Lifetime implications and cost-effectiveness of using finasteride to prevent prostate cancer

PURPOSE: We estimate the lifetime implications of daily treatment with finasteride following the results of the Prostate Cancer Prevention Trial (PCPT). In this trial, prostate cancer prevalence was reduced by 25%; however, an increase in the number of high-grade tumors among the treatment group necessitates the long-term projection of the likely benefits and costs. METHODS: We use a Markov decision analysis model with data from the trial, the SEER program, and published literature. The model measures the cost per life-year and cost per quality-adjusted life-year (QALY) gained for a cohort of men age 55 years who initiate preventive treatment with finasteride. RESULTS: Finasteride is associated with a gain of 6 life-years per 1000 men treated at an incremental cost of 1660000 dollars per life-year gained. The quality-adjusted analysis results in 46 QALYs gained per 1000 men treated at an incremental cost of 200000 dollars per QALY gained, due primarily to the favorable effects of finasteride on benign prostatic hyperplasia. Under the assumption that the increase in high-grade tumors observed among finasteride treated men is a pathologic artifact, the incremental costs are 290000 dollars per life-year gained and 130000 dollars per QALY gained. CONCLUSIONS: The cost burden associated with finasteride is substantial, while its survival benefit is small and only realized many years after initiating treatment. To achieve an incremental cost below 100000 dollars per QALY gained, the price of finasteride must be reduced by 50% from its current average wholesale price and finasteride must be shown to prevent high-grade as well as low-grade disease.     

Cost-effectiveness of screening for anal squamous intraepithelial lesions and anal cancer in human immunodeficiency virus-negative homosexual and bisexual men

PURPOSE: Homosexual and bisexual men are at an increased risk for human papillomavirus-induced squamous intraepithelial lesions and cancer of the anus. Our objective was to estimate the cost-effectiveness of screening for anal squamous intraepithelial lesions in these high-risk patients. SUBJECTS AND METHODS: A Markov model was developed to evaluate alternative screening strategies using anal cytology in a hypothetical cohort of homosexual and bisexual men. Data were obtained from prospective cohort studies, national databases, Medicare reimbursement rates, and the published literature. Model outcomes included life expectancy, quality-adjusted life expectancy, total lifetime costs, and incremental cost-effectiveness ratios. RESULTS: The undiscounted life expectancy gain associated with anal cytology screening every 3 years was 5.5 months. Compared with no screening, screening every 3 years increased the discounted quality-adjusted life expectancy by 1.8 months and cost $7,000 per quality-adjusted life year (QALY) gained. Screening every 2 years cost $15,100 per QALY gained compared with screening every 3 years. Annual screening provided incremental benefits of less than 0.5 quality-adjusted months and had an incremental cost of $34,800 per QALY gained. Screening every 6 months provided little additional benefit (i.e, 5 days) over that of annual screening and had an incremental cost of $143,500 per QALY gained. CONCLUSION: In homosexual and bisexual men, screening every 2 or 3 years for anal squamous intraepithelial lesions with anal cytology would provide life-expectancy benefits comparable with other accepted preventive health measures, and would be cost-effective.     

Lifetime cancer-attributable cost of care for long term survivors of colorectal cancer

OBJECTIVES: We aimed to determine cancer-related medical care costs for long term survivors of colorectal cancer. METHODS: The SEER-Medicare database was used to measure lifetime cancer-attributable costs of care for those with colorectal cancer surviving at least 5 yr versus age- and gender-matched controls. Costs were directly estimated, stratified by age at diagnosis and stage at diagnosis, for years 6-11 after diagnosis and then modeled to estimate lifetime costs. Cost differences between cancer cases and controls were compared to expected costs based on published guidelines for postcancer surveillance. RESULTS: Lifetime medical costs for long term survivors (future years not discounted) were up to $19,516 higher than control costs, and were highest for younger age groups and those with early-stage disease. Excess costs for cancer survivors exceeded expected surveillance costs by $2,223-8,822 for years 6-10 from the date of initial diagnosis. CONCLUSIONS: Cancer-attributable medical costs can be substantial for long term survivors, and exceed expected costs of surveillance. Future research is need to determine the components of excess cost in this survivor group.     

