Economic evaluations in shoulder pathologies: a systematic review of the literature

BACKGROUND

Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies.

MATERIALS AND METHOD

A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature.

RESULTS

The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality.

CONCLUSION

Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.

Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures

PURPOSE

Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures.

METHODS

We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis.

RESULTS

Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased.

CONCLUSIONS

Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic Decision Analysis IV.

Cost-minimization analysis of lanthanum carbonate versus sevelamer hydrochloride in US patients with end-stage renal disease

PURPOSE

Sevelamer hydrochloride (SH) and lanthanum carbonate (LC) are calcium-free phosphate binders used in the clinical management of hyperphosphatemia in patients with end-stage renal disease (ESRD). The objective of this analysis was to assess the cost-effectiveness of LC monotherapy compared with SH monotherapy in US patients with ESRD in a clinical practice setting.

METHODS

This was a post hoc assessment of phosphate binder costs among US patients with ESRD who converted from SH to LC monotherapy in a previously published, 16-week, Phase IV, real-world study. Calculations of drug costs used both average wholesale price (AWP) and wholesale acquisition cost (WAC).

FINDINGS

There were 953 patients with available baseline SH dose data; 950 also had a recorded LC dose >0 mg at baseline, and 691 had dose data available for both SH at baseline and LC at week 16 (post hoc analysis population). Baseline demographic characteristics were similar in excluded patients and the post hoc analysis population. Mean (SD) serum phosphate levels were 5.91 (1.66) mg/dL at baseline and 5.93 (1.85) mg/dL after conversion to LC monotherapy for 16 weeks. Mean AWP costs were US$35.72 (16.89) per day at baseline and US$24.69 (8.28) per day at week 16, yielding an overall mean cost change (defined as LC cost - SH cost) of -US$11.03 (16.37) per day in favor of LC. The overall mean WAC cost change was -US$9.17 (13.64) per day. Within baseline SH dose subgroups 2400 to 4800, >4800 to 7200, >7200 to 9600, and >9600 mg/d, the mean AWP cost change ranged from US$2.78 (9.26) per day in favor of SH for the 2400- to 4800-mg/d subgroup to -US$33.15 (12.58) per day in favor of LC for the >9600-mg/d subgroup. Mean WAC cost changes showed a similar trend, ranging from US$2.33 (7.72) per day to -US$27.59 (10.48) per day. Linear regression analyses revealed that the inflection SH doses corresponding to a mean cost change of zero were 4905 mg/d (AWP) and 4908 mg/d (WAC). For the 455 (66%) patients in the post hoc analysis population who had baseline SH doses at least as high (≥ 5600 mg/d) as these point estimates, the mean SH:LC tablet ratio was ≥ 3.7, indicating a mean reduction in the tablet burden after conversion to LC of ≥ 73%.

IMPLICATIONS

This real-world assessment of comparative phosphate binder drug costs between SH and LC among US patients with ESRD indicates that average cost savings with LC use increased with increasing SH doses. Conversion to LC from SH ≥ 5600 mg/d reduced drug costs and tablet burden while maintaining serum phosphate levels.

Calcipotriol and betamethasone dipropionate in the treatment of mild-to-moderate psoriasis: a cost-effectiveness analysis of the ointment versus gel formulation

Background

Psoriasis is a chronic inflammatory skin disease with a major impact on the quality of life of affected individuals. Topical therapy has an important role in the treatment of psoriasis. Poor treatment outcomes from topical therapy regimens likely result from poor adherence and ineffective use of medication.

Methods

A cost-minimization analysis was performed with the purpose of assessing the use of a gel containing calcipotriol and betamethasone dipropionate (Dovobet^® gel) versus the ointment formulation (Dovobet ointment) in the treatment of psoriasis. The analysis was carried out using a Markov model with a one-year time horizon in a hypothetical cohort of patients with a Psoriasis Area and Severity Index score < 10. The model simulates different therapy adherence scenarios for the two different formulations.

Results

The Dovobet gel strategy allows a 5% reduction in the number of patients who could potentially be treated with more expensive therapies (biologics and conventional systemic drugs) in comparison with the Dovobet ointment strategy, with a consequent impact on costs for the National Healthcare Service. The total annual cost of Dovobet gel is about €407.00 per patient, ie, 19% less that the total cost of about €500.00 of the Dovobet ointment strategy. The base case results were then examined by sensitivity analysis and budget impact analysis to correlate the various scenarios of Dovobet gel use with cost savings to the National Healthcare Service.

