Another Step Toward Hepatitis C Elimination: An Economic Evaluation of an Irish National Birth Cohort Testing Program

ObjectivesWe aimed to evaluate the cost-effectiveness of offering once-off birth cohort testing for hepatitis C virus (HCV) to people in Ireland born between 1965 and 1985, the cohort with the highest reported prevalence of undiagnosed chronic HCV infection.MethodsSystematic and opportunistic HCV birth cohort testing programs, implemented over a 4-year timeframe, were compared with the current practice of population risk-based testing only in a closed-cohort decision tree and Markov model hybrid over a lifetime time horizon. Outcomes were expressed in quality-adjusted life-years (QALYs). Costs were presented from the health system’s perspective in 2020 euro (€). Uncertainty was assessed via deterministic, probabilistic, scenario, and threshold analyses.ResultsIn the base case, systematic testing yielded the largest cost and health benefits, followed by opportunistic testing and risk-based testing. Compared with risk-based testing, the incremental cost-effectiveness ratio for opportunistic testing was €14 586 (95% confidence interval €4185-€33 527) per QALY gained. Compared with opportunistic testing, the incremental cost-effectiveness ratio for systematic testing was €16 827 (95% confidence interval €5106-€38 843) per QALY gained. These findings were robust across a range of sensitivity analyses.ConclusionsBoth systematic and opportunistic birth cohort testing would be considered an efficient use of resources, but systematic testing was the optimal strategy at willingness-to-pay threshold values typically used in Ireland. Although cost-effective, any decision to introduce birth cohort testing for HCV (in Ireland or elsewhere) must be balanced with considerations regarding the feasibility and budget impact of implementing a national testing program given high initial costs and resource use.     

Cost-Effectiveness of Pulmonary Rehabilitation in Patients With Bronchial Asthma: An Analysis of the EPRA Randomized Controlled Trial

ObjectivesAt 3 months after the intervention, this study evaluates the cost-effectiveness of a 3-week inpatient pulmonary rehabilitation (PR) in patients with asthma compared with usual care alongside the single-center randomized controlled trial—Effectiveness of Pulmonary Rehabilitation in Patients With Asthma.MethodsAdopting a societal perspective, direct medical costs and productivity loss were assessed using the Questionnaire for Health-Related Resource Use-Lung, a modification of the FIM in an Elderly Population. The effect side was operationalized as minimal important differences (MIDs) of the Asthma Control Test (ACT) and the Asthma Quality of Life Questionnaire (AQLQ) and through quality-adjusted life-years (QALYs) gained. Adjusted mean differences in costs (gamma-distributed model) and each effect parameter (Gaussian-distributed model) were simultaneously calculated within 1000 bootstrap replications to determine incremental cost-effectiveness ratios (ICERs) and to subsequently delineate cost-effectiveness acceptability curves.ResultsPR caused mean costs per capita of €3544. Three months after PR, we observed higher mean costs (Δ€3673; 95% confidence interval (CI) €2854-€4783) and improved mean effects (ACT Δ1.59 MIDs, 95% CI 1.37-1.81; AQLQ Δ1.76 MIDs, 95% CI 1.46-2.08; QALYs gained Δ0.01, 95% CI 0.01-0.02) in the intervention group. The ICER was €2278 (95% CI €1653-€3181) per ACT-MID, €1983 (95% CI €1430-€2830) per AQLQ-MID, and €312 401 (95% CI €209 206-€504 562) per QALY gained.ConclusionsContrasting of PR expenditures with ICERs suggests that the intervention, which achieves clinically relevant changes in asthma-relevant parameters, has a high probability to be already cost-effective in the short term. However, in terms of QALYs, extended follow-up periods are likely required to comprehensively judge the added value of a one-time initial investment in PR.     

