Cost-Effectiveness of Interventions for Reducing Road Traffic Injuries Related to Driving under the Influence of Alcohol

ObjectiveTo determine the cost-effectiveness of interventions to reduce road traffic injuries caused by driving under the influence of alcohol in Thailand.MethodsWe used generalized cost-effectiveness analysis and included costs from a health sector perspective. The model considered road traffic crash victims who were injured, disabled, or died. We obtained proportions of alcohol-related crashes from the Thai Injury Surveillance system. Intervention effectiveness was derived from published reviews and a study in one province of Thailand. Random breath testing, selective breath testing, and mass media campaigns, both current and intervention scenarios, were compared with a “do-nothing” scenario. We calculated intervention costs and cost offsets of prevented treatment costs in 2004 Thai baht (US $1 = 41 baht) and measured benefits in terms of disability-adjusted life-years averted. Interventions with incremental cost-effectiveness ratios below 110,000 Thai baht (1×gross domestic product per capita) per disability-adjusted life-year (US $2,680) were considered very cost-effective.ResultsCompared with doing nothing, mass media campaigns, random breath testing, and selective breath testing are all cost saving. When averted treatment costs are ignored and only intervention costs are included, all three interventions are very cost-effective, with incremental cost-effectiveness ratios of 10,300, 14,300 and 13,000 baht/disability-adjusted life-year, respectively. The current mix of mass media campaigns and sobriety checkpoints is therefore also cost-effective, but underinvestment in checkpoints limits its overall effect.ConclusionsA greater intensity of conducting sobriety checkpoints in Thailand is recommended to complement the investment in mass media campaigns. Together these interventions have the potential to reduce the burden of alcohol-related road traffic injuries by 24%.     

Designing Guidelines for Those Who Do Not Follow Them: The Impact of Adherence Assumptions on Optimal Screening Guidelines

ObjectivesModel-based cost-effectiveness analyses can inform decisions about screening guidelines by quantifying consequences of alternative algorithms. Although actual screening adherence is imperfect, incorporating nonadherence into analyses that aim to determine optimal screening may affect the policy recommendations. We evaluated the impact of nonadherence assumptions on the optimal cervical cancer screening in Norway.MethodsWe used a microsimulation model of cervical carcinogenesis to project the long-term health and economic outcomes under alternative screening algorithms and adherence patterns. We compared 18 algorithms involving primary human papillomavirus testing (5-yearly) that varied follow-up management of different human papillomavirus results. We considered 12 adherence scenarios: perfect adherence, 8 high- and low-coverage “random-complier” scenarios, and 3 “systematic-complier” scenarios that reflect conditional screening behavior over a lifetime. We calculated incremental cost-effectiveness ratios and considered a strategy with the highest incremental cost-effectiveness ratio < 55 000 US dollars/quality-adjusted life-year as “optimal.”ResultsUnder perfect adherence, the least intensive screening strategy was optimal; in contrast, assuming any nonadherence resulted in a more intensive optimal strategy. Accounting for lower adherence resulted in both lower costs and health benefits, which allowed for a more intensive strategy to be considered optimal, but more harms for women who screen according to guidelines (ie, up to 41% more colposcopies when comparing the optimal strategy in the lowest-adherence scenario with the optimal strategy under perfect adherence).ConclusionsAssuming nonadherence in analyses designed to inform national guidelines may lead to a relatively more intensive recommendation. Designing guidelines for those who do not adhere to them may lead to over-screening of those who do.     

