricing settings.

FINDINGS

In the base-case scenario, during a 50-year time horizon, the total costs for patients treated with olaparib therapy and active surveillance were €124,359 and €97,043, respectively, and QALYs gained were 7.29 and 4.88, respectively, with an ICER of €9,515 per life-year gained, an ICUR of €11,345 per QALY gained, and an INMB of €12,104. In scenario analyses, considering maximum selling prices for all other drugs, ICUR decreased to €11,311 per QALY and €7,498 per QALY when a 10% and 20% discount, respectively, was applied to the olaparib official price, and the INMB increased to €12,186 and €21,366, respectively. DSA found that the model results were most sensitive to the proportion of patients with relapsing disease in response to platinum-based chemotherapy, time receiving olaparib first-line maintenance treatment, and subsequent treatments price. According to PSAresults, olaparib was associated with a probability of being cost-effective at a €16,372 per QALY WTP threshold ranging from 70% to 100% in the scenarios examined.

IMPLICATIONS

Our analysis indicates that olaparib maintenance therapy may deliver a significant health benefit with a contained upfront cost during a 50-year time horizon, from the Italian NHS perspective, providing value in a setting with curative intent.

Machine Learning for Precision Health Economics and Outcomes Research (P-HEOR): Conceptual Review of Applications and Next Steps

Precision health economics and outcomes research (P-HEOR) integrates economic and clinical value assessment by explicitly discovering distinct clinical and health care utilization phenotypes among patients. Through a conceptualized example, the objective of this review is to highlight the capabilities and limitations of machine learning (ML) applications to P-HEOR and to contextualize the potential opportunities and challenges for the wide adoption of ML for health economics. We outline a P-HEOR conceptual framework extending the ML methodology to comparatively assess the economic value of treatment regimens. Latest methodology developments on bias and confounding control in ML applications to precision medicine are also summarized.

Who Benefits Most from Collaborative Dementia Care from a Patient and Payer Perspective? A Subgroup Cost-Effectiveness Analysis

BACKGROUND

Dementia care management (DCM) aims to provide optimal treatment for people with dementia (PwD). Treatment and care needs are dependent on patients' sociodemographic and clinical characteristics and thus, economic outcomes could depend on such characteristics.

OBJECTIVE

To detect important subgroups that benefit most from DCM and for which a significant effect on cost, QALY, and the individual cost-effectiveness could be achieved.

METHODS

The analysis was based on 444 participants of the DelpHi-trial. For each subgroup, the probability of DCM being cost-effective was calculated and visualized using cost-effectiveness acceptability curves. The impact of DCM on individual costs and QALYs was assessed by using multivariate regression models with interaction terms.

RESULTS

The probability of DCM being cost-effective at a willingness-to-pay of 40,000€ /QALY was higher in females (96% versus 16% for males), in those living alone (96% versus 26% for those living not alone), in those being moderately to severely cognitively (100% versus 3% for patients without cognitive impairment) and functionally impaired (97% versus 16% for patients without functional impairment), and in PwD having a high comorbidity (96% versus 26% for patients with a low comorbidity). Multivariate analyses revealed that females (b = -10,873; SE = 4,775, p = 0.023) who received the intervention had significantly lower healthcare cost. DCM significantly improved QALY for PwD with mild and moderate cognitive (b = +0.232, SE = 0.105) and functional deficits (b = +0.200, SE = 0.095).

CONCLUSION

Patients characteristics significantly affect the cost-effectiveness. Females, patients living alone, patients with a high comorbidity, and those being moderately cognitively and functionally impaired benefit most from DCM. For those subgroups, healthcare payers could gain the highest cost savings and the highest effects on QALYs when DCM will be implemented.

Tenders for the Procurement of Medical Devices: Adapting Cost-Effectiveness Rules to the Requirements of the European Public Procurement Directive

BACKGROUND

In evaluating 3 or more comparators, pharmacoeconomic analyses can be improved by using the methodology of net monetary benefit (NMB) as opposed to incremental cost-effectiveness ratio (ICER). NMB is particularly suitable for managing competitive tenders that evaluate 3 or more devices in the same lot. For scientific purposes, the methodology of NMB is perfectly adequate. However, when tenders are managed in European countries, the Public Procurement Directive states that the tender score for price should be kept separate from that of clinical benefits. As a result, the traditional mathematical approach of NMB must be rearranged to comply with this administrative requirement.

METHODS

In this report, we describe how the classic equations of NMB should be modified to achieve this purpose. The mathematical principle of proportionality, which is typical of the ICER, must be replaced by the principle of mathematical additivity, which is typical of NMB. Furthermore, to rearrange the scale of benefits according to the NMB, an estimate is needed of the minimum acceptable benefit converted into monetary units, which is associated with 0 in the benefit scale.