Clopidogrel versus Aspirin in Patients with Atherothrombosis

Background: Atherothrombosis represents a leading cause of morbidity and mortality worldwide. Given the prominent role of platelet aggregation in atherothrombosis, antiplatelet therapy forms the cornerstone of treatment, with proven efficacy in the secondary prevention of atherothrombotic events. Although clopidogrel seems to be superior to aspirin in terms of risk reduction for an atherothrombotic event, whether this clinical advantage is cost effective in Greece is unknown. Objective: The aim of this study was to conduct a cost-effectiveness analysis comparing clopidogrel with aspirin in the secondary prevention of atherothrombotic events in patients with peripheral artery disease, a recent stroke or a recent myocardial infarction, from the third-party-payer perspective in Greece. Methods: A Markov model with a 6-month cycle length was developed. Transition probabilities used in the model were obtained from the event rates reported in the CAPRIE trial. The effect of clopidogrel was applied only during the first 2 years of the model. Utility data were used to estimate quality-adjusted life-years (QALYs). Costs (for the year 2012) assigned to each health state included antiplatelet treatment cost, cost for the management of adverse events related to antiplatelet therapy and the direct healthcare cost of patients (i.e. concomitant medication, hospitalization, outpatient visits, rehabilitation, laboratory and imaging diagnostic examinations as well as interventions) in the acute and follow-up phase, separately. The incremental cost-effectiveness ratio (ICER) was calculated for life-years (LYs) and QALYs, separately. A probabilistic sensitivity analysis was conducted in order to evaluate the impact of the variation that characterizes the majority of model parameters to the cost-effectiveness results. Results: The Markov analysis revealed that the discounted survival was 11.83 (95% CI 11.40, 12.22) years and 12.17 (95% CI 11.75, 12.55) years in the aspirin and clopidogrel treatment groups, respectively, a difference of 0.34 (95% CI 0.09, 0.618) LYs. The corresponding discounted QALYs were 8.63 (95% CI 8.34, 8.90) and 8.84 (95% CI 8.54, 9.10), respectively, a difference of 0.21 (95% CI 0.05, 0.37) QALYs. The cumulated lifetime costs per patient were €20 678 (95% CI 19 675, 21 724) and €21 688 (95% CI 20 649, 22 773), for aspirin and clopidogrel treatment arm, respectively. The ICER for clopidogrel was calculated to be €4038 (95% CI 2743, 7837) for each LY saved and €5518 (95% CI 3358, 12921) for each QALY saved. Conclusion: The analysis indicates that clopidogrel is cost effective for the secondary prevention of atherothrombotic events in the Greek setting. These findings are in line with those reported in other European countries.     

Estimating costs and health outcomes of publicly funded tick-born encephalitis vaccination: A cost-effectiveness analysis

BackgroundThe number of notified cases of Tick-Borne Encephalitis (TBE) in Sweden has been increasing the past years despite the increased use of TBE-vaccine not subsidized by the healthcare system. Stockholm County is a high endemic area and an earlier study has shown that low-income households have lower vaccination coverage even when they are at high risk. This paper aims to determine the cost-effectiveness of a publicly funded TBE vaccination program in Stockholm.MethodsIn three different cohorts with individuals aged 3, 40 or 50 years, long-term costs and health outcomes of an out-of-pocket strategy (53% of the cohort is vaccinated on their own expenses) and a structured vaccination program (full cohort is vaccinated covered by the publicly funded health care system), were estimated using a Markov model. The Markov model predicts the costs and effects in term of Quality-adjusted Life Years (QALYs) over a lifetime horizon using a third-party healthcare payer perspective. The primary results are presented as an incremental cost effectiveness ratio (ICER) indicating the additional cost required to achieve one additional QALY with the structured vaccination program.ResultsThe results show that the structured vaccination program is associated with a gain in QALYs and increased costs compared with an out-of-pocket strategy. The calculated ICERs were 27 761, 99 527 and 160 827 SEK/QALY in cohorts of age 3, 40 and 50, respectively. The sensitivity analyses showed that the results are robust when varying different parameters.ConclusionGiven the setting of Stockholm county, this analysis shows a cost per QALY of a free vaccinations program, especially for children of 3 years old, below generally acceptable cost-effectiveness thresholds in Sweden.     