Cost and Cost-Effectiveness of a Digital Adherence Technology for Tuberculosis Treatment Support in Uganda

ObjectivesDigital adherence technologies like 99DOTS are increasingly considered as an alternative to directly observed therapy for tuberculosis (TB) treatment supervision. We evaluated the cost and cost-effectiveness of 99DOTS in a high-TB-burden setting.MethodsWe assessed the costs of implementing 99DOTS in Uganda through a pragmatic, stepped-wedge randomized trial. We measured costs from the health system perspective at 5 of 18 study facilities. Self-reported service activity time data were used to assess activity-based service costs; other costs were captured from budgets and key informant discussions using standardized forms. We estimated costs and effectiveness considering the 8-month study period (“trial specific”) and using a 5-year time horizon (“extended activities”), the latter including a “marginal clinic” expansion scenario that ignored above-site implementation costs. Cost-effectiveness was assessed as cost per patient successfully completing treatment, using Monte Carlo simulation, cost-effectiveness acceptability curves, and sensitivity analyses to evaluate uncertainty and robustness of results.ResultsThe total cost of implementing 99DOTS in the “trial-specific” scenario was $99 554 across 18 clinics (range $3771-$6238 per clinic). The cost per treatment success in the “trial-specific” scenario was $355 (range $229-$394), falling to $59 (range $50-$70) assuming “extended activities,” and $49 (range $42-$57) in the “marginal clinic” scenario. The incremental cost-effectiveness of 99DOTS in the “extended-activity” scenario was $355 per incremental treatment success.ConclusionsCosts and cost-effectiveness of 99DOTS were influenced by the degree to which infrastructure is scaled over time. If sustained and scaled up, 99DOTS can be a cost-effective option for TB treatment adherence support in high-TB-burden settings like Uganda.     

Value of Triage Treatment Strategies to Distribute Hepatitis C Direct-Acting Antiviral Agents in an Integrated Healthcare System: A Cost-Effectiveness Analysis

ObjectivesThis study aimed to assess the cost-effectiveness of fibrosis-based direct-acting antiviral treatment policies for patients with chronic hepatitis C virus at the Kaiser Permanente Mid-Atlantic States health system.MethodsWe used a Markov model to compare the lifetime costs and effects of treating patients with chronic hepatitis C virus at different stages of disease severity, or all stages simultaneously, based on a fibrosis score from the US healthcare sector perspective and societal perspective. The initial distribution of patients across fibrosis scores, the effectiveness of direct-acting antiviral therapy, and follow-up and monitoring protocols were specific to the Kaiser Permanente Mid-Atlantic States health system. Direct and indirect costs, transition probabilities, and utilities were derived from the literature. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of our results.ResultsThe “Treat All” option was dominant from both the societal and healthcare sector perspectives. The conclusion was robust in deterministic sensitivity analysis. The range of incremental costs between the less restrictive policies was small—the difference between the “Treat F1+” and the “Treat All” option was only $111 per person. Probabilistic sensitivity analyses showed, at both the $100 000/quality-adjusted life-year and $150 000/quality-adjusted life-year thresholds, there was a 70% chance that the “Treat All” option was more cost-effective than the “Treat F1+” option.ConclusionsWe found that expanded treatment access is cost-effective and, in many cases, cost saving. Although our results are primarily applicable to a regional integrated healthcare system, it offers some direction to any healthcare setting faced with resource constraints in the face of highly priced drugs.     

The Impact of Broader Value Elements on Cost-Effectiveness Analysis: Two Case Studies

ObjectivesThis study aimed to explore the impact of including broader value elements in cost-effectiveness analyses by presenting 2 case studies, one on human papillomavirus (HPV) infection and one on early-stage Hodgkin’s lymphoma (ESHL).MethodsWe identified broader value elements (eg, patient and caregiver time, spillover health effects, productivity) from the Second Panel’s Impact Inventory and the ISPOR Special Task Force’s value flower. We then evaluated the cost-effectiveness of HPV vaccination versus no vaccination (case 1) and combined modality therapy (CMT) versus chemotherapy alone for treatment of adult ESHL (case 2) using published simulation models. For each case study, we compared incremental cost-effectiveness ratios considering health sector impacts only (the “base-case” scenario) with incremental cost-effectiveness ratios incorporating broader value elements.ResultsFor vaccination of US girls against HPV before sexual debut versus no vaccination, the base-case result was $38 334 per disability-adjusted life-year averted. Including each broader value element made cost-effectiveness progressively more favorable, with HPV vaccination becoming cost-saving (ie, reducing costs and averting more disability-adjusted life-years) when the analysis incorporated productivity costs. For CMT versus chemotherapy alone in patients with ESHL, the base-case result indicated that CMT was cost-saving. Including all elements made this treatment’s net monetary benefits (the sum of its averted resource costs and the net value of its health impacts) less favorable, even as the contribution from CMT’s near-term health benefits grew.ConclusionsIncluding broader value elements can substantially influence cost-effectiveness ratios, although the direction and the magnitude of their impact can differ across interventions and disease context.     