Cost-effectiveness of the lower treatment goal (of JNC VI) for diabetic hypertensive patients. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

BACKGROUND: The recommendation of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) to lower blood pressure (BP) in diabetic patients to less than 130/85 mm Hg may have negative economic consequences. A formal cost-effectiveness analysis was therefore performed, comparing the costs and potential benefits of a BP goal of less than 140/90 mm Hg (as recommended by JNC V) vs less than 130/85 mm Hg (as inJNC VI). METHODS: A 24-cell computer model was populated with costs (1996 dollars), relative risks, and age-specific base-line rates for death and 4 nonfatal adverse events (stroke, myocardial infarction, heart failure, and end-stage renal disease), derived from published data. Costs and benefits were discounted at 3%. RESULTS: For 60-year-old diabetic persons with hypertension, treating to the lower BP goal increases life expectancy by 0.48 (discounted) years and lowers (discounted) lifetime medical costs by $1450 compared with treating BP to less than 140/90 mm Hg. The lower treatment BP goal results in an overall cost savings over a wide range of initial conditions, and for nearly all analyses for patients older than 60 years. CONCLUSIONS: Any incremental treatment for 60-year-olds that costs less than $414 annually and successfully lowers BP from below 140/90 to below 130/85 mm Hg would be cost saving in the long term, due to the reduction in attendant costs of future morbidity. The lower treatment goal recommended for high-risk hypertensive patients compares favorably in cost-effectiveness with many other frequently recommended treatment strategies, and saves money overall for patients aged 60 years and older.     

Cost and cost-effectiveness of antiretroviral therapy for HIV infection in Singapore

The objective of this study was to determine the cost and cost-effectiveness of antiretroviral therapy (ART) in Singapore. The use and cost of HIV services was calculated for patients managed at the national HIV referral centre in Singapore between 1996 and 2001 from a hospital perspective. Three groups of patients were compared by Centers for Disease Control and Prevention (CDC) stage of HIV infection: those who had never received ART; those who had received only dual therapy; and those who had only received highly active antiretroviral therapy (HAART). Hospital charges were used to estimate the average hospital inpatient and outpatient care costs. Life years gained (LYG) were calculated for different stages of HIV infection and the incremental costs per LYG were calculated comparing those on dual ART and HAART with those who did not receive ART. Patients on ART progressed less rapidly across all CDC stages. For CDC stage A, the incremental cost per LYG was 17,007 dollars (Singaporean dollar) (interquartile range [IQR] 7963-25,113 dollars ) and 22,511 dollars (IQR 11,299-33,724 dollars) for those on dual therapy and HAART, respectively. The incremental cost per LYG in stage B was 10,868 dollars (IQR 4506-17,239 dollars) and 21,094 dollars (IQR 7774-34,431 dollars) for patients on dual therapy and HAART, respectively, while the incremental cost per LYG for stage C patients was 9,848 dollars (IQR 5256-14,419 dollars ) and 16,513 dollars (IQR 8677-24,337 dollars) for dual therapy and HAART, respectively. Dual ART therapy and HAART were cost-effective interventions in Singapore. Cost-effectiveness is likely to improve if drug prices continue to decrease.     

