Cost-effectiveness analysis and screening tests for women

Cost-effectiveness analysis is a method for identifying those medical interventions that are most effective given the resources available. This commentary focuses on the cost effectiveness of screening tests, with particular emphasis on such factors as the frequency and accuracy of the test; the risk of the condition and of adverse effects; the costs of screening, follow-up, and treatment; and the target population. The same test can be much more or less costly per year of life saved, and thus a better or worse use of medical resources, depending on how it is used. Results from cost-effectiveness analyses of a variety of screening interventions important to women (screening for cervical cancer and breast cancer, heart disease, diabetes, and mild thyroid failure) highlight the importance of developing screening protocols wisely so that women will receive the greatest possible benefit from their use.     

Cost-effectiveness of prenatal screening and immunization for hepatitis B virus

Perinatal transmission of hepatitis B virus is associated with substantial morbidity and mortality, yet controversy still exists regarding the value of routine screening of pregnant women in the United States and subsequent immunization of their at-risk neonates. To evaluate the cost-effectiveness of such a screening and immunization program, we developed a decision analysis model and obtained data from published reports, chart review, and a Delphi survey to determine outcome probabilities and costs. When considering direct and indirect costs, routine screening and immunization would be cost-effective at a prevalence of 0.06%, significantly lower than the national prevalence of 0.2%. At an annual national birth rate of 3.5 million births, a national policy of routine screening of all pregnant women would result in an annual net savings of more than $105 million. In the high-risk groups, as many as 140 cases of acute neonatal hepatitis and as many as 1400 cases of chronic liver disease would be prevented yearly per 100,000 pregnant women screened, at a net annual savings of as much as $765 million.     

Cost-effectiveness of screening for colorectal cancer in the general population

CONTEXT: A recent expert panel recommended that persons at average risk of colorectal cancer (CRC) begin screening for CRC at age 50 years using 1 of several strategies. However, many aspects of different CRC screening strategies remain uncertain. OBJECTIVE: To assess the consequences, costs, and cost-effectiveness of CRC screening in average-risk individuals. DESIGN: Cost-effectiveness analysis from a societal perspective using a Markov model. SUBJECTS: Hypothetical subjects representative of the 50-year-old US population at average risk for CRC. SETTING: Simulated clinical practice in the United States. MAIN OUTCOME MEASURES: Discounted lifetime costs, life expectancy, and incremental cost-effectiveness (CE) ratio, compared used 22 different CRC screening strategies, including those recommended by the expert panel. RESULTS: In 1 base-case analysis, compliance was assumed to be 60% with the initial screen and 80% with follow-up or surveillance colonoscopy. The most effective strategy for white men was annual rehydrated fecal occult blood testing (FOBT) plus sigmoidoscopy (followed by colonoscopy if either a low- or high-risk polyp was found) every 5 years from age 50 to 85 years, which resulted in a 60% reduction in cancer incidence and an 80% reduction in CRC mortality compared with no screening, and an incremental CE ratio of $92,900 per year of life gained compared with annual unrehydrated FOBT plus sigmoidoscopy every 5 years. In a base-case analysis in which compliance with screening and follow-up is assumed to be 100%, screening more often than every 10 years was prohibitively expensive; annual rehydrated FOBT plus sigmoidoscopy every 5 years had an incremental CE ratio of $489,900 per life-year gained compared with the same strategy every 10 years. Other strategies recommended by the expert panel were either less effective or cost more per year of life gained than the alternatives. Colonoscopy every 10 years was less effective than the combination of annual FOBT plus sigmoidoscopy every 5 years. However, a single colonoscopy at age 55 years achieves nearly half of the reduction in CRC mortality obtainable with colonoscopy every 10 years. Because of increased life expectancy among white women and increased cancer mortality among blacks, CRC screening was even more cost-effective in these groups than in white men. CONCLUSIONS: Screening for CRC, even in the setting of imperfect compliance, significantly reduces CRC mortality at costs comparable to other cancer screening procedures. However, compliance rates significantly affect the incremental CE ratios. In this model of CRC, 60% compliance with an every 5-year schedule of screening was roughly equivalent to 100% compliance with an every 10-year schedule. Mathematical modeling used to inform clinical guidelines needs to take into account expected compliance rates. JAMA. 2000;284:1954-1961.     

