Cost-Effectiveness of Pergolide Compared to Bromocriptine in the Treatment of Parkinson's Disease: A Decision-Analytic Model

ObjectiveTo develop a decision-analytic model to assess the cost-effectiveness of pergolide versus bromocriptine in the treatment of Parkinson's disease (PD).MethodsA Markov decision-analytic model is used to examine cost-effectiveness. The model ran for 20 cycles of 6 months' duration, and the patients progress through six stages: Hoehn-Yahr stages 1–5 and death. The transitional probabilities for each stage are derived from a 12-year longitudinal study of patients with PD. The costs in the model are derived from an expert panel containing six Australian neurologists. A review of the randomized controlled trials comparing the efficacy and safety of pergolide versus bromocriptine was undertaken. Five studies were identified, with four showing that pergolide offers superior efficacy when compared to bromocriptine. The Mizuno et al. (1995) study was the largest of the controlled trials and also measured patient Hoehn-Yahr status before and after treatment. This was identified as the most appropriate source of relative efficacy data for the model. The model examined various scenarios based on alternate durations of superior clinical benefit with pergolide compared to bromocriptine. The main analysis assumed that patients in each arm of the model would have identical Hoehn-Yahr status by the fifth year. Sensitivity analysis was used to determine cost-effectiveness in the case where the therapeutic benefit was of a shorter duration.ResultsThe Mizuno study indicates that an additional 19.09% of patients improved by at least one stage on pergolide over bromocriptine, with an odds ratio of 2.26 (p < .01). The total health care cost per patient over the 10-year period was $46,323 in the pergolide treatment arm and $47,351 in the bromocriptine treatment arm, an incremental saving of $1028. Patients also spent extra time in Hoehn-Yahr stages 1, 2, and 3. In sensitivity analyses, when the benefit from pergolide expired between 6 months and 5 years after treatment cessation, cost savings ranged from $68 to $2535.ConclusionPergolide is cost saving and more efficacious than bromocriptine, and is therefore cost-effective.     

Cost-Effectiveness of a Technology-Facilitated Depression Care Management Adoption Model in Safety-Net Primary Care Patients with Type 2 Diabetes

Background

The Diabetes-Depression Care-Management Adoption Trial is a translational study of safety-net primary care predominantly Hispanic/Latino patients with type 2 diabetes in collaboration with the Los Angeles County Department of Health Services.

The Cost-Effectiveness of Bosentan in the United Kingdom for Patients with Pulmonary Arterial Hypertension of WHO Functional Class III

Objectives:  To assess whether bosentan or no active intervention, in addition to palliative care, is the more cost-effective first-line treatment option for patients with idiopathic pulmonary arterial hypertension (iPAH) or PAH associated with connective tissue disease (PAH-CTD) of WHO functional classification (FC) III in the United Kingdom.
Methods:  A cost-utility model simulated the treatment of patients with PAH of FC III. Patients remained on the selected intervention until death or clinical deterioration to FC IV, which would trigger initiation of epoprostenol treatment. The initial first-line treatment choice was assumed to not affect survival, but to affect the time until clinical deterioration, with this assumption being relaxed in sensitivity analyses. The distribution of time to clinical deterioration was estimated from long-term clinical trial databases of bosentan and from published literature. Utility associated with FC was taken from published literature. Costs were sourced from published literature and from specialist PAH centers. The time horizon was that of patients' lifetimes, with costs and benefits discounted at 3.5% per annum.
Results:  In the base case, bosentan dominated no active intervention because of the longer time to clinical deterioration and therefore the reduced time, per patient, spent in FC IV, which was associated with high costs of epoprostenol and reduced utility. In sensitivity analyses, bosentan was estimated to be more cost-effective than no active intervention, provided that any survival benefit was not greater than 2 years for patients with iPAH and 1 year for those with PAH-CTD.
Conclusions:  Bosentan is likely to be a more cost-effective first-line therapy for patients with PAH FC III in the UK than no active intervention.     