Direct medical costs and their predictors in patients with rheumatoid arthritis: a three-year study of 7,527 patients

OBJECTIVE: To estimate total direct medical costs in persons with rheumatoid arthritis (RA) and to characterize predictors of these costs. METHODS: Patients (n = 7,527) participating in a longitudinal study of outcome in RA completed 25,050 semiannual questionnaires from January 1999 through December 2001. From these we determined direct medical care costs converted to 2001 US dollars using the consumer price index. We used generalized estimating equations to examine potential predictors of the costs. Monte Carlo simulations and sensitivity analyses were performed to evaluate the varying prevalence and cost of biologic therapy. RESULTS: The mean total annual direct medical care cost in 2001 for a patient with RA was 9,519 US dollars. Drug costs were 6,324 US dollars (66% of the total), while hospitalization costs were only 1,573 US dollars (17%). Approximately 25% of patients received biologic therapy. The mean total annual direct cost for patients receiving biologic agents was 19,016 US dollars per year, while the cost for those not receiving biologic therapy was 6,164 US dollars. RA patients who were in the worst quartile of functional status, as measured by the Health Assessment Questionnaire, experienced direct medical costs for the subsequent year that were 5,022 US dollars more than the costs incurred by those in the best quartile. Physical status as determined by the Short Form 36 physical component scale had a similar large effect on RA costs, as did comorbidity. Medical insurance type played a more limited role. However, those without insurance had substantially lower service utilization and costs, and health maintenance organization patients had lower drug costs and total medical costs. Increased years of education, increased income, and majority ethnic status were all associated with increased drug costs but not hospitalization costs. Costs in all categories decreased after age 65 years. CONCLUSION: Estimates of direct medical costs for patients with RA are substantially higher than cost estimates before the biologic therapy era, and costs are now driven predominantly by the cost of drugs, primarily biologic agents. RA patients with poor function continue to incur substantially higher costs, as do those with comorbid conditions, and sociodemographic characteristics also play an important role in determination of costs.     

Toward optimal screening strategies for older women

CONTEXT: Optimal ages of breast cancer screening cessation remain uncertain. OBJECTIVE: To evaluate screening policies based on age and quartiles of life expectancy (LE). DESIGN AND POPULATION: We used a stochastic model with proxies of age-dependent biology to evaluate the incremental U.S. societal costs and benefits of biennial screening from age 50 until age 70, 79, or lifetime. MAIN OUTCOME MEASURES: Discounted incremental costs per life years saved (LYS). RESULTS: Lifetime screening is expensive (151,434 dollars per LYS) if women have treatment and survival comparable to clinical trials (idealized); stopping at age 79 costs 82,063 dollars per LYS. This latter result corresponds to costs associated with an LE of 9.5 years at age 79, a value expected for 75% of 79-year-olds, about 50% of 80-year-olds, and 25% of 85-year-olds. Using actual treatment and survival patterns, screening benefits are greater, and lifetime screening of all women might be considered (114,905 dollars per LYS), especially for women in the top 25% of LE for their age (50,643 dollars per LYS, life expectancy of approximately 7 years at age 90). CONCLUSIONS: If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age.     

The lifetime economic costs of rheumatoid arthritis

The lifetime economic costs of rheumatoid arthritis (RA) were estimated in a cohort with initial onset of RA in 1977. These costs included medical care expenses as well as the costs associated with illness-related work loss, overall and by age/sex category. The present value of the lifetime economic costs of RA was estimated to be $20,412/case in 1977 dollars, which is nearly as great as that for stroke and coronary heart disease. The study also highlighted the need for improved data on disease incidence, treatment costs, and survival experience of RA patients.     

Can Hip Protector Use Cost‐Effectively Prevent Fractures in Community‐Dwelling Geriatric Populations?