Cost-Effectiveness of Early Assisted Discharge for COPD Exacerbations in The Netherlands

ObjectivesHospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands.MethodsIn the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs.ResultsSeven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]−0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%–36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI−0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:−€244 (treatment phase, 95% CI−€315 to−€168) and−€168 (3 months, 95% CI−€1253 to €922). Societal perspective:−€65 (treatment phase, 95% CI−€152 to €25) and €908 (3 months, 95% CI−€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant.ConclusionsNo clear evidence was found to conclude that either treatment was more effective or less costly.     

Cost-effectiveness of inactivated influenza vaccination in children with medical risk conditions in the Netherlands

BackgroundIn many countries, annual immunization with inactivated influenza vaccine (IIV) is recommended for children with medical risk conditions. Prior cost-effectiveness analyses found such immunization to be cost saving, but assumed effectiveness against non-severe influenza outcomes and a higher effectiveness against severe influenza outcomes than recent studies would suggest. However, recent vaccine studies do not indicate any reduction in community or outpatient disease episodes in IIV immunized individuals. We therefore evaluated cost-effectiveness of IIV immunization in children with medical risk conditions in the Netherlands, assuming that IIV reduces influenza-related hospitalization and death, but has no meaningful impact on non-severe health outcomes.MethodsA health economic decision tree model was developed to evaluate health effects and costs of annual IIV immunization versus no immunization. Model inputs were based on our study on influenza-related primary care visits and other literature. Immunization was considered cost effective if associated costs were less than €20,000 per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analyses were performed to assess robustness of results, and one-way sensitivity analyses and scenario analyses were done to assess the influence of individual parameters.ResultsAnnual IIV prevents an average of 1.59 influenza-related hospitalizations and 0.02 deaths per 1,000 children with medical risk conditions. This results in an expected QALY gain of 0.43 at incremental costs of €21,564 per 1,000 children, corresponding to an incremental cost-effectiveness ratio (ICER) of €50,297/QALY compared to no immunization. Under base case assumptions, immunization had a 5% probability of being cost effective. Results were most influenced by vaccine efficacy against fatal influenza, QALY loss due to death, and mortality rate.ConclusionsIf IIV only reduces severe disease outcomes, as current evidence suggests, annual immunization of medical risk children is unlikely to be cost effective. Results should however be interpreted with caution as cost-effectiveness is largely dependent on incidence and QALY losses for fatal influenza, for which evidence is scarce.     

Is Dietetic Treatment for Undernutrition in Older Individuals in Primary Care Cost-Effective?

ObjectivesUndernutrition in older age is associated with adverse clinical outcomes and high health care costs. This study aimed to evaluate the cost-effectiveness of a dietetic treatment in primary care compared with usual care in older, undernourished, community-dwelling individuals.DesignA parallel randomized controlled trial.SettingPrimary care.ParticipantsA total of 146 undernourished, independently living older (≥65 years) individuals.InterventionDietetic treatment.MeasurementsMain outcomes were change in kilogram body weight compared with baseline and quality-adjusted life years (QALYs) after 6 months. Costs were measured from a societal perspective. The main analysis was performed according to the intention-to-treat principle. Multiple imputation was used to impute missing data and bootstrapping was used to estimate uncertainty surrounding cost differences and incremental cost-effectiveness ratios. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated.ResultsThe participants were randomized to receive either dietetic treatment (n = 72) or usual care (n = 74). After 6 months, no statistically significant differences were found between the dietetic treatment and usual care group in body weight change (mean difference 0.78 kg, 95% CI −0.26–1.82), QALYs (mean difference 0.001, 95% CI −0.04–0.04) and total costs (mean difference €1645, 95% CI −525–3547). The incremental cost-utility ratio (ICUR) for QALYs was not interpretable. The incremental cost-effectiveness ratio (ICER) for body weight gain was 2111. The probability that dietetic treatment is cost-effective compared with usual care was 0.78 for a ceiling ratio of €5000 for body weight and 0.06 for a ceiling ratio of €20.000 for QALY.ConclusionIn this study, dietetic treatment in older, undernourished, community-dwelling individuals was not cost-effective compared with usual care.     