Economic Evaluation of Vaccination Programs: A Guide for Selecting Modeling Approaches

ObjectivesIllustrate 3 economic evaluation methods whose value measures may be useful to decision makers considering vaccination programs.MethodsKeyword searches identified example publications of cost-effectiveness analysis (CEA), fiscal health modeling (FHM), and constrained optimization (CO) for economic evaluation of a vaccination program in countries where at least 2 of the methods had been used. We examined the extent to which different value measures may be useful for decision makers considering adoption of a new vaccination program. With these findings, we created a guide for selecting modeling approaches illustrating the decision-maker contexts and policy objectives for which each method may be useful.ResultsWe identified 8 countries with published evaluations for vaccination programs using >1 method for 4 infections: influenza, human papilloma virus, rotavirus, and malaria. CEA studies targeted health system decision makers using a threshold to determine the efficiency of a new vaccination program. FHM studies targeted public sector spending decision makers estimating lifetime changes in government tax revenue net of transfer payments. CO studies targeted decision makers selecting from a mix of options for preventing an infectious disease within budget and feasibility constraints. Cost and utility inputs, epidemiologic models, comparators, and constraints varied by modeling method.ConclusionsAlthough CEAs measures of incremental cost-effectiveness ratios are critical for understanding vaccination program efficiency for all decision makers determining access and reimbursement, FHMs provide measures of the program’s impact on public spending for government officials, and COs provide measures of the optimal mix of all prevention interventions for public health officials.     

Illustrating Potential Efficiency Gains from Using Cost-Effectiveness Evidence to Reallocate Medicare Expenditures

ObjectivesThe Centers for Medicare & Medicaid Services does not explicitly use cost-effectiveness information in national coverage determinations. The objective of this study was to illustrate potential efficiency gains from reallocating Medicare expenditures by using cost-effectiveness information, and the consequences for health gains among Medicare beneficiaries.MethodsWe included national coverage determinations from 1999 through 2007. Estimates of cost-effectiveness were identified through a literature review. For coverage decisions with an associated cost-effectiveness estimate, we estimated utilization and size of the “unserved” eligible population by using a Medicare claims database (2007) and diagnostic and reimbursement codes. Technology costs originated from the cost-effectiveness literature or were estimated by using reimbursement codes. We illustrated potential aggregate health gains from increasing utilization of dominant interventions (i.e., cost saving and health increasing) and from reallocating expenditures by decreasing investment in cost-ineffective interventions and increasing investment in relatively cost-effective interventions.ResultsComplete information was available for 36 interventions. Increasing investment in dominant interventions alone led to an increase of 270,000 quality-adjusted life-years (QALYs) and savings of $12.9 billion. Reallocation of a broader array of interventions yielded an additional 1.8 million QALYs, approximately 0.17 QALYs per affected Medicare beneficiary. Compared with the distribution of resources prior to reallocation, following reallocation a greater proportion was directed to oncology, diagnostic imaging/tests, and the most prevalent diseases. A smaller proportion of resources went to cardiology, treatments (including drugs, surgeries, and medical devices, as opposed to nontreatments such as preventive services), and the least prevalent diseases.ConclusionsUsing cost-effectiveness information has the potential to increase the aggregate health of Medicare beneficiaries while maintaining existing spending levels.     