OBJECTIVES: To estimate the cost-effectiveness from a societal perspective of a hip protector (HP) program over the remaining lifetime of individuals initially living at home. DESIGN: A state-transition Markov model considering outcomes of HP use in cohorts stratified by age, sex, and functional and residential status. Costs, transition probabilities, HP adherence, and efficacy were derived from published sources. SETTING: Community and nursing homes in the United States. PARTICIPANTS: Hypothetical cohort of individuals aged 65 and older without a hip fracture and initially living at home. INTERVENTION: HP program. MEASUREMENTS: Fractures, life years, and dollars saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER). RESULTS: HP use prevented fractures and increased life expectancy in all cohorts. HP use saved costs and improved QALYs in women initiating HP use at age 80 and in men at age 85. In women initiating HP use at age 75, the HP ICER was 19,000 dollars/QALY. In men initiating HP use at age 80, HP use saved costs but slightly decreased QALYs. In younger cohorts, HP use was neither cost saving nor QALY improving. In sensitivity analyses, if there was no QALY loss from wearing a HP, the ICER was less than 50,000 dollars/QALY for all age and sex cohorts. If HP cost was reduced 50%, HP use was cost saving for women initiating HP use at age 75. In probabilistic sensitivity analyses, the HP ICER was less than 50,000 dollars/QALY in 68% of simulations for women initiating HP use at age 75 and 61% of simulations for men initiating at age 85. CONCLUSION: HP use saved costs and QALYs for older age cohorts of both sexes. Additional research on the quality-of-life effects and obstacles to wearing HP is warranted.     

Photodynamic therapy for Barrett's esophagus with high-grade dysplasia: a cost-effectiveness analysis.

OBJECTIVES: To assess the cost-effectiveness of photodynamic therapy (PDT) and esophagectomy (ESO) relative to surveillance (SURV) for patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD). METHODS: A Markov decision tree was constructed to estimate costs and health outcomes of PDT, ESO and SURV in a hypothetical cohort of male patients, 50 years of age, with BE and HGD. Outcomes included unadjusted life-years (LYs) and quality-adjusted LYs (QALYs). Direct medical costs (2003 CDN$) were measured from the perspective of a provincial ministry of health. The time horizon for the model was five years (cycle length three months), and costs and outcomes were discounted at 3%. Model parameters were assigned unique distributions, and a probabilistic analysis with 10,000 Monte Carlo simulations was performed. RESULTS: SURV was the least costly strategy, followed by PDT and ESO, but SURV was also the least effective. In terms of LYs, the incremental cost-effectiveness ratios were 814 dollars/LY for PDT versus SURV and 3,397 dollars/LY for ESO versus PDT. PDT dominated ESO for QALYs in the base-case. The incremental cost-effectiveness ratio of PDT versus SURV was 879 dollars/QALY. In probabilistic analysis, PDT was most likely to be cost-effective at willingness-to-pay (WTP) values between 100 dollars/LY and 3,500 dollars/LY, and ESO was most likely to be cost-effective for WTP values over 3500 dollars/LY. For quality-adjusted survival, PDT was most likely to be cost-effective for all WTP thresholds above 1,000 dollars/QALY. The likelihood that PDT was the most cost-effective strategy reached 0.99 at a WTP ceiling of 25,000 dollars/QALY. CONCLUSIONS: In male patients with BE and HGD, PDT and ESO are cost-effective alternatives to SURV.     

Cost-effectiveness of prophylaxis against Pneumocystis carinii pneumonia in patients with Wegner's granulomatosis undergoing immunosuppressive therapy