RESULTS

A detailed example is presented to explain the practical application of these mathematical equations. These equations are widely applicable in the field of implantable devices.

CONCLUSION

Since the expenditure for medical devices in European hospitals is close to that of hospital medicines, tenders for the in-hospital procurement of devices may represent a decisive tool to manage sustainability and ensure access to innovation. In this context, the methodology for managing clinical outcomes through tenders requires a specific mathematical approach that we have described in the present article.

Cost-effectiveness of denosumab for the prevention of skeletal-related events in patients with solid tumors and bone metastases in the United States

Aims: Bone complications (also known as skeletal-related events [SREs]) pose significant health and financial burdens on patients with bone metastases. Denosumab demonstrated superiority over zoledronic acid in delaying the time to first SRE. This study examined the lifetime cost-effectiveness of denosumab vs zoledronic acid from both US payer and societal perspectives.Methods: This analysis used a lifetime Markov model and included patients with breast cancer, prostate cancer, and other solid tumors and bone metastases. The societal perspective included direct medical, direct non-medical, and indirect costs associated with denosumab and zoledronic acid; the payer perspective included direct medical costs only. Bone complication rates for each tumor type were estimated from three pivotal phase 3 studies and modified to reflect real-world incidence.Results: From a societal perspective, compared with zoledronic acid, denosumab use resulted in an incremental cost of $9,043, an incremental benefit of 0.128 quality-adjusted life-years (QALYs), a lifetime cost per QALY of $70,730, and a net monetary benefit (NMB) of $10,135 in favor of denosumab. Direct drug costs for denosumab ($28,352) were higher than zoledronic acid/untreated ($578), but were offset by reduced costs associated with bone complications. From a payer perspective, denosumab use was associated with an incremental cost of $13,396, and an incremental benefit of 0.128 QALYs, for a cost of $104,778 per QALY and an NMB of $5,782 in favor of denosumab.Limitations: Some model inputs had limited information and, given that the results may be sensitive to changes in these inputs, our findings should be interpreted within the context of the data inputs and modeling assumptions used in the analysis.Conclusions: Denosumab is a cost-effective option to prevent bone complications in patients with solid tumors when considering both payer and broader societal perspectives.

Economic evaluation of a supported employment program for veterans with spinal cord injury

Objective: To estimate the net monetary benefit of an individual placement and support-based supported employment program for Veterans with spinal cord injuries.Design: Economic evaluation comparing a supported employment program to treatment as usual, using cost and quality-of-life data from a longitudinal study of Veterans with spinal cord injuries.Setting: Spinal cord injury centers in the Veterans Health Administration.Participants: Subjects (N = 213) who participated in a 24-month supported employment program at seven spinal cord injury centers. Supported employment participants were compared with a group of spinal cord injury Veterans who received treatment as usual in a prior study.Main outcome measures: Costs and quality-adjusted life years using the Veterans Rand-6 Dimension, estimated from the Veterans Rand 36-Item Health Survey.Results: The supported employment program was more effective at both 1- and 2-year periods compared with treatment as usual. Outpatient costs were significantly higher for supported employment, but inpatient costs were not significantly different from treatment as usual. When cost and effectiveness were compared jointly using net monetary benefit, a supported employment program following the core principles of Individual Placement and Supported employment was more effective but not cost-effective at standard willingness to pay thresholds. When we considered a sub-group of the supported employment participants who more closely resemble the treatment as usual group from a randomized trial, there was no significant difference in the cost-effectiveness of supported employment when compared to treatment as usual.Conclusions: With higher effectiveness and similar costs, supported employment for spinal cord injury Veterans has the potential to be cost-effective. Future studies need to randomize participants or carefully match participants based on observable patient characteristics to improve cost-effectiveness evaluations of this population.Implications for RehabilitationSupported employment as part of ongoing rehabilitation care helps individuals with spinal cord injury return to work and improve their quality of life.Many studies show that supported employment programs are cost effective for persons with mental disabilities, but there is only limited economic evaluation data on use of supported employment with persons with spinal cord injury.This study shows that supported employment integrated with ongoing rehabilitation care is more effective in restoring employment and health-related quality of life.

Handling the procurement of prostheses for total hip replacement: description of an original value based approach and application to a real-life dataset reported in the UK

OBJECTIVES

In most European countries, innovative medical devices are not managed according to cost-utility methods, the reason being that national agencies do not generally evaluate these products. The objective of our study was to investigate the cost-utility profile of prostheses for hip replacement and to calculate a value-based score to be used in the process of procurement and tendering for these devices.