A model for evaluating the economic value of prevention programs for illicit use of anabolic androgenic steroids

BackgroundThe illicit use of anabolic androgenic steroids (AAS) has become a societal concern. We developed a decision-analytic model for assessing the cost-effectiveness of preventive interventions targeting AAS-use. We used scenario analyses to demonstrate: a) the potential health economic consequences of AAS use in Sweden, and b) the cost-effectiveness of a hypothetical preventive intervention.MethodsA population-based cohort model compared a hypothetical preventive intervention targeting AAS with a ‘no intervention’ scenario, from a limited societal perspective. The model simulated how a cohort of 18 year-old males transitioned between different states and predicted their health status and complications until the age of 41. Health outcomes were estimated as quality-adjusted life-years (QALY). Costs included intervention costs, drug costs, and costs of complications.ResultsTotal yearly costs related to AAS use amounted to nearly half a million US$, with the largest cost borne by the healthcare sector. Results suggest that AAS prevention could entail large costs and benefits with a mean incremental cost-effectiveness ratio of $550 per QALY, in a scenario where the intervention would decrease the probability of initiating AAS use by 5%.ConclusionResults show large AAS related costs, and suggest that the implementation of a preventive intervention could offer good value for money given different effectiveness scenarios. This model can be used to estimate the value of interventions targeting AAS use.     

Inquiry into the Relationship between Equity Weights and the Value of the QALY

BackgroundA commonly held view of the decision rule in economic evaluations in health care is that the final incremental cost-effectiveness ratio needs to be judged against some threshold, which is equal for all quality-adjusted life-year (QALY) gains. This reflects the assumption that “a QALY is a QALY” no matter who receives it, or the equity notion that all QALY gains are equally valuable, regardless of the context in which they are realized. If such an assumption does not adequately reflect the distributional concerns in society, however, different thresholds could be used for different QALY gains, whose relative values can be seen as “equity weights.”AimOur aim was to explore the relationship between equity or distributional concerns and the social value of QALYs within the health economics literature. In light of the empirical interest in equity-related concerns as well as the nature and height of the incremental cost-effectiveness ratio threshold, this study investigates the “common ground” between the two streams of literature and considers how the empirical literature estimating the incremental cost-effectiveness ratio threshold treats existing distributional considerations.     

Economic Evaluation of User-Fee Exemption Policies for Maternal Healthcare in Burkina Faso: Evidence From a Cost-Effectiveness Analysis

ObjectivesThe reduction and removal of user fees for essential care services have recently become a key instrument to advance universal health coverage in sub-Saharan Africa, but no evidence exists on its cost-effectiveness. We aimed to address this gap by estimating the cost-effectiveness of 2 user-fee exemption interventions in Burkina Faso between 2007 and 2015: the national 80% user-fee reduction policy for delivery care services and the user-fee removal pilot (ie, the complete [100%] user-fee removal for delivery care) in the Sahel region.MethodsWe built a single decision tree to evaluate the cost-effectiveness of the 2 study interventions and the baseline. The decision tree was populated with an own impact evaluation and the best available epidemiological evidence.ResultsRelative to the baseline, both the national 80% user-fee reduction policy and the user-fee removal pilot are highly cost-effective, with incremental cost-effectiveness ratios of $210.22 and $252.51 per disability-adjusted life-year averted, respectively. Relative to the national 80% user-fee reduction policy, the user-fee removal pilot entails an incremental cost-effectiveness ratio of $309.74 per disability-adjusted life-year averted.ConclusionsOur study suggests that it is worthwhile for Burkina Faso to move from an 80% reduction to the complete removal of user fees for delivery care. Local analyses should be done to identify whether it is worthwhile to implement user-fee exemptions in other sub-Saharan African countries.     