OBJECTIVE: To assess the incremental cost-effectiveness of 3 Pneumocystis carinii pneumonia (PCP) prophylaxis strategies in patients with Wegener's granulomatosis (WG) receiving immunosuppressive therapies: 1) no prophylaxis; 2) trimethoprim/sulfamethoxazole (TMP/SMX) 160 mg/800 mg 3 times a week, which is discontinued if patients experience an adverse drug reaction (ADR); and 3) TMP/SMX 160 mg/800 mg 3 times a week, which is replaced by monthly aerosolized pentamidine (300 mg) if patients experience an ADR. METHODS: A Markov state-transition model was developed to follow a hypothetical cohort of WG patients over their lifetimes starting from the time of initial exposure to the immunosuppressive therapy. The effect of PCP prophylaxis on life expectancy, quality-adjusted life expectancy, average discounted lifetime cost (ADLC), and incremental cost-effectiveness was estimated based on data obtained from a literature review. Direct medical costs were examined from a societal perspective, and costs and benefits were discounted at 3% annually. RESULTS: No prophylaxis resulted in a life expectancy of 13.36 quality-adjusted life years (QALY) at an ADLC of $4,538. In comparison, prophylaxis with TMP/ SMX alone increased the QALY to 13.54 and was cost saving, with an ADLC of $3,304. The addition of pentamidine in patients who had an ADR to TMP/SMX resulted in 13.61 QALY, with an ADLC of $7,428. Compared with TMP/SMX alone, TMP/SMX followed by pentamidine increased the QALY by 0.07 at an incremental cost of $58,037 per QALY. Both TMP/SMX alone and TMP/SMX followed by pentamidine prophylaxis strategies dominated the no prophylaxis strategy until the incidence of PCP fell below 0.2% and 2.25%, respectively. Institution of pentamidine therapy for patients with a TMP/SMX ADR increased quality-adjusted life expectancy compared with that with TMP/ SMX alone until the incidence of PCP rose above 7.5%. CONCLUSION: Prophylaxis using TMP/SMX alone increased life expectancy and reduced cost for patients with WG receiving immunosuppressive therapy. Replacing TMP/SMX with monthly aerosolized pentamidine in cases of ADR further increased life expectancy, although at an increased cost.     

Cost-effectiveness of gastric bypass for severe obesity

PURPOSE: To estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity. SUBJECTS AND METHODS: We performed a cost-effectiveness analysis of gastric bypass versus no treatment from the payer perspective. We discounted quality-adjusted life-years (QALYs), life-years, and cost during the patient's lifetime. Our target group comprised women and men aged 35 to 55 years with a body mass index between 40 and 50 kg/m(2), and who did not have cardiovascular disease and in whom conservative bariatric therapies had been unsuccessful. RESULTS: The base case cost-effectiveness ratios ranged from 5000 dollars to 16,100 dollars per QALY for women and from 10,000 dollars to 35,600 dollars per QALY for men, depending on age and initial body mass index. In a few subgroups of older, less obese men, variation in parameters such as loss of excess weight, obesity-related quality of life, complication rates, and perioperative mortality affected the cost-effectiveness ratios. Parameter variation did not result in meaningful changes in the remaining patients. CONCLUSION: Gastric bypass is a cost-effective alternative to no treatment, providing substantial lifetime benefits in patients who are severely obese.     

Suspected acute pulmonary emboli: cost-effectiveness of chest helical computed tomography versus a standard diagnostic algorithm incorporating ventilation-perfusion scintigraphy

Background : There is a controversy regarding the investigation of patients with suspected acute pulmonary embolism (PE).
Aims : To compare the cost-effectiveness of alternative methods of diagnosing acute PE. Chest helical computed tomography (CT) alone and in combination with venous ultrasound (US) of legs and pulmonary angiography (PA) were compared to a conventional algorithm using ventilation-perfusion (V/Q) scintigraphy supplemented in selected cases by US and PA.
Methods : A decision-analytical model was constructed to model the costs and effects of the three diagnostic strategies in a hypothetical cohort of 1000 patients each. Transition probabilities were based on published data. Life years gained by each strategy were estimated from published mortality rates. Schedule fees were used to estimate costs.
Results : The V/Q protocol is both more expensive and more effective than CT alone resulting in 20.1 additional lives saved at a (discounted) cost of $940 per life year gained. An additional 2.5 lives can be saved if CT replaces V/Q scintigraphy in the diagnostic algorithm but at a cost of $23,905 per life year saved.
Conclusions : The more effective diagnostic strategies are also more expensive. In patients with suspected PE, the incremental cost-effectiveness of the V/Q based strategy over CT alone is reasonable in comparison with other health interventions. The cost-effectiveness of the supplemented CT strategy is more questionable.     