HIV自检模式在男男性行为者中的成本效果分析

目的 分析珠海市MSM中HIV自我检测（HIVST）模式和现场HIV快速检测（HIV-RDT）模式的成本效果和支付意愿,为政府合理配置卫生资源提供参考依据。方法 以卫生服务提供者的视角,收集珠海市在2019年1-9月MSM参与两种HIV检测模式的成本投入和效果产出,采用TreeAge Pro 2019软件构建10 000名MSM队列决策树模型,测算成本效果比（CER）和增量成本效果比（ICER）,以敏感性分析模型中各参数的不确定性,绘制成本效果可支付曲线评价策略的可支付性。结果 珠海市男同社会组织通过互联网+社交媒体动员参与HIVST和现场HIV-RDT的MSM人次数为2 303 vs.816,发现HIV筛查阳性者人数为33 vs.35,筛查阳性率为1.7% vs.4.3%。每筛查1例的成本为60.45元vs.240.43元,每发现1例筛查阳性的成本为4 218元vs.5 606元。决策树模型运行结果显示,每检测1例MSM的平均费用为44.67元vs.148.42元,ICER为负值。当发现1例HIV筛查阳性支付意愿低于6 528元时,HIVST更具成本效果的选择;当投入高于该阈值时,现场HIV-RDT是更具成本效果的选择。结论 珠海市现行的HIVST模式是具有经济学价值的公共卫生项目,决策者应加大社会组织扶持力度,推广HIVST在MSM中的应用。     

Cost-Effectiveness of First-Line Pembrolizumab Monotherapy Versus Chemotherapy in High Programmed Death-Ligand 1 Advanced Non–Small Cell Lung Cancer in the Irish Healthcare Setting

ObjectivesThis study aimed to assess the cost-effectiveness of pembrolizumab monotherapy in the first-line treatment of advanced non–small cell lung cancer (NSCLC) in adults whose tumors expressed programmed death-ligand 1 (PD-L1) with a tumor proportion score (TPS) ≥ 50% in the Irish healthcare setting.MethodsEffectiveness inputs were derived from the 5-year analysis of KEYNOTE-024 phase III clinical trial. The intervention was pembrolizumab monotherapy; the comparator was a weighted average of the 5 chemotherapy regimens from the trial. The population included those with previously untreated advanced PD-L1 TPS ≥ 50% NSCLC. A de novo partitioned survival model was developed. Survival modeling was done using Bayesian model averaging on fitted parametric functions. Costs included drug acquisition, treatment initiation, administration and monitoring, adverse events, subsequent treatments, and terminal care. Costs and health state utilities were sourced from the literature and Irish sources. The model had a 20-year time horizon. The perspective taken was the Health Service Executive. A 4% discount rate was applied. Outcomes were expressed as an incremental cost-effectiveness ratio (ICER), measured in terms of incremental costs per quality-adjusted life-year (QALY). Probabilistic sensitivity analysis and 1-way sensitivity analyses were conducted.ResultsThe model estimated a base case ICER of €54 237 per QALY. The probabilistic sensitivity analysis estimated an average ICER of €54 568 per QALY and a 11% probability of cost-effectiveness at the Irish cost-effectiveness threshold of €45 000 per QALY.ConclusionAt the current list price, first-line pembrolizumab monotherapy is not considered cost-effective for the treatment of advanced PD-L1 TPS ≥ 50% NSCLC in the Irish healthcare setting.     