METHODS

The first phase of our study was aimed at retrieving the studies reporting the values of QALYs, direct cost, and net monetary benefit (NMB) from patients undergoing total hip arthroplasty (THA) with different brands of hip prosthesis. The second phase was aimed at calculating, on the basis of the results of cost-utility analysis, a tender score for each device (defined according to standard tendering equations and adapted to a 0-100 scale). This allowed us to determine the ranking of each device in the simulated tender.

RESULTS

We identified a single study as the source of information for our analysis. Nine device brands (cemented, cementless, or hybrid) were evaluated. The cemented prosthesis Exeter V40/Elite Plus Ogee, the cementless device Taperloc/Exceed, and the hybrid device Exeter V40/Trident had the highest NMB (£152 877, £156 356, and £156 210, respectively) and the best value-based tender score.

CONCLUSIONS

The incorporation of value-based criteria in the procurement process can contribute to optimising the value for money for THA devices. According to the approach described herein, the acquisition of these devices does not necessarily converge on the product with the lowest cost; in fact, more costly devices should be preferred when their increased cost is offset by the monetary value of the increased clinical benefit.

Value-based procurement of prostheses for total knee replacement

Cost-effectiveness evaluations concerning devices for total knee arthroplasty (TKA) have little impact on real-life management of these devices. This study explored how pharmacoeconomic models can inform the procurement of TKA devices to improve their value for money. Our study included three phases: i) literature search for data of outcome, cost, and device type in TKA; ii) development of a Markov model predicting costs, QALYs, and net monetary benefit (NMB); iii) simulation of tenders aimed at value-based device procurement. Phases 1 and 2 were managed by selecting a single study as the source of data for our analysis. In Phase 3, each TKA device was associated with its values of NMB, and the tender scores were estimated. Finally, the ranking of each device in the simulated tender was determined. We identified a study published in 2016 as our source of data. Five devices were evaluated. For these devices, QALYs were 7.3952, 7.2939, 7.4952, 7.1919, 7.2930; NMB: £142,005, £140,653, £144,184, £138,040, £140,261; tender scores: 64.53, 42.53, 100, 0, 36.15, respectively. We showed that incorporating the principles of cost-effectiveness into the tendering process is feasible for TKA devices. This can maximize the value for money for these devices.

Cost-effectiveness of liposomal amphotericin B in hospitalised patients with mucocutaneous leishmaniasis

OBJECTIVE

To compare the cost-effectiveness of L-AmB with that of Sb^V and AmB-D, for the treatment of mucocutaneous leishmaniasis in a hospital in north-east Brazil.

METHODS

We developed an economic model based on retrospective data of 73 hospitalised patients in 2006-2012, from hospital and public health system perspectives.

RESULTS

In the economic model, 82.2% of patients who started treatment with L-AmB had completed it after 2 months, vs. 22.0% for the Sb^V and 19.9% for the AmB-D groups. After 12 months of follow-up, these proportions were 100% in the L-AmB, 77.4% in the AmB-D and 72.2% in the Sb^V group. Markov chain analyses showed that the group that started therapy with Sb^V had the lowest mean total cost (US$ 3782.38), followed by AmB-D (US$ 5211.27) and L-AmB (US$ 11 337.44). The incremental cost-effectiveness ratio for L-AmB was US$ 18 816.23 against Sb^V and US$ 24 504.65 against AmB-D. In the sensitivity analysis, the drug acquisition cost of L-AmB significantly influenced the results.

CONCLUSIONS

In the treatment of mucocutaneous leishmaniasis, L-AmB is a cost-effective alternative to Sb^V and AmB-D owing to its higher effectiveness, safety and shorter course.

Cost-effectiveness analysis of fecal microbiota transplantation for inflammatory bowel disease

There is a lack of health economics evidence on the use of fecal microbiota transplantation (FMT) for inflammatory bowel disease (IBD). This study aims to evaluate the cost-effectiveness before (with conventional therapy) and after introducing FMT for treating IBD. 104 patients with IBD received FMT were recruited. Health status was evaluated by European dimension health table (ED-5Q). Incremental cost-effectiveness ratio (ICER) and net monetary benefit (NB) were calculated by different age groups, genders, smoking status, and disease subtypes. The willingness-to-pay threshold was set to the value equal to three times China's per capita GDP (141240 CNY/QALY, 2014). From the health-care perspective, FMT strategy was 73% likely to be cost-effective compared with the conventional therapy before FMT with an ICER of -185712 CNY/QALY and a positive NB of CNY 45150. From the societal perspective, FMT strategy was 75% likely to be cost-effective with an ICER of -207417 CNY/QALY and a positive NB of CNY 48395. Moreover, younger patients (≤ 24), females, non-smokers and Crohn's disease (CD) achieved more benefits. This study for the first time demonstrated that FMT showed its cost-effectiveness, especially on improving the life quality and decreasing the medical and societal cost, for the moderate to severe IBD in a Chinese cohort.