Estimating Cost-Effectiveness Using Alternative Preference-Based Scores and Within-Trial Methods: Exploring the Dynamics of the Quality-Adjusted Life-Year Using the EQ-5D 5-Level Version and Recovering Quality of Life Utility Index

ObjectivesThis study aimed to explore quality-adjusted life-year (QALY) and subsequent cost-effectiveness estimates based on the more physical health–focused EQ-5D 5-level version (EQ-5D-5L) value set for England or cross-walked EQ-5D 3-level version UK value set scores or more mental health recovery-focused Recovering Quality of Life Utility Index (ReQoL-UI), when using alternative within-trial statistical methods. We describe possible reasons for the different QALY estimates based on the interaction between item scores, health state profiles, preference-based scores, and mathematical and statistical methods chosen.MethodsQALYs are calculated over 8 weeks from a case study 2:1 (intervention:control) randomized controlled trial in patients with anxiety or depression. Complete case and with missing cases imputed using multiple-imputation analyses are conducted, using unadjusted and regression baseline-adjusted QALYs. Cost-effectiveness is judged using incremental cost-effectiveness ratios and acceptability curves. We use previously established psychometric results to reflect on estimated QALYs.ResultsA total of 361 people (241:120) were randomized. EQ-5D-5L crosswalk produced higher incremental QALYs than the value set for England or ReQoL-UI, which produced similar unadjusted QALYs, but contrasting baseline-adjusted QALYs. Probability of cost-effectiveness <£30 000 per QALY ranged from 6% (complete case ReQoL-UI baseline-adjusted QALYs) to 64.3% (multiple-imputation EQ-5D-5L crosswalk unadjusted QALYs). The control arm improved more on average than the intervention arm on the ReQoL-UI, a result not mirrored on the EQ-5D-5L nor condition-specific (Patient-Health Questionnaire-9, depression; Generalized Anxiety Disorder-7, anxiety) measures.ConclusionsReQoL-UI produced contradictory cost-effectiveness results relative to the EQ-5D-5L. The EQ-5D-5L’s better responsiveness and “anxiety/depression” and “usual activities” items drove the incremental QALY results. The ReQoL-UI’s single physical health item and “personal recovery” construct may have influenced its lower 8-week incremental QALY estimates in this patient sample.     

A Cost-Effectiveness Framework for Amyotrophic Lateral Sclerosis,Applied to Riluzole

ObjectivesReexamine cost-effectiveness of riluzole in the treatment of amyotrophic lateral sclerosis (ALS) in light of recent advances in disease staging and understanding of stage-specific drug effect.MethodsALS was staged according to the “fine’til 9” (FT9) staging method. Stage-specific health utilities (EQ-5D, US valuation) were estimated from an institutional cohort, whereas literature informed costs and transition probabilities. Costs at 2018 prices were disaggregated into recurring costs (RCs) and “one-off” transition/“tollgate” costs (TCs). Five- and 10-year horizons starting in stage 1 disease were examined from healthcare sector and societal perspectives using Markov models to evaluate riluzole use, at a threshold of $100 000/quality-adjusted life year (QALY). Probabilistic and deterministic sensitivity analyses were conducted.ResultsMean EQ-5D utilities for stages 0 to 4 were 0.79, 0.74, 0.63, 0.54, and 0.46, respectively. From the healthcare sector perspective at the 5-year horizon, riluzole use contributed to 0.182 QALY gained at the cost difference of $12 348 ($5403 riluzole cost, $8870 RC and −$1925 TC differences), translating to an incremental cost-effectiveness ratio (ICER) of $67 658/QALY. Transition probability variation contributed considerably to ICER uncertainty (−30.2% to +90.0%). ICER was sensitive to drug price and RCs, whereas higher TCs modestly reduced ICER due to delayed tollgates.ConclusionThis study provides a framework for health economic studies of ALS treatments using FT9 staging. Prospective stage-specific and disaggregated cost measurement is warranted for accurate future cost-effectiveness analyses. Appropriate separation of TCs from RCs substantially mitigates the high burden of background cost of care on the ICER.     