Direct medical costs and their predictors in patients with rheumatoid arthritis

Objective

To estimate total direct medical costs in persons with rheumatoid arthritis (RA) and to characterize predictors of these costs.

Methods

Patients (n = 7,527) participating in a longitudinal study of outcome in RA completed 25,050 semiannual questionnaires from January 1999 through December 2001. From these we determined direct medical care costs converted to 2001 US dollars using the consumer price index. We used generalized estimating equations to examine potential predictors of the costs. Monte Carlo simulations and sensitivity analyses were performed to evaluate the varying prevalence and cost of biologic therapy.

Results

The mean total annual direct medical care cost in 2001 for a patient with RA was $9,519. Drug costs were $6,324 (66% of the total), while hospitalization costs were only $1,573 (17%). Approximately 25% of patients received biologic therapy. The mean total annual direct cost for patients receiving biologic agents was $19,016 per year, while the cost for those not receiving biologic therapy was $6,164. RA patients who were in the worst quartile of functional status, as measured by the Health Assessment Questionnaire, experienced direct medical costs for the subsequent year that were $5,022 more than the costs incurred by those in the best quartile. Physical status as determined by the Short Form 36 physical component scale had a similar large effect on RA costs, as did comorbidity. Medical insurance type played a more limited role. However, those without insurance had substantially lower service utilization and costs, and health maintenance organization patients had lower drug costs and total medical costs. Increased years of education, increased income, and majority ethnic status were all associated with increased drug costs but not hospitalization costs. Costs in all categories decreased after age 65 years.

Conclusion

Estimates of direct medical costs for patients with RA are substantially higher than cost estimates before the biologic therapy era, and costs are now driven predominantly by the cost of drugs, primarily biologic agents. RA patients with poor function continue to incur substantially higher costs, as do those with comorbid conditions, and sociodemographic characteristics also play an important role in determination of costs.

     

Cost-effectiveness of abatacept in patients with moderately to severely active rheumatoid arthritis and inadequate response to methotrexate

Objective. To assess cost–effectiveness of abatacept inpatients with moderately to severely active RA and inadequateresponse to MTX. Methods. We developed a simulation model to depict progressionof disability [in terms of the HAQ Disability Index (HAQ-DI)]in women aged 55–64 yrs with moderately to severely activeRA and inadequate response to MTX. At model entry, patientswere assumed to receive either only MTX or MTX plus abatacept.Patients were then tracked from model entry until death. Futurehealth-state utilities and medical-care costs (except studytherapy) were estimated based on predicted values of the HAQ-DI.The model was estimated using data from a Phase III clinicaltrial of abatacept plus various secondary sources. Cost–effectivenesswas expressed in terms of incremental cost (2006 US$) per quality-adjustedlife-year (QALY) gained over alternatively 10 yrs and a lifetime.Costs and health effects were both discounted at 3% annually. Results. Over 10 yrs, abatacept would yield 1.2 additional QALYs(undiscounted) per patient (4.6 vs 3.4 for MTX) at an incremental(discounted) cost of $51 426 ($103 601 vs $52 175, respectively);over a lifetime, corresponding figures were 2.0 QALYS (6.8 vs4.8) and $67 757 ($147 853 vs $80 096). Cost–effectivenesswas [mean (95% CI)] $47 910 ($44 641, $52 136) per QALY gainedover 10 yrs and $43 041 ($39 070, $46 725) per QALY gained overa lifetime. Findings were robust in sensitivity analyses. Conclusion. Abatacept is cost-effective by current standardsof medical practice in patients with moderately to severelyactive RA and inadequate response to MTX. KEY WORDS: Abatacept, Methotrexate, Rheumatoid arthritis, Outcomes, Cost–effectiveness Submitted 3 May 2007; revised version accepted 4 January 2008.     