Cost-Effectiveness of Disease Management Programs for Cardiovascular Risk and COPD in The Netherlands

BackgroundDisease management programs (DMPs) for cardiovascular risk (CVR) and chronic obstructive pulmonary disease (COPD) are increasingly implemented in The Netherlands to improve care and patient’s health behavior.ObjectiveThe aim of this study was to provide evidence about the (cost-) effectiveness of Dutch DMPs as implemented in daily practice.MethodsWe compared the physical activity, smoking status, quality-adjusted life-years, and yearly costs per patient between the most and the least comprehensive DMPs in four disease categories: primary CVR prevention, secondary CVR prevention, both types of CVR prevention, and COPD (N = 1034). Propensity score matching increased comparability between DMPs. A 2-year cost-utility analysis was performed from the health care and societal perspectives. Sensitivity analysis was performed to estimate the impact of DMP development and implementation costs on cost-effectiveness.ResultsPatients in the most comprehensive DMPs increased their physical activity more (except for primary CVR prevention) and had higher smoking cessation rates. The incremental QALYs ranged from –0.032 to 0.038 across all diseases. From a societal perspective, the most comprehensive DMPs decreased costs in primary CVR prevention (certainty 57%), secondary CVR prevention (certainty 88%), and both types of CVR prevention (certainty 98%). Moreover, the implementation of comprehensive DMPs led to QALY gains in secondary CVR prevention (certainty 92%) and COPD (certainty 69%).ConclusionsThe most comprehensive DMPs for CVR and COPD have the potential to be cost saving, effective, or cost-effective compared with the least comprehensive DMPs. The challenge for Dutch stakeholders is to find the optimal mixture of interventions that is most suited for each target group.     

Cost-Effectiveness and Value of Information Analysis of Brief Interventions to Promote Physical Activity in Primary Care

Background

Brief interventions (BIs) delivered in primary care have shown potential to increase physical activity levels and may be cost-effective, at least in the short-term, when compared with usual care. Nevertheless, there is limited evidence on their longer term costs and health benefits.

Optimizing the Position and Use of Omalizumab for Severe Persistent Allergic Asthma Using Cost-Effectiveness Analysis

BackgroundThere has been some controversy on whether the costs of omalizumab outweigh its benefits for severe persistent allergic asthma.ObjectivesThis study aimed to resolve the uncertainties and limitations of previous analyses and establish the cost-effectiveness of omalizumab under the list price and Patient Access Scheme (PAS) discounted price for the UK National Health Service.MethodsA decision-analytic model was developed to evaluate the long-term cost-effectiveness of omalizumab under the perspective of the National Health Service. Outcomes were expressed as quality-adjusted life-years (QALYs). Patient subgroups were defined post hoc on the basis of data collected in clinical trials: previous hospitalization, on maintenance oral corticosteroids, and three or more previous exacerbations.ResultsThe incremental cost-effectiveness ratio varied from £30,109 to £57,557 per QALY gained depending on the population considered using the PAS price; incremental cost-effectiveness ratios were over a third higher using the list price. Omalizumab is likely to be cost-effective at the threshold of £30,000 per QALY gained in the severe subgroups if the improvement in health-related quality of life from omalizumab is mapped from an asthma-specific measure to the EuroQol five-dimensional questionnaire (vs. the EuroQol five-dimensional questionnaire directly collected from patients) or asthma mortality refers to death after hospitalization from asthma (vs. asthma-mortality risk in the community).ConclusionsAlthough the cost-effectiveness of omalizumab is more favorable under the PAS price, it represents good value for money only in severe subgroups and under optimistic assumptions regarding asthma mortality and improvement in health-related quality of life. For these reasons, omalizumab should be carefully targeted to ensure value for money.     

The Cost-Effectiveness of a Novel SIAscopic Diagnostic Aid for the Management of Pigmented Skin Lesions in Primary Care: A Decision-Analytic Model

ObjectivesPigmented skin lesions are commonly presented in primary care. Appropriate diagnosis and management is challenging because the vast majority are benign. The MoleMate system is a handheld SIAscopy scanner integrated with a primary care diagnostic algorithm aimed at improving the management of pigmented skin lesions in primary care.MethodsThis decision-model–based economic evaluation draws on the results of a randomized controlled trial of the MoleMate system versus best practice (ISRCTN79932379) to estimate the expected long-term cost and health gain of diagnosis with the MoleMate system versus best practice in an English primary care setting. The model combines trial results with data from the wider literature to inform long-term prognosis, health state utilities, and cost.ResultsResults are reported as mean and incremental cost and quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness ratio with probabilistic sensitivity analysis, and value of information analysis. Over a lifetime horizon, the MoleMate system is expected to cost an extra £18 over best practice alone, and yield an extra 0.01 QALYs per patient examined. The incremental cost-effectiveness ratio is £1,896 per QALY gained, with a 66.1% probability of being below £30,000 per QALY gained. The expected value of perfect information is £43.1 million.ConclusionsGiven typical thresholds in the United Kingdom (£20,000–£30,000 per QALY), the MoleMate system may be cost-effective compared with best practice diagnosis alone in a primary care setting. However, there is considerable decision uncertainty, driven particularly by the sensitivity and specificity of MoleMate versus best practice, and the risk of disease progression in undiagnosed melanoma; future research should focus on reducing uncertainty in these parameters.     