An Efficient, Noniterative Method of Identifying the Cost-Effectiveness Frontier

Cost-effectiveness analysis aims to identify treatments and policies that maximize benefits subject to resource constraints. However, the conventional process of identifying the efficient frontier (i.e., the set of potentially cost-effective options) can be algorithmically inefficient, especially when considering a policy problem with many alternative options or when performing an extensive suite of sensitivity analyses for which the efficient frontier must be found for each. Here, we describe an alternative one-pass algorithm that is conceptually simple, easier to implement, and potentially faster for situations that challenge the conventional approach. Our algorithm accomplishes this by exploiting the relationship between the net monetary benefit and the cost-effectiveness plane. To facilitate further evaluation and use of this approach, we also provide scripts in R and Matlab that implement our method and can be used to identify efficient frontiers for any decision problem.

Current challenges in spinal cord stimulation

OBJECTIVES

This study aims to review the current state of spinal cord stimulation for the treatment of chronic pain associated with failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) and to describe intraspinal targets and stimulation parameters, patient selection, therapy cost-effectiveness, and strategies to improve outcomes.

MATERIALS AND METHODS

We drew on professional literature spanning four decades, our work with national and international professional societies, and our own extensive clinical experience to summarize contemporary knowledge of the safety, efficacy, cost-efficiency, and challenges associated with spinal cord stimulation in treating chronic pain.

RESULTS

The safety, efficacy, and cost-efficiency of spinal cord stimulation in treating chronic pain associated with FBSS and CRPS are well established through randomized controlled trials and long-term observational studies. Challenges include reducing wait-times before implant, which are associated with lower success rates; increasing awareness of this therapy among referring physicians, patients, and payers; decreasing device-related complications by incorporating advanced technology, improved operative and trialing techniques, and appropriate patient selection; and capturing functional and quality-of-life outcomes. Spinal cord stimulation must be part of an overall treatment plan to manage chronic pain, and must engage physicians, patients, their families, pharmacists, nursing staff, and mental health experts in supporting a return to employment, if possible, and to a full domestic and social life.

CONCLUSIONS

Innovation in spinal cord stimulation therapy has intensified with numerous new technical capabilities, safety advances, and novel stimulation targets. This progress holds hope for the many sufferers of chronic pain.

Optimal timing of influenza vaccination in patients with human immunodeficiency virus: a Markov cohort model based on serial study participant hemoagglutination inhibition titers

BACKGROUND

Seasonal influenza vaccination offers one of the best population-level protections against influenza-like illness (ILI). For most people, a single dose prior to the flu season offers adequate immunogenicity. HIV+ patients, however, tend to exhibit a shorter period of clinical protection, and therefore may not retain immunogenicity for the entire season. Building on the work of Nosyk et al. (2011) that determined a single dose is the optimal dosing strategy for HIV+ patients, we investigate the optimal time to administer this vaccination.

METHODS

Using data from the "single dose" treatment arm of an RCT conducted at 12 CIHR Canadian HIV Trials Network sites we estimated semimonthly clinical seroprotection levels for a cohort (N=93) based on HAI titer levels. These estimates were combined with CDC attack rate data for the three main strains of seasonal influenza to estimate instances of ILI over different vaccination timing strategies. Using bootstrap resampling of the cohort, nine years of CDC data, and parameter distributions, we developed a Markov cohort model that included probabilistic sensitivity analysis. Cost, quality adjusted life-years (QALYs), and net monetary benefits are presented for each timing strategy.

RESULTS

The beginning of December is the optimal time for HIV+ patients to receive the seasonal influenza vaccine. Assuming a willingness-to-pay threshold of $50,000, the net monetary benefit associated with a Dec 1 vaccination date is $19,501.49 and the annual QALY was 0.833744.

INTERPRETATION

Our results support a policy of administering the seasonal influenza vaccination for this population in the middle of November or beginning of December, assuming nothing is know about the upcoming flu season. But because the difference in between this strategy and the CDC guideline is small-12 deaths averted per year and a savings of $60 million across the HIV+ population in the US-more research is needed concerning strategies for subpopulations.