Conclusion

The Dovobet gel strategy seems more acceptable to patients, shows better overall adherence, and appears to be favorable from the pharmacoeconomic point of view than the ointment formulation for treatment of patients with mild-to-moderate psoriasis.

Nasal Glucagon Versus Injectable Glucagon for Severe Hypoglycemia: A Cost-Offset and Budget Impact Analysis

BACKGROUND

Severe hypoglycemic events (SHEs) in patients with diabetes are associated with substantial health care costs in the United States (US). Injectable glucagon (IG) is currently available for treatment of severe hypoglycemia but is associated with frequent handling errors. Nasal glucagon (NG) is a novel, easier-to-use treatment that is more often administered successfully. The economic impact of this usability advantage was explored in cost-offset and budget impact analyses for the US setting.

METHODS

A health economic model was developed to estimate mean costs per SHE for which treatment was attempted using NG or IG, which differed only in the probability of treatment success, based on a published usability study. The budget impact of NG was projected over 2 years for patients with type 1 diabetes (T1D) and type 2 diabetes treated with basal-bolus insulin (T2D-BB). Epidemiologic and cost data were sourced from the literature and/or fee schedules.

RESULTS

Mean costs were $992 lower if NG was used compared with IG per SHE for which a user attempted treatment. NG was estimated to reduce SHE-related spending by $1.1 million and $230 000 over 2 years in 10 000 patients each with T1D and T2D-BB, respectively. Reduced spending resulted from reduced professional emergency services utilization as successful treatment was more likely with NG.

CONCLUSIONS

The usability advantage of NG over IG was projected to reduce SHE-related treatment costs in the US setting. NG has the potential to improve hypoglycemia emergency care and reduce SHE-related treatment costs.

Economic Analysis of Panitumumab Compared With Cetuximab in Patients With Wild-type KRAS Metastatic Colorectal Cancer That Progressed After Standard Chemotherapy

PURPOSE

In this analysis, we compared costs and explored the cost-effectiveness of subsequent-line treatment with cetuximab or panitumumab in patients with wild-type KRAS (exon 2) metastatic colorectal cancer (mCRC) after previous chemotherapy treatment failure. Data were used from ASPECCT (A Study of Panitumumab Efficacy and Safety Compared to Cetuximab in Patients With KRAS Wild-Type Metastatic Colorectal Cancer), a Phase III, head-to-head randomized noninferiority study comparing the efficacy and safety of panitumumab and cetuximab in this population.

METHODS

A decision-analytic model was developed to perform a cost-minimization analysis and a semi-Markov model was created to evaluate the cost-effectiveness of panitumumab monotherapy versus cetuximab monotherapy in chemotherapy-resistant wild-type KRAS (exon 2) mCRC. The cost-minimization model assumed equivalent efficacy (progression-free survival) based on data from ASPECCT. The cost-effectiveness analysis was conducted with the full information (uncertainty) from ASPECCT. Both analyses were conducted from a US third-party payer perspective and calculated average anti-epidermal growth factor receptor doses from ASPECCT. Costs associated with drug acquisition, treatment administration (every 2 weeks for panitumumab, weekly for cetuximab), and incidence of infusion reactions were estimated in both models. The cost-effectiveness model also included physician visits, disease progression monitoring, best supportive care, and end-of-life costs and utility weights estimated from EuroQol 5-Dimension questionnaire responses from ASPECCT.

FINDINGS

The cost-minimization model results demonstrated lower projected costs for patients who received panitumumab versus cetuximab, with a projected cost savings of $9468 (16.5%) per panitumumab-treated patient. In the cost-effectiveness model, the incremental cost per quality-adjusted life-year gained revealed panitumumab to be less costly, with marginally better outcomes than cetuximab.

IMPLICATIONS

These economic analyses comparing panitumumab and cetuximab in chemorefractory wild-type KRAS (exon 2) mCRC suggest benefits in favor of panitumumab. ClinicalTrials.gov identifier: NCT01001377.