基于ICCC框架的医联体模式下高血压健康管理实践分析

按照ICCC框架要素对定性访谈资料和文献资料进行整理,分析医联体模式下高血压健康管理实践,总结了现有管理模式的特点和不足。研究发现,医联体模式下高血压健康管理模式整体上运行良好,宏观层面要素齐备,但是中观和微观层面部分要素尚不完善。为完善高血压健康管理模式,建议强化社区作用,建立医疗卫生机构和公共卫生机构的合作制度,完善医疗卫生人员激励机制,满足患者不同层次、不同深度的需求,形成管理完善、运行高效的高血压健康管理模式,取得最佳的慢性病防控管理效果。     

Differences in Cardiovascular Disease Risk Factor Management in Primary Care by Sex of Physician and Patient

PURPOSE The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice.METHODS We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England.RESULTS Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12–4.40) and obesity (OR = 2.14; 95% CI, 1.30–3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30–3.18) and diabetes (OR = 6.55; 95% CI, 2.01–21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25–0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22–0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15–0.58).CONCLUSION Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.     

Cost-Effectiveness of a Comprehensive Approach for Hypertension Control in Low-Income Settings in Argentina: Trial-Based Analysis of the Hypertension Control Program in Argentina

Background

A recent cluster randomized trial evaluating a multicomponent intervention showed significant reductions in blood pressure in low-income hypertensive subjects in Argentina.

Cost-Effectiveness of Different Formats for Delivery of Cognitive Behavioral Therapy for Depression: A Systematic Review Based Economic Model

ObjectivesCognitive behavioral therapy (CBT) is an effective treatment for depression. Different CBT delivery formats (face-to-face [F2F], multimedia, and hybrid) and intensities have been used to expand access to the treatment. The aim of this study is to estimate the long-term cost-effectiveness of different CBT delivery modes.MethodsA decision-analytic model was developed to evaluate the cost-effectiveness of different CBT delivery modes and variations in intensity in comparison with treatment as usual (TAU). The model covered an average treatment period of 4 months with a 5-year follow-up period. The model was populated using a systematic review of randomized controlled trials and various sources from the literature.ResultsIncremental cost-effectiveness ratios of treatments compared with the next best option after excluding all the dominated and extended dominated options are: £209/quality-adjusted life year (QALY) for 6 (sessions) × 30 (minutes) F2F-CBT versus TAU; £4 453/QALY for 8 × 30 F2F versus 6 × 30 F2F; £12 216/QALY for 8 × 60 F2F versus 8 × 30 F2F; and £43 072/QALY for 16 × 60 F2F versus 8 × 60 F2F. The treatment with the highest net monetary benefit for thresholds of £20 000 to £30 000/QALY was 8 × 30 F2F-CBT. Probabilistic sensitivity analysis illustrated 6 × 30 F2F-CBT had the highest probability (32.8%) of being cost-effective at £20 000/QALY; 16 × 60 F2F-CBT had the highest probability (31.0%) at £30 000/QALY.ConclusionsAll CBT delivery modes on top of TAU were found to be more cost-effective than TAU alone. Four F2F-CBT options (6 × 30, 8 × 30, 8 × 60, 16 × 60) are on the cost-effectiveness frontier. F2F-CBT with intensities of 6 × 30 and 16 × 60 had the highest probabilities of being cost-effective. The results, however, should be interpreted with caution owing to the high level of uncertainty.     