The Use of Cost-Effectiveness Thresholds for Evaluating Health Interventions in Low- and Middle-Income Countries From 2015 to 2020: A Review

ObjectivesEvidence-informed priority setting, in particular cost-effectiveness analysis (CEA), can help target resources better to achieve universal health coverage. Central to the application of CEA is the use of a cost-effectiveness threshold. We add to the literature by looking at what thresholds have been used in published CEA and the proportion of interventions found to be cost-effective, by type of threshold.MethodsWe identified CEA studies in low- and middle-income countries from the Global Health Cost-Effectiveness Analysis Registry that were published between January 1, 2015, and January 6, 2020. We extracted data on the country of focus, type of interventions under consideration, funder, threshold used, and recommendations.ResultsA total of 230 studies with a total 713 interventions were included in this review; 1 to 3× gross domestic product (GDP) per capita was the most common type of threshold used in judging cost-effectiveness (84.3%). Approximately a third of studies (34.2%) using 1 to 3× GDP per capita applied a threshold at 3× GDP per capita. We have found that no study used locally developed thresholds. We found that 79.3% of interventions received a recommendation as “cost-effective” and that 85.9% of studies had at least 1 intervention that was considered cost-effective. The use of 1 to 3× GDP per capita led to a higher proportion of study interventions being judged as cost-effective compared with other types of thresholds.ConclusionsDespite the wide concerns about the use of 1 to 3× GDP per capita, this threshold is still widely used in the literature. Using this threshold leads to more interventions being recommended as “cost-effective.” This study further explore alternatives to the 1 to 3× GDP as a decision rule.     

Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States

ObjectivesGastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective.MethodsFixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the “Meta-Analysis with R” software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years.ResultsComparing scatter plots and incremental cost-effectiveness ratio results, –$1024 and –$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention.ConclusionOnyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.     

The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge

ObjectivesThe machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective.MethodsA 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses.ResultsPC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter “reduction in ICU length of stay.”ConclusionsWe showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter “reduction in ICU length of stay” and potential spill-over effects.     

Application of cost-effectiveness analysis of health care interventions in developing countries. A case study in Mauritius

OBJECTIVE: Cost-effectiveness analysis is a tool to help inform the decision maker of efficient allocation of scarce health care resources and its application has increased in developing countries during the past decade. There are, however, a variety of different approaches used to calculate cost-effectiveness ratios, given the range and the controversies surrounding the use of some components of total cost, depending on the constraints faced by various decision-making bodies. This study is an investigation of cost-effectiveness of both currently delivered and prospective health interventions in Mauritius to set priorities and assess allocative efficiency by taking into account such constraints. METHODS: Resource use and unit cost data were collected from the representative health facilities and the Ministry of Health to estimate costs of each health intervention per person. Effectiveness of each intervention was estimated from the results of the national burden of disease study and the efficacy database compiled for this exercise. Several types of cost-effectiveness were calculated for each intervention according to its characteristics and the constraints imposed by the existing infrastructures and other health interventions. RESULTS: Cost-effectiveness ratios with and without the decision maker's constraints differed significantly. Infrastructure-constrained average cost-effectiveness of thirteen currently delivered and twenty one prospective interventions ranged from $127 to $92,949 and from $77 to $66,302 per DALY averted, respectively. Incremental cost-effectiveness of the prospective interventions was from $83 to $70,553. Among the currently delivered interventions, those for perinatal disorders, mental illness, and ischemic heart disease were particularly less cost-effective than the prospective interventions. Sensitivity analysis of both effectiveness and discount rates did not change the cost-effectiveness ranking significantly. CONCLUSION: The present study showed that cost-effectiveness ratios differ significantly depending on the decision maker's constraints and that an interpretation of each cost-effectiveness study should be made with great caution when implementing its results in practice. Both average cost-effectiveness of the currently delivered interventions and incremental cost-effectiveness of the prospective interventions suggest that there is an allocative inefficiency among the currently delivered health interventions in Mauritius and a possibility of enhancing allocative efficiency through introducing alternative interventions.     

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.     