Financial Implications of Intravenous Anesthetic Drug Wastage in Operation Room

Background and Objectives:

Anesthetic drugs and material wastage are common in operation rooms (ORs). In this era of escalating health-care expenditure, cost reduction strategies are highly relevant. The aim of this study was to assess the amount of daily intravenous anesthetic drug wastage from major ORs and to estimate its financial burden. Any preventive measures to minimize drug wastage are also looked for.

Methods:

It was a prospective study conducted at the major ORs of a tertiary care hospital after getting the Institutional Research Committee approval. The total amount of all drugs wasted at the end of a surgical day from each major OR was audited for five nonconsecutive weeks. Drug wasted includes the drugs leftover in the syringes unutilized and opened vials/ampoules. The total cost of the wasted drugs and average daily loss were estimated.

Results:

The drugs wasted in large quantities included propofol, thiopentone sodium, vecuronium, mephentermine, lignocaine, midazolam, atropine, succinylcholine, and atracurium in that order. The total cost of the wasted drugs during the study period was Rs. 59,631.49, and the average daily loss was Rs. 1987.67. The average daily cost of wasted drug was maximum for vecuronium (Rs. 699.93) followed by propofol (Rs. 662.26).

Interpretation and Conclusions:

Financial implications of anesthetic drug wastage can be significant. Propofol and vecuronium contributed maximum to the financial burden. Suggestions for preventive measures to minimize the wastage include education of staff and residents about the cost of drugs, emphasizing on the judicial use of costly drugs.

Economic evaluation of biosimilars for reimbursement purposes - what, when, how?

Background: Limited previous research and guidelines on the design of economic evaluation for biosimilars have led to unresolved methodological questions on how to assess biosimilars. Objectives: We want to raise awareness of and explore methodological issues for the economic evaluation of biosimilars. Methods: We relied on a literature review, exploratory interviews, and our experiences. Results and Conclusions: In the majority of cases in which reimbursement for a biosimilar is sought, it will not be necessary to conduct an economic evaluation, given that the reference product is already reimbursed and standard of care. If the latter is not the case, a full economic evaluation of the biosimilar versus standard of care is needed. This might also be needed in the case of differences in administration form or adherence (for example, due to a nocebo effect) and to take into account value-added services. The entry of biosimilars and of next-generation biological products should trigger a re-assessment of the entire product class. HTA bodies and reimbursement agencies should provide clear guidance on how to assess the value of a biosimilar in each of these circumstances.

Cost-Minimization Analysis of Metformin and Acarbose in Treatment of Type 2 Diabetes

BACKGROUND

Metformin is the first-line oral hypoglycemic agent for type 2 diabetes mellitus (T2DM) per international guidelines with proven efficacy, safety, and cost-effectiveness. However, little information comparing it with acarbose exists.

OBJECTIVE

To study the cost-effectiveness of metformin and acarbose-two extensively adopted agents-in treating T2DM.

METHODS

Cost-minimization analysis was conducted on the assumption that metformin and acarbose have equivalent clinical effectiveness. The cost of treatment was detected and evaluated from a payer's perspective. In sensitivity analyses, several clinical scenarios were developed according to clinical practices and physicians' prescribing behaviors in China.

RESULTS

Metformin can save annual treatment costs by 39.87% to 40.97% compared with acarbose. Under a wide range of assumptions on utilization profile and physician prescribing behavior, it saves costs by 19.83% to 40.97% in patients whose weight is 60 kg or less and by 39.87% to 70.49% in patients whose weight is more than 60 kg, which corroborates the results that metformin is more cost-effective than acarbose.

CONCLUSIONS

Metformin appears to provide better value for money than does acarbose. Findings from this study are consistent with those from previous studies that metformin is undoubtedly the first choice in the management of T2DM, with significant glucose-lowering effects and low treatment costs.

A Predictive Model to Estimate Cost Savings of a Novel Diagnostic Blood Panel for Diagnosis of Diarrhea-predominant Irritable Bowel Syndrome

PURPOSE

A high incidence of irritable bowel syndrome (IBS) is associated with significant medical costs. Diarrhea-predominant IBS (IBS-D) is diagnosed on the basis of clinical presentation and diagnostic test results and procedures that exclude other conditions. This study was conducted to estimate the potential cost savings of a novel IBS diagnostic blood panel that tests for the presence of antibodies to cytolethal distending toxin B and anti-vinculin associated with IBS-D.