莱州市农村居民高血压健康教育干预效果评价

目的了解高血压健康教育对农村居民高血压的意义,为高血压的预防提供科学依据。方法采用随机整群抽样的方法,于2012年8月—2012年11月,在莱州市苗家抽取辖区2行政村的30⁶5岁的常驻居民为研究对象,采用统一问卷进行高血压教育干预前后的问卷调查。结果与健康教育干预前相比,干预后血压值的正常范围知晓率,高盐饮食、过量饮酒、超重肥胖、遗传以及精神紧张与高血压发病的关系知晓率以及高血压危害的知晓率七项均高于干预前,差异具有统计学意义(P<0.05);除了体育锻炼在干预前后无明显变化外(P>0.05),其他高血压预防的正确行为(控制钠盐的摄入、控制体重、控制酒的摄入以及保持好的心态)正确率均高于健康教育实施前,且差异具有统计学意义(P<0.05)。结论高血压健康教育,能够提高农村居民的高血压预防知识水平,改善其行为。     

Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project

PURPOSE Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.METHODS The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.RESULTS DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P=.012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.CONCLUSIONS The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.     

Ethnic Disparities in Blood Pressure Management in Patients With Hypertension After the Introduction of Pay for Performance

PURPOSE Little is known about the impact of pay-for-performance incentives on health care disparities. We examined ethnic disparities in the management of hypertension among patients with and without cardiovascular comorbidities after the implementation of a major pay-for-performance incentive scheme in UK primary care.     

Cost-Effectiveness Analysis of a Pharmacist-Led Medication Therapy Management Program: Hypertension Management

ObjectivesUncontrolled hypertension is a common cause of cardiovascular disease, which is the deadliest and costliest chronic disease in the United States. Pharmacists are an accessible community healthcare resource and are equipped with clinical skills to improve the management of hypertension through medication therapy management (MTM). Nevertheless, current reimbursement models do not incentivize pharmacists to provide clinical services. We aim to investigate the cost-effectiveness of a pharmacist-led comprehensive MTM clinic compared with no clinic for 10-year primary prevention of stroke and cardiovascular disease events in patients with hypertension.MethodsWe built a semi-Markov model to evaluate the clinical and economic consequences of an MTM clinic compared with no MTM clinic, from the payer perspective. The model was populated with data from a recently published controlled observational study investigating the effectiveness of an MTM clinic. Methodology was guided using recommendations from the Second Panel on Cost-Effectiveness in Health and Medicine, including appropriate sensitivity analyses.ResultsCompared with no MTM clinic, the MTM clinic was cost-effective with an incremental cost-effectiveness ratio of $38 798 per quality-adjusted life year (QALY) gained. The incremental net monetary benefit was $993 294 considering a willingness-to-pay threshold of $100 000 per QALY. Health-benefit benchmarks at $100 000 per QALY and $150 000 per QALY translate to a 95% and 170% increase from current reimbursement rates for MTM services.ConclusionsOur model shows current reimbursement rates for pharmacist-led MTM services may undervalue the benefit realized by US payers. New reimbursement models are needed to allow pharmacists to offer cost-effective clinical services.     

A Participatory Model of the Paradox of Primary Care

PURPOSE

The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care.

METHODS

In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity.

RESULTS

In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters.

CONCLUSION

This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.     

Cost-Effectiveness of Drug-Eluting Stents in a US Medicare Setting: A Cost-Utility Analysis with 3-Year Clinical Follow-Up Data

Background:  There is only limited information about cost-effectiveness of drug-eluting compared with bare metal stents (BMS) over a time horizon of more than 1 year.
Methods and Results:  We developed a Markov model based on clinical outcome data from a meta-analysis including 17 randomized controlled trials comparing drug-eluting versus BMS with a minimum follow-up of 1 (n = 8221) and a maximum follow-up of 3 years (n = 4105) in patients with chronic coronary artery disease. Costs were obtained as reimbursement rates for diagnosis related groups from the US Centers for Medicare and Medicaid Services. All costs and effects were discounted at 3% annually. All costs are reported in US dollars of the financial year 2007. The incremental effects are 0.002 (95% confidence interval −0.039 to 0.041) quality-adjusted life-years (QALYs) for the sirolimus- and −0.001 (−0.040 to 0.038) QALYs for the paclitaxel-eluting stents (PES). The incremental costs are $2790 for the sirolimus- and $3838 for the PES. The incremental cost-effectiveness ratio is >$1,000,000 per QALY for the sirolimus-eluting stent. PES are dominated by BMS (i.e., less effective and more costly). Among various sensitivity analyses performed, the model proved to be robust.
Conclusions:  Our analysis from a US Medicare perspective suggests that drug-eluting stents are not cost-effective compared with BMS when implanted in unselected patients with symptomatic ischemic coronary artery disease.