Cost-Effectiveness Analysis of Treating Patients With NTRK-Positive Cancer With the Histology-Independent Therapy Entrectinib

ObjectivesThis study tackles several challenges of evaluating histology-independent treatments using entrectinib as an example. Histology-independent treatments are provided based on genetic marker(s) of tumors, regardless of the tumor type. We evaluated the lifetime cost-effectiveness of testing all patients for NTRK fusions and treating the positive cases with entrectinib compared with no testing and standard of care (SoC) for all patients.MethodsThe health economic model consisted of a decision tree reflecting the NTRK testing phase followed by a microsimulation model reflecting treatment with either entrectinib or SoC. Efficacy of entrectinib was based on data from basket trials, whereas historical data from NTRK-negative patients were corrected for the prognostic value of NTRK fusions to model SoC.Results“Testing” (testing for NTRK fusions, with subsequent entrectinib treatment in NTRK-positive patients and SoC in NTRK-negative patients) had higher per-patient quality-adjusted life-years (QALYs) and costs than “No testing” (SoC for all patients), with a difference of 0.0043 and €732, respectively. This corresponded to an incremental cost-effectiveness ratio (ICER) of €169 957/QALY and, using a cost-effectiveness threshold of €80 000/QALY, an incremental net monetary benefit of ?€388. When excluding the costs of genetic testing for NTRK fusions, the ICER was reduced to €36 290/QALY and the incremental net monetary benefit increased to €188.ConclusionsWhen treatment requires the identification of a genetic marker, the associated costs and effects need to be accounted for. Because of the low prevalence of NTRK fusions, the number needed-to-test to identify patients eligible for entrectinib is large. Excluding the testing phase reduces the ICER substantially.     

Public health impact and cost-effectiveness of a nine-valent gender-neutral HPV vaccination program in France

ObjectivesIn France, 9-valent HPV vaccination is recommended routinely for 11–14-years-old girls and as catch-up for 15–19-years-old girls. Recently, recommendation for gender-neutral vaccination (GNV) has been approved. The objectives of the study were to assess the public health impact and cost-effectiveness of a 9-valent GNV compared with girls-only vaccination program (GOV).MethodsA published HPV disease transmission dynamic model accounting for herd protection effects with a 100-year time horizon was adapted and calibrated to French data. Epidemiological and economic outcomes included disease cases averted and quality-adjusted life years (QALY). Costs and incremental cost-effectiveness ratio (ICER) were measured in 2018 Euros (€). A coverage rate of 26.2% among girls and boys was assumed for the GNV program based on the current female coverage rate in France. The base case included genital warts, cervical, vulvar, vaginal, and anal cancers. Scenario analyses included all HPV-related diseases and considered higher vaccination coverage rate (60%). Deterministic sensitivity analyses on key inputs were performed.ResultsOver 100 years, GNV resulted in an additional reduction of 9,519 and 3,037 cervical cancer cases and deaths; 6,901 and 1,166 additional anal cancer cases and deaths; and a reduction of additional 1,284,077 genital warts compared with current GOV and an ICER of 24,763€/QALY. When including all HPV-related diseases, the ICER was 15,184€/QALY. At a higher coverage rate (60%), GNV would prevent 17,430 and 4,334 additional anogenital cancer cases and deaths and over two million genital warts compared with GOV with an ICER of 40,401€/QALY. Results were sensitive to a higher discount rate (6% versus 4%) and a shorter duration of protection (20 years versus lifetime).ConclusionsIn France, GNV has a significant impact in terms of public health benefits and may be considered cost-effective compared with GOV at low and high coverage rates.     

Cost-Effectiveness Assessment of Monitoring Abiraterone Levels in Metastatic Castration-Resistant Prostate Cancer Patients