Economic evaluation of posaconazole versus standard azole therapy as prophylaxis against invasive fungal infections in patients with prolonged neutropenia in Canada

INTRODUCTION:

Posaconazole prophylaxis in high-risk neutropenic patients prevents invasive fungal infection (IFI). An economic model was used to assess the cost effectiveness of posaconazole from a Canadian health care system perspective.

METHODS:

A decision-analytic model was developed based on data from a randomized trial comparing posaconazole with standard azole (fluconazole or itraconazole) therapy. The model was extrapolated to a lifetime horizon using one-month Markov cycles; lifetime survival was specific to the underlying disease. Drug and treatment costs associated with IFI were estimated using published literature. The model was used to estimate total costs, IFIs avoided, life-years gained and the incremental cost-effectiveness ratio of posaconazole versus standard azole therapy, in 2007 Canadian dollars.

RESULTS:

Based on the clinical trial data, posaconazole was associated with fewer cases of IFI (0.05 versus 0.11; P=0.003), increased life-years (2.52 years versus 2.43 years) and slightly lower costs ($6,601 versus $7,045) per patient relative to standard azole therapy over a lifetime horizon. Higher acquisition costs for posaconazole were offset by IFI-associated inpatient costs for those prophylaxed with standard azoles. Probabilistic sensitivity analysis indicated a 59% probability that posaconazole was cost-saving versus standard azole therapy and a 96% probability that the incremental cost-effectiveness ratio for posaconazole was at or below the $50,000 per life-year saved threshold.

DISCUSSION:

In Canada, posaconazole appears to be cost-saving relative to standard azole therapy in IFI prevention among high-risk neutropenic patients.     

Cost effectiveness of vaccination strategies in adults without a history of chickenpox

PURPOSE: Some authorities recommend varicella antibody testing or vaccination for adults without a history of chickenpox, but the cost effectiveness of these interventions is uncertain. SUBJECTS AND METHODS: Using a Markov decision model, we estimated the cost effectiveness of three strategies for adults with no history of chickenpox: no vaccination, varicella antibody testing followed by vaccination for those without antibody, and vaccinating all. Societal and third-party payer perspectives were taken, with costs and benefits discounted at 3% per year. Assumptions for the baseline analysis were chosen to bias against no vaccination. RESULTS: In the baseline analysis for 20- to 29-year-old patients, testing followed by vaccination compared with no vaccination is cost saving from a societal perspective and costs $6,670 per quality-adjusted life-year (QALY) gained from a third-party payer perspective. When less favorable assumptions are used, results are sensitive to the rates of compliance with vaccination follow-up; testing followed by vaccination costs more than $50,000 per QALY if <75% comply. For patients 30 years of age and older, the incremental cost of testing followed by vaccination is at least $97,100 per QALY compared with no vaccination, with costs greater than $50,000 per QALY unless testing costs less than $7.73, the chickenpox case-fatality rate is >0.067% (baseline 0.025%), or immunity with no chickenpox history is <25% (baseline 71%). In either age group, vaccinating all has an incremental cost of $2 to $16 million per QALY gained compared with testing followed by vaccination. CONCLUSION: Testing followed by vaccination for varicella in US adults aged 20 to 29 years may be cost effective by conventional criteria but is sensitive to rates of compliance with vaccination protocols. Testing or vaccination of older adults is expensive but may be cost effective in patients with lower probabilities of immunity or in those who have a greater risk of complications from chickenpox.     