METHODS

A cost-minimization (CM) decision tree model was used to compare the costs of a novel IBS diagnostic blood panel pathway versus an exclusionary diagnostic pathway (ie, standard of care). The probability that patients proceed to treatment was modeled as a function of sensitivity, specificity, and likelihood ratios of the individual biomarker tests. One-way sensitivity analyses were performed for key variables, and a break-even analysis was performed for the pretest probability of IBS-D. Budget impact analysis of the CM model was extrapolated to a health plan with 1 million covered lives.

FINDINGS

The CM model (base-case) predicted $509 cost savings for the novel IBS diagnostic blood panel versus the exclusionary diagnostic pathway because of the avoidance of downstream testing (eg, colonoscopy, computed tomography scans). Sensitivity analysis indicated that an increase in both positive likelihood ratios modestly increased cost savings. Break-even analysis estimated that the pretest probability of disease would be 0.451 to attain cost neutrality. The budget impact analysis predicted a cost savings of $3,634,006 ($0.30 per member per month).

IMPLICATIONS

The novel IBS diagnostic blood panel may yield significant cost savings by allowing patients to proceed to treatment earlier, thereby avoiding unnecessary testing.

Systematic Review of Cost-Effectiveness Analyses Comparing Open and Minimally Invasive Lumbar Spinal Surgery

BACKGROUND

Minimally invasive surgery (MIS) has benefits over open surgery for lumbar decompression and/or fusion. Published literature on its cost-effectiveness vs open techniques is mixed.

OBJECTIVE

Systematically review the cost-effectiveness of minimally invasive vs open lumbar spinal surgical decompression, fusion, or discectomy using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A systematic electronic search of databases (MEDLINE, Embase, and Cochrane Library) and a manual search from the cost-effectiveness analysis (CEA) database and National Health Service economic evaluation database was conducted. Studies that included adult populations undergoing surgery for degenerative changes in the lumbar spine (stenosis, radiculopathy, and spondylolisthesis) and reported outcomes of costing analysis, CEA, or incremental cost-effectiveness ratio were included.

RESULTS

A total of 17 studies were included. Three studies assessed outcomes of MIS vs open discectomy. All 3 reported statistically significant lower total costs in the MIS, compared with the open group, with similar reported gains in quality-adjusted life years (QALYs). Two studies reported cost differences in MIS vs open laminectomy, with significantly lower total costs attributed to the MIS group. Twelve studies reported findings on the relative direct costs of MIS vs open lumbar fusion. Among those, 3 of the 4 studies comparing single-level MIS-transforaminal lumbar interbody fusion (TLIF) and open TLIF reported lower total costs associated with MIS procedures. Six studies reported cost evaluation of single- and 2-level TLIF procedures. Lower total costs were found in the MIS group compared with the open fusion group in all studies except for the subgroup analysis of 2-level fusions in a single study. Three of these 6 studies reported cost-effectiveness (cost/QALY). MIS fusion was found to be more cost-effective than open fusion in all 3 studies.

CONCLUSION

The studies reviewed were of poor to moderate methodological quality. Generally, studies reported a reduced cost associated with MIS vs open surgery and suggested better cost-effectiveness, particularly in MIS vs open single- and 2-level TLIF procedure. Most studies had a high risk of bias. Therefore, this review was unable to conclusively recommend MIS over open surgery from a cost-effectiveness perspective.

CLINICAL RELEVANCE

The incidence of spinal decompressive and fusion surgey and financial constraints on healthcare services continue to increase. This study aims to identify the cost and clinical effectiveness of common approaches to spinal surgery.

LEVEL OF EVIDENCE

3a.

Cost-minimization analysis of alemtuzumab compared to fingolimod and natalizumab for the treatment of active relapsing-remitting multiple sclerosis in the Netherlands

AIM

In active relapsing remitting multiple sclerosis (RRMS) patients requiring second-line treatment, the Dutch National Health Care Institute (ZiN) has not stated a preference for either alemtuzumab, fingolimod, or natalizumab. The aim was to give healthcare decision-makers insight into the differences in cost accumulation over time between alemtuzumab-with a unique, non-continuous treatment schedule-and fingolimod and natalizumab for second-line treatment of active RRMS patients in the Netherlands.