ObjectivesAbiraterone acetate is registered for the treatment of metastatic castration-sensitive and resistant prostate cancer (mCRPC). Treatment outcome is associated with plasma trough concentrations (C_min) of abiraterone. Patients with a plasma C_min below the target of 8.4 ng/mL may benefit from treatment optimization by dose increase or concomitant intake with food. This study aims to investigate the cost-effectiveness of monitoring abiraterone C_min in patients with mCRPC.MethodsA Markov model was built with health states progression-free survival, progressed disease, and death. The benefits of monitoring abiraterone C_min followed by a dose increase or food intervention were modeled via a difference in the percentage of patients achieving adequate C_min taking a healthcare payer perspective. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainties and their impac to the incremental cost-effectiveness ratio (ICER).ResultsMonitoring abiraterone followed by a dose increase resulted in 0.149 incremental quality-adjusted life-years (QALYs) with €22 145 incremental costs and an ICER of €177 821/QALY. The food intervention assumed equal effects and estimated incremental costs of €7599, resulting in an ICER of €61 019/QALY. The likelihoods of therapeutic drug monitoring (TDM) with a dose increase or food intervention being cost-effective were 8.04%and 81.9%, respectively.ConclusionsMonitoring abiraterone followed by a dose increase is not cost-effective in patients with mCRPC from a healthcare payer perspective. Monitoring in combination with a food intervention is likely to be cost-effective. This cost-effectiveness assessment may assist decision making in future integration of abiraterone TDM followed by a food intervention into standard abiraterone acetate treatment practices of mCRPC patients.     

Targeted outreach hepatitis B vaccination program in high-risk adults: The fundamental challenge of the last mile

BackgroundThe aim of this study was to evaluate the cost-effectiveness of the on-going decentralised targeted hepatitis B vaccination program for behavioural high-risk groups operated by regional public health services in the Netherlands since 1-November-2002. Target groups for free vaccination are men having sex with men (MSM), commercial sex workers (CSW) and hard drug users (HDU). Heterosexuals with a high partner change rate (HRP) were included until 1-November-2007.MethodsBased on participant, vaccination and serology data collected up to 31-December-2012, the number of participants and program costs were estimated. Observed anti-HBc prevalence was used to estimate the probability of susceptible individuals per risk-group to become infected with hepatitis B virus (HBV) in their remaining life. We distinguished two time-periods: 2002–2006 and 2007–2012, representing different recruitment strategies and target groups. Correcting for observed vaccination compliance, the number of future HBV-infections avoided was estimated per risk-group. By combining these numbers with estimates of life-years lost, quality-of-life losses and healthcare costs of HBV-infections - as obtained from a Markov model-, the benefit of the program was estimated for each risk-group separately.ResultsThe overall incremental cost-effectiveness ratio of the program was €30,400/QALY gained, with effects and costs discounted at 1.5% and 4%, respectively. The program was more cost-effective in the first period (€24,200/QALY) than in the second period (€42,400/QALY). In particular, the cost-effectiveness for MSM decreased from €20,700/QALY to €47,700/QALY.Discussion and conclusionThis decentralised targeted HBV-vaccination program is a cost-effective intervention in certain unvaccinated high-risk adults. Saturation within the risk-groups, participation of individuals with less risky behaviour, and increased recruitment investments in the second period made the program less cost-effective over time. The project should therefore discus how to reduce costs per risk-group, increase effects or when to integrate the vaccination in regular healthcare.     

Cost-Effectiveness of a Specialized Breathlessness Service Versus Usual Care for Patients With Advanced Diseases

ObjectivesThe Munich Breathlessness Service (MBS) significantly improved control of breathlessness measured by the Chronic Respiratory Questionnaire (CRQ) Mastery in a randomized controlled fast track trial with waitlist group design spanning 8 weeks in Germany. This study aimed to assess the within-trial cost-effectiveness of MBS from a societal perspective.MethodsData included generic (5-level version of EQ-5D) health-related quality of life and disease-specific CRQ Mastery. Quality-adjusted life years (QALYs) were calculated based on 5-level version of EQ-5D utilities valued with German time trade-off. Direct medical costs and productivity loss were calculated based on standardized unit costs. Incremental cost-effectiveness ratios (ICER) and cost-effectiveness–acceptance curves were calculated using adjusted mean differences (AMD) in costs (gamma-distributed model) and both effect parameters (Gaussian-distributed model) and performing 1000 simultaneous bootstrap replications. Potential gender differences were investigated in stratified analyses.ResultsBetween March 2014 and April 2019, 183 eligible patients were enrolled. MBS intervention demonstrated significantly better effects regarding generic (AMD of QALY gains of 0.004, 95% confidence interval [CI] 0.0003 to 0.008) and disease-specific health-related quality of life at nonsignificantly higher costs (AMD of €605 [95% CI ?1109 to 2550]). At the end of the intervention, the ICER was €152 433/QALY (95% CI ?453 545 to 1 625 903) and €1548/CRQ Mastery point (95% CI ?3093 to 10 168). Intervention costs were on average €357 (SD = 132). Gender-specific analyses displayed dominance for MBS in males and higher effects coupled with significantly higher costs in females.ConclusionsOur results show a high ICER for MBS. Considering dominance for MBS in males, implementing MBS on approval within the German health care system should be considered.     