The cost of health care for children and adults with sickle cell disease

Although sickle cell disease (SCD) is marked by high utilization of medical resources, the full cost of care for patients with SCD, including care not directly related to SCD, is unknown. The purpose of this study was to estimate the total cost of medical care for a population of children and adults with SCD. We used data from individuals diagnosed with SCD enrolled in the Florida Medicaid program during 2001–2005 to estimate total, SCD‐related, and non‐SCD‐related cost per patient‐month based on patient age at the time of health care use. Across the 4,294 patient samples, total health care costs generally rose with age, from $892 to $2,562 per patient‐month in the 0–9‐ and 50–64‐year age groups, respectively. Average cost per patient‐month was $1,389. Overall, 51.8% of care was directly related to SCD, the majority of which (80.5%) was associated with inpatient hospitalizations. Notably, non‐SCD‐related costs were substantially higher than those reported for the general US population. These results suggest a discounted (3% discount rate) lifetime cost of care averaging $460,151 per patient with SCD. Interventions designed to prevent SCD complications and avoid hospitalizations may reduce the significant economic burden of the disease. Am. J. Hematol. 2009. © 2009 Wiley‐Liss, Inc.     

Modeling the progression of rheumatoid arthritis: a two-country model to estimate costs and consequences of rheumatoid arthritis

OBJECTIVE: Two simulation models were developed to analyze the cost-effectiveness of new treatments that affect the progression of rheumatoid arthritis (RA). METHODS: We used data from 2 cohorts of patients with early RA who had been followed up since disease onset (up to 15 years). In the Swedish study, 183 patients were followed up for a mean of 11.3 years. In the UK study, 916 patients were followed up for a mean of 7.8 years. Disease progression over 10 years was modeled as annual transitions between disease states, defined by Health Assessment Questionnaire (HAQ) scores. A regression model was used to estimate transition probabilities conditional on age, sex, and time since onset of disease, in order to allow simulation of different patient cohorts. Costs and utilities associated with different HAQ levels were based on data from the cohort studies and cross-sectional surveys. RESULTS: Costs increase and quality of life decreases as RA progresses. In Sweden, total annual costs range from 4,900 dollars to 33,000 dollars per patient, compared with 4,900 dollars to 14,600 dollars in the UK. Cumulative costs over 10 years for patients starting in disease state 1 (HAQ < 0.6) are 54,600 dollars in Sweden and 26,600 dollars in the UK. The cumulative numbers of quality-adjusted life-years (QALYs) are 5.5 and 5.6, respectively. Both costs and QALYs were discounted at 3%. CONCLUSION: The 2 models, which were based on different patient cohorts, reach a similar conclusion in terms of the effect of RA over 10 years. They appear to accurately capture disease progression and its effects and can therefore be useful in estimating the cost-effectiveness of new treatments in RA.     

Cost-effectiveness of rivaroxaban compared to warfarin for stroke prevention in atrial fibrillation

Rivaroxaban has been found to be noninferior to warfarin for preventing stroke or systemic embolism in patients with high-risk atrial fibrillation (AF) and is associated with a lower rate of intracranial hemorrhage. To assess the cost-effectiveness of rivaroxaban compared to adjusted-dose warfarin for the prevention of stroke in patients with AF, we built a Markov model using a United States payer/Medicare perspective and a lifetime time horizon. The base-case analysis assumed a cohort of patients with AF 65 years of age with a congestive heart failure, hypertension, age, diabetes, stroke (2 points) score of 3 and no contraindications to anticoagulation. Data sources included the Rivaroxaban Once-daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) and other studies of anticoagulation. Outcome measurements included costs in 2011 United States dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Patients with AF treated with rivaroxaban lived an average of 10.03 QALYs at a lifetime treatment cost of $94,456. Those receiving warfarin lived an average of 9.81 QALYs and incurred costs of $88,544. The ICER for rivaroxaban was $27,498 per QALY. These results were most sensitive to changes in the hazard decrease of intracranial hemorrhage and stroke with rivaroxaban, cost of rivaroxaban, and time horizon. Monte Carlo simulation demonstrated rivaroxaban was cost-effective in 80% and 91% of 10,000 iterations at willingness-to-pay thresholds of $50,000 and $100,000 per QALY, respectively. In conclusion, this Markov model suggests that rivaroxaban therapy may be a cost-effective alternative to adjusted-dose warfarin for stroke prevention in AF.