METHODS

In line with ZiN's assessment, a cost-minimization analysis was performed from a Dutch healthcare perspective over a 5-year time horizon. Resource use was derived from hospital protocols and summaries of product characteristics, and validated by two MS specialists. Unit costs were based on national tariffs and guidelines. Robustness of the base case results was verified with multiple sensitivity and scenario analyses.

RESULTS

Alemtuzumab results in cost savings compared to fingolimod and natalizumab from, respectively, 3.3 and 2.8 years since treatment initiation onwards. At 5 years, total discounted costs per patient of alemtuzumab were €79,717, followed by fingolimod with €110,044 and natalizumab with €122,238, resulting in cost savings of €30,327 and €42,522 for alemtuzumab compared to fingolimod and natalizumab, respectively. Key drivers of the model are drug acquisition costs and the proportions of patients that do not require further alemtuzumab treatment after either two, three, or four courses.

LIMITATIONS

No treatment discontinuation and associated switching between treatments were incorporated. Consequences of JC virus seropositivity while continuing natalizumab treatment (e.g. additional monitoring) were omitted from the base case.

CONCLUSION

The current cost-minimization analysis demonstrates that, from the Dutch healthcare perspective, treating active RRMS patients with alemtuzumab results in cost savings compared to second-line alternatives fingolimod and natalizumab from ∼3 years since treatment initiation onwards. After 5 years, alemtuzumab's cost savings are estimated at €30k compared to fingolimod and €43k compared to natalizumab.

Assessment of the quality and trend of reporting of health economic evaluation research in India

Objectives: This study was conducted to assess the reporting quality of health economic evaluation studies using Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement along with an analysis of their trend in India.Methods: Following ethical review exemption, PubMed and Google scholar were searched for Indian studies published in 5 years (2014-2019). Keywords used were cost-effectiveness, cost-benefit, cost-utility, and cost-minimization analysis, economic evaluation, and India. CHEERS statement was used to assess the reporting quality and trend was studied using variables like a published year, type of analysis, therapy area, intervention. Data were analyzed using descriptive statistics.Results: Of the 39 studies analyzed, 17 scored less than 18 (represents 75% compliance) with a minimum score of 9 and a maximum of 23. The reporting quality was deficient with respect to heterogeneity characterization (25 studies), discount rate (18 studies), model choice, and assumptions (18 studies). Cost - effectiveness was the most common PE analysis (27 studies). The most commonly studied therapy area was infectious disorders (10) followed by oncology (5), and the commonest intervention was drugs (22).Conclusion: Inadequacy in reporting quality of health economic evaluation studies is evident. The trend revealed cost-effectiveness to be the most commonly performed type of analysis.Expert Opinion: Health economic evaluation research has gained considerable importance in healthcare decision making. Reporting quality is critical to enable efficient interpretation of health economic evaluation research. These studies have many elements, each of which have a significant impact on the conduct and outcome of the study. Hence, it is advisable to refer to any of the available guidelines [eg. CHEERS checklist] while preparing the manuscript so as to ensure all crucial elements of the study have been reported.

Healthcare Costs in the United States by Demographic Characteristics and Comorbidity Status

OBJECTIVES

Current, real-world healthcare cost information is needed to project future expenditures and inform policy. We estimated the healthcare costs for adults in 2019 in the United States by age, sex, race/ethnicity, geographic region, and comorbidity.

METHODS

We aggregated and summarized the healthcare costs in 2021 US dollars using claims data derived from Optum's deidentified Clinformatics® Data Mart Database, which includes inpatient, outpatient, and prescription claims for commercial and Medicare Advantage beneficiaries nationwide.

RESULTS

A total of 9 227 901 adults were included in the analysis. The largest group represented was 71 to 75 years old (13%), female (53%), White (68%), received care in the South (41%), and had commercial health insurance (56%). There was a positive relationship between healthcare cost and age. Females had a 1.3-fold multiplicative increase in costs than males (95% CI 1.33-1.34). There were 92.5% of individuals who had health claims in the Northeast, 89.6% in the Midwest, 88.9% in the South, 77.1% in the West, and 12.7% with unknown geographic region. Patients with severe renal failure, heart failure, or metastatic cancer incurred the highest mean yearly costs ($139 844, $113 031, and $85 299, respectively). Metastatic cancer and severe renal failure were associated with a 5.3-fold multiplicative increase in costs than not having these conditions, after adjusting for potential confounders (95% CI 5.26-5.41 and 4.98-5.16, respectively).