Cost-Effectiveness of Specialized Multidisciplinary Heart Failure Clinics in Ontario,Canada

BackgroundSpecialized multidisciplinary clinics have been shown to reduce mortality in heart failure (HF). Our objective was to evaluate the cost-effectiveness of this model of care delivery.MethodsWe performed a cost-effectiveness analysis, with a 12-year time horizon, from the perspective of the Ontario Ministry of Health and Long-term Care, comparing a standard care cohort, consisting of all patients admitted to hospital with HF in 2005, to a hypothetical cohort treated in HF clinics. Survival curves describing the natural history of HF were constructed using mortality estimates from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. Survival benefits and resource uptake associated with HF clinics were estimated from a meta-analysis of published trials. HF clinics costs were obtained by costing a representative clinic in Ontario. Health-related costs were determined through linkage to administrative databases. Outcome measures included life expectancy (years), costs (in 2008 Canadian dollars) and the incremental cost-effectiveness ratio (ICER).ResultsHF clinics were associated with a 29% reduction in all-cause mortality (risk ratio [RR] 0.71; 95% confidence interval [CI] 0.56–0.91) but a 12% increase in hospitalizations (RR 1.12; 95% CI 0.92–1.135). The cost of care in HF clinics was $52 per 30 patient-days. Projected life-expectancy of HF clinic patients was 3.91 years, compared to 3.21 years for standard care. The 12-year cumulative cost per patient in the HF clinic group was $66,532 versus $53,638 in the standard care group. The ICER was $18,259/life-year gained.ConclusionsHF clinics appear to be a cost effective way of delivering ambulatory care to HF patients.     

Economic evaluation of URMEL-ICE, a school-based overweight prevention programme comprising metabolism, exercise and lifestyle intervention in children

Objective

Measuring the impact of the URMEL-ICE school-based overweight prevention programme on anthropometric measures in primary-school children, computing incremental cost-effectiveness relation (ICER) and net monetary benefit (NMB).

Methods

This is an intervention study with historical control. Propensity score method is applied to account for group differences. One-year teacher-driven classroom implementation is used, which is based on especially developed teaching material including health education, physical activity breaks and parent involvement. 354 children in the control and 365 children in the intervention group at baseline and follow-up were analysed. Effectiveness is measured as cm waist circumference (WC) and unit (0.01) waist-to-height ratio (WHtR) increase prevented in intervention vs. control group using an adjusted two-level model. Standard cost-effectiveness analysis methods, net benefit regression and a societal perspective for a 1-year time horizon are applied.

Results

WC gain was 1.61 cm and WHtR gain was 0.014 significantly less in intervention vs. control group. Intervention costs were €24.09 per child. ICER was €11.11 (95% confidence interval (CI) [8.78; 15.02]) per cm WC and €18.55 (95% CI [14.04; 26.86]) per unit WHtR gain prevented. At a maximum willingness to pay (MWTP) of €35, both values of the CIs for NMB regarding WC and WHtR are located in the positive range.

Conclusions

The study gives new information about the cost-effectiveness of structured health promotion embedded in daily routine at primary schools. Assuming a MWTP of €35 the intervention is cost-effective with a positive NMB. This result may help decision makers in implementing programmes to prevent childhood overweight in school settings.     