Which Is More Valuable,Longer Survival or Better Quality of Life? Israeli Oncologists’ and Family Physicians’ Attitudes Toward the Relative Value of New Cancer and Congestive Heart Failure Interventions

ObjectivesWe determined how Israeli oncologists and family physicians value life-prolongation versus quality-of-life (QOL)-enhancing outcomes attributable to cancer and congestive heart failure interventions.MethodsWe presented physicians with two scenarios involving a hypothetical patient with metastatic cancer expected to survive 12 months with current treatment. In a life-prolongation scenario, we suggested that a new treatment increases survival at an incremental cost of $50,000 over the standard of care. Participants were asked what minimum improvement in median survival the new therapy would need to provide for them to recommend it over the standard of care. In the QOL-enhancing scenario, we asked the maximum willingness to pay for an intervention that leads to the same survival as the standard treatment, but increases patient’s QOL from 50 to 75 (on a 0–100 scale). We replicated these scenarios by substituting a patient with congestive heart failure instead of metastatic cancer. We derived the incremental cost-effectiveness ratio per quality-adjusted life-year (QALY) gained threshold implied by each response.ResultsIn the life-prolongation scenario, the cost-effectiveness thresholds implied by oncologists were $150,000/QALY and $100,000/QALY for cancer and CHF, respectively. Cost-effectiveness thresholds implied by family physicians were $50,000/QALY regardless of the disease type. Willingness to pay for the QOL-enhancing scenarios was $60,000/QALY and did not differ by physicians’ specialty or disease.ConclusionsOur findings suggest that family physicians value life-prolonging and QOL-enhancing interventions roughly equally, while oncologists value interventions that extend survival more highly than those that improve only QOL. These findings may have important implications for coverage and reimbursement decisions of new technologies.     

Determinants of tuberculosis diagnosis delay in limited resources countries

BackgroundDelayed diagnoses of pulmonary tuberculosis contribute to the spread of the epidemic.MethodsThis study aims to identify risk factors associated with patient delay (from symptoms onset to the first visit), health system delay (from the first visit to the tuberculosis treatment initiation) and total delay (sum of the patient and the health system delay) in low income and high tuberculosis burden countries. A systematic literature review has been performed using the keywords: “tuberculosis”; “delay”, care seeking”; “health care seeking behavior”; “diagnosis” and “treatment”. Only quantitative studies showing delays for pulmonary tuberculosis adult cases were included in this review.ResultsLow income, gender, rural life, unemployment, ageing and misunderstanding the microbial cause of tuberculosis are associated with delayed diagnoses. Systemic factors including low health care coverage, patient expenditures and entry into the health system by consulting a traditional healer or a non-skilled professional delay the beginning of tuberculosis treatment.ConclusionDelays can be used as indicators to evaluate tuberculosis control programs. Active case finding in the households of contagious patients can help to diminish diagnostic delays in low-income countries with high endemicity.     

Long-Term Cost-Effectiveness of Smoking Cessation Interventions in People With Mental Disorders: A Dynamic Decision Analytical Model

ObjectivesPeople with mental disorders are more likely to smoke than the general population. The objective of this study is to develop a decision analytical model that estimates long-term cost-effectiveness of smoking cessation interventions in this population.MethodsA series of Markov models were constructed to estimate average lifetime smoking-attributable inpatient cost and expected quality-adjusted life-years. The model parameters were estimated using a variety of data sources. The model incorporated uncertainty through probabilistic sensitivity analysis using Monte Carlo simulations. It also generated tables presenting incremental cost-effectiveness ratios of the proposed interventions with varying incremental costs and incremental quit rates. We used data from 2 published trials to demonstrate the model’s ability to make projections beyond the observational time frame.ResultsThe average smoker’s smoking-attributable inpatient cost was 3 times higher and health utility was 5% lower than ex-smokers. The intervention in the trial with a statistically insignificant difference in quit rate (19% vs 25%; P=.2) showed a 45% to 49% chance of being cost-effective compared with the control at willingness-to-pay thresholds of £20 000 to £30 000/quality-adjusted life-years. The second trial had a significant outcome (quit rate 35.9% vs 15.6%; P<.001), and the corresponding probability of the intervention being cost-effective was 65%.ConclusionsThis model provides a consistent platform for clinical trials to estimate the potential lifetime cost-effectiveness of smoking cessation interventions for people with mental disorders and could help commissioners direct resources to the most cost-effective programs. However, direct comparisons of results between trials must be interpreted with caution owing to their different designs and settings.