CONCLUSIONS

We identified patient characteristics and medical conditions that are associated with high healthcare cost burden and could benefit from tailored interventions. We provided detailed cost estimates to aid healthcare modeling, cost projection, and cost-minimizing interventions.

Stability, survival, patient satisfaction, and cost-minimization of CAD/CAM versus conventional multistranded fixed retainers in orthodontic patients: a 2-year follow-up of a two-centre randomized controlled trial

BACKGROUND

CAD/CAM (computer-aided design/computer-aided manufacturing) fixed retainers (FRs) as an alternative to multistranded FRs to maintain orthodontic treatment outcome.

OBJECTIVES

The primary aim was to compare CAD/CAM versus conventional multistranded FRs in terms of stability until 2 years. Secondary outcomes were failure rates, patient satisfaction, and cost-minimization.

TRIAL DESIGN

2-arm parallel, two-centre randomized controlled trial.

METHODS

Patients were randomized to CAD/CAM or conventional FRs in both arches, in a 1:1 ratio and blocks of four. Allocation concealment was secured by using sequentially numbered envelopes. Patients were blinded. FRs were bonded at the end of treatment, and patients were recalled after 12 and 24 months. First-time retainer failures were recorded and digital impressions were taken. Arch widths and lengths, as well as Little's Irregularity Index (LII), were measured. Additionally, patients answered satisfaction questionnaires. Linear mixed models were applied for measurements and patient satisfaction. Survival analyses were estimated with Kaplan-Meier curves, along with Cox-regression modelling. Cost-minimization analysis was undertaken.

RESULTS

One hundred and eighty-one patients were randomized (98 in Centre 1, and 83 in Centre 2): 90 in CAD/CAM and 91 in conventional group. One hundred and fifty three patients attended T24 follow-up. There were no significant differences in LII and arch dimensions between groups for failure-free patients. Within 24 months, 34% maxillary CAD/CAM FRs and 38% maxillary conventional FRs failed, along with 42% mandibular CAD/CAM FRs and 40% mandibular conventional FRs, with no significant difference in survival between groups (hazard ratios conventional to CAD/CAM: maxillary arch: 1.20 [P = 0.46], mandibular arch: 0.98 [P = 0.94]). There were no significant differences in patient satisfaction between groups. No harms were observed. Cost-minimization analysis showed that CAD/CAM FRs were slightly cheaper than conventional FRs.

CONCLUSIONS

There were no clinically significant differences in LII, arch widths, and lengths between CAD/CAM and conventional FRs after 24 months. There were no differences in failures and patient satisfaction between groups. CAD/CAM FRs were slightly cheaper than conventional FRs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04389879.

Resource Over-Utilization in Hospitalized Patients With Uncomplicated Skin and Soft Tissue Infections

BACKGROUND

Inpatient management of SSTIs utilizes considerable healthcare resources. The CREST+SEWS score categorizes patients with SSTIs into 4 severity classes. Hospitalizations can be avoided in Class I as they are treated as outpatients with oral antibiotics, whereas Class IV require hospitalization for intravenous antibiotics.

OBJECTIVE

The purpose of this study was to perform a budget impact analysis on CREST+SEWS Class 1 patients, to compare the medical costs of current treatment, in the inpatient setting with intravenous antibiotics, with a proposed alternative of using oral antibiotics in the outpatient setting. Further, resource utilization in Class I was evaluated.

METHODS

This was a retrospective study of adult patients hospitalized in 2015 for SSTIs who received >24 hours of antimicrobials. The CREST+SEWS scoring system was used to stratify patients into Class I to IV. Pharmacy and medical costs and resources associated with inpatient management of Class I SSTIs were derived from the itemized discharge records.

RESULTS

Of the 252 patients who met the inclusion criteria, 61 (24%) were classified as Class I. The total cost of treating Class I SSTI patients in the inpatient setting was $281,816 (cost per patient: $4,619) in 2015 USD. In the hypothetical situation of treatment with oral antibiotics in the outpatient setting, the cost savings were estimated to be $4,398 per patient. Fifty-three percent of patients had blood cultures, and on average, each patient received 2 radiographic tests.