Clinical effectiveness and cost-effectiveness of quadrivalent human papillomavirus vaccination in HIV-negative men who have sex with men to prevent recurrent high-grade anal intraepithelial neoplasia

We examined the long-term clinical and economic benefits of quadrivalent human papillomavirus (qHPV) vaccine as a secondary/adjunct prevention strategy in the prevention of recurrent high-grade intraepithelial neoplasia (HGAIN) in HIV-negative men who have sex with men (MSM) and are 27 years or older. We constructed a Markov model to evaluate the clinical effectiveness and cost-effectiveness of two strategies: (1) no qHPV vaccine after treatment for HGAIN versus (2) qHPV vaccine after treatment for HGAIN. Model parameters, including natural history of anal cancer, vaccine efficacy measured in terms of hazard ratio (HR) (decrease in the risk of recurrent HGAIN), HGAIN treatment efficacy, utilities, and costs, were obtained from the literature. The outcomes were measured in terms of lifetime risk of anal cancer, lifetime cost, quality-adjusted life years, and incremental cost-effectiveness ratios (ICERs). Sensitivity analysis was conducted on all model parameters. We found that vaccinating HIV-negative MSM reduced the lifetime risk of anal cancer by 60.77% at an ICER of US$87,240 per quality-adjusted life-year. The results were highly sensitive to vaccine efficacy, transition of HGAIN to anal cancer, cost of treatment for HGAIN, vaccine degree of protection over time, and the vaccine duration of protection and less sensitive to HPV clearance, cost of qHPV vaccine, and the transitions from normal to low-grade anal intraepithelial neoplasia (LGAIN) and normal to HGAIN. With an HR of 0.3, the ICER was well below a $50,000 willingness-to-pay threshold; with an HR of 0.5, the ICER was still below a threshold of $100,000. The most critical disease-related factor influencing the cost-effectiveness was the progression of HGAIN to anal cancer. At an annual transition probability below 0.001, the ICER was below $50,000. Vaccinating HIV-negative MSM treated for HGAIN decreases the lifetime risk of anal cancer and is likely to be a cost-effective intervention.     

Cost and Quality of Life Outcomes of the STepped Exercise Program for Patients With Knee OsteoArthritis Trial

ObjectivesThis study aimed to evaluate the cost-effectiveness of the randomized clinical trial STEP-KOA (STepped Exercise Program for patients with Knee OsteoArthritis).MethodsThe trial included 230 intervention and 115 control participants from 2 Veterans Affairs (VA) medical centers. A decision tree simulated outcomes for cohorts of patients receiving arthritis education (control) or STEP-KOA (intervention), which consisted of an internet-based exercise training program (step 1), phone counseling (step 2), and physical therapy (step 3) according to patient’s response. Intervention costs were assessed from the VA perspective. Quality of life (QOL) was measured using 5-level EQ-5D US utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in costs divided by the difference in quality-adjusted life-years (QALYs) between arms at 9 months. A Monte Carlo probabilistic sensitivity analysis was used to generate a cost-effectiveness acceptability curve.ResultsThe adjusted model found differential improvement in QOL utility weights of 0.042 (95% confidence interval 0.003-0.080; P=.03) for STEP-KOA versus control at 9 months. In the base case, STEP-KOA resulted in an incremental gain of 0.028 QALYs and an incremental cost of $279 per patient for an ICER of $10 076. One-way sensitivity analyses found the largest sources of variation in the ICER were the impact on QOL and the need for a VA-owned tablet. The probabilistic sensitivity analysis found a 98% probability of cost-effectiveness at $50 000 willingness-to-pay per QALY.ConclusionsSTEP-KOA improves QOL and has a high probability of cost-effectiveness. Resources needed to implement the program will decline as ownership of mobile health devices increases.     

Surveying the Cost-Effectiveness of the 20 Procedures with the Largest Public Health Services Waiting Lists in Ireland: Implications for Ireland’s Cost-Effectiveness Threshold

Objectives

To survey the cost effectiveness of procedures with the largest waiting lists in the Irish public health system to inform a reconsideration of Ireland’s current cost-effectiveness threshold of €45,000/quality-adjusted life-year (QALY).