CONCLUSIONS

Identifying outpatient candidates, and avoiding tests with low diagnostic can reduce the economic burden of SSTIs.

Increased use of 6-monthly gonadotropin-releasing hormone agonist therapy for prostate cancer: a capacity and cost-minimization analysis for England

AIMS

The National Health Service (NHS) in England is facing extreme capacity pressures. The backbone of prostate cancer care is gonadotropin-releasing hormone agonist (GnRHa) therapy, commonly administered every month or 3 months. We estimated the cost and capacity savings associated with increased use of 6-monthly GnRHa therapy in England.

METHODS

A capacity and cost-minimization model including a societal perspective was developed (in Microsoft Excel) to generate cost and capacity estimates for GnRHa drug acquisition and administration for "Current practice" and for a "Base case" scenario. In the "Base case" scenario, 50% of patients who were receiving monthly or 3-monthly GnRHa therapy in "Current practice" switched/transitioned to a 6-monthly formulation. Cost/capacity estimates were calculated per patient per administration and scaled to annualized population levels. Sensitivity analyses were conducted to assess the impact of individual model assumptions: 1 tested the impact of drug acquisition costs; 2 and 3 tested the level of nurse grade and the time associated with treatment administration, respectively; 4 tested the rate of switch/transition to 6-monthly GnRHa therapy; and 5 tested differing diagnostic patterns following the coronavirus disease 2019 pandemic.

RESULTS

Compared with "Current practice", the "Base case" scenario was associated with annual cost savings of £5,164,296 (148,478 fewer appointments/year and 37,119 fewer appointment-hours/year). The largest savings were in drug administration (£2.2 million) and acquisition (£1.6 million) costs. Annual societal cost savings totaled £1.4 million, mainly in reduced appointment-related travel, productivity and leisure time opportunity losses. Increased use of 6-monthly versus monthly or 3-monthly GnRHa therapy consistently achieved system-wide annual cost and capacity savings across all sensitivity analysis scenarios.

CONCLUSIONS

Our holistic model suggests that switching/transitioning men from monthly or 3- monthly GnRHa therapy to a 6-monthly formulation can reduce NHS cost and capacity pressures and the societal and environmental costs associated with prostate cancer care.

Resources Utilization Assessment and Cost-Minimization Analysis of the 6-Monthly Formulation of Triptorelin in the Treatment of Prostate Cancer in China

Objective

Prostate Cancer can be treated with various formulations of Gonadotropin-Releasing Hormone Agonists (GnRHa), but cost analyses of these treatments in China are lacking. This study aims to evaluate the differences in cost and resource utilization between various formulations of GnRHa for Prostate Cancer by conducting a resource utilization assessment and cost minimization analysis.

Methods

From the perspective of society and medical healthcare, this study used the cost minimization model to generate cost and resource estimates for GnRHa drug acquisition and administration for "Current practice" and for a "Base case" scenario. In the "Base case" scenario, all of the patients who were receiving 1-monthly or 3-monthly GnRHa therapy in "Current practice" switched to a 6-monthly formulation triptorelin. Cost/Resource estimates were calculated per patient per administration and scaled to annualized population levels. Deterministic sensitivity analysis was conducted to explore the uncertainty of the model variables and applied assumptions.

Results

From a societal perspective, if all 1-monthly and 3-monthly formulations of GnRHa were switched to a 6-monthly formulation triptorelin, it is conservatively estimated that the annual societal cost could be reduced by ¥13,382,951.13, with an average annual cost savings of ¥46.53 per patient. Additionally, the 6-monthly formulation could save 3,608,973.91 hours annually, translating to an average time savings of 12.55 hours per patient, reducing treatment time by 78%. From a healthcare system perspective, if the introduction of the 6-monthly formulation of GnRHa is delayed, it would lead to an annual increase of ¥94 million in medical costs, and require an additional 64,445.96 working days for doctors and nurses. Deterministic sensitivity analysis demonstrated the model's robustness, showing the 6-monthly GnRHa remains cost-effective across various parameter changes, with drug price being the most influential factor.

Conclusion

Compared to current 1-monthly and 3-monthly formulations, the 6-monthly GnRHa can reduce the total burden associated with prostate cancer treatment.