5个发展中国家宫颈癌筛查的成本效益研究

背景：包括多次常规细胞学检查的宫颈癌筛查方案在发展中国家一直得不到有力推行。方法：本研究应用计算机模型评价不同宫颈癌筛查方案在印度、肯尼亚、秘鲁、南非及泰国的成本效益。原始数据包括文献中对年龄特异性癌症发病率与死亡率比的估计，以及对癌前病变的筛查和治疗的有效性。本研究根据不同的筛查测试、目标人群（以年龄划分）、筛查频率和要求就诊的次数等对相关的医疗成本、时间消耗和该项目有关成本进行了评价。单次就诊方案是指假定筛查和治疗可以在同一天完成。     

Cost-effectiveness of screening women at moderate risk for genital infections caused by Chlamydia trachomatis

We evaluated the cost-effectiveness of screening women at moderate (prevalence, 7.9%) risk for urogenital infections with Chlamydia trachomatis. The characteristics of culture and direct antigen tests were based on published values. Those of serology were based on a comparative study in 434 college women. Three serological tests were evaluated: microimmunofluorescence, an indirect fluorescent antibody assay, and an enzyme-linked immunoassay. Their sensitivities and specificities were 97% and 64%, 87% and 64%, and 84% and 51%, respectively, compared with culture. Screening all patients with a direct antigen test costing less than $12 was more cost-effective than neither testing nor treating patients, although only 53% of patients with positive test results would actually be infected. The use of culture alone or as a confirmatory test was less cost-effective but had high positive predictive values. Seropositivity was not highly predictive of active infection. Chlamydial screening can be cost-effective in moderate-risk women.     

佛山市新生儿CH筛查的成本效益和成本效用研究

目的 研究佛山市新生儿先天性甲状腺功能减低症筛查的成本效益、成本效用方面的经济学数据,对筛查工作的效果做出评价.方法 通过筛查中心,文献、官方资源,问卷调查3种途径搜集经济学相关资料,并利用统计学工具、Tree Age Pro卫生决策分析软件对筛查工作进行成本效益和成本效用的评估.结果 2000年6月至2007年12月共投入成本1 794.61万元,获得效益11 769.99万元,净效益9 975.52万元,成本效益比为1.00∶6.56.筛查每投入3 216元可避免一个伤残调整寿命年.结论 筛查项目具有良好的经济学适用性,值得更多的资金投入,以进一步推广和普及.     

Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. I. Hematuria and proteinuria

We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.     

广州市大东街2015—2019年大肠癌人群筛查及伺机性筛查效果及成本效益分析

目的 依据广州市越秀区大东街2015—2019年大肠癌筛查数据,分析人群筛查和伺机筛查的筛查效果,并从经济学角度分析大肠癌筛查的经济和社会效益,为下一轮大肠癌筛查提供建议.方法 利用统计学分析和x2检验分析人群筛查和伺机筛查的结果,利用成本效益分析测定筛查的直接成本、直接效益和间接效益,计算筛查净效益及效益成本比.结果...     

Cost-effectiveness of screening BRCA1/2 mutation carriers with breast magnetic resonance imaging

Context  Women with inherited BRCA1/2 mutations are at high risk for breast cancer, which mammography often misses. Screening with contrast-enhanced breast magnetic resonance imaging (MRI) detects cancer earlier but increases costs and results in more false-positive scans. Objective  To evaluate the cost-effectiveness of screening BRCA1/2 mutation carriers with mammography plus breast MRI compared with mammography alone. Design, Setting, and Patients  A computer model that simulates the life histories of individual BRCA1/2 mutation carriers, incorporating the effects of mammographic and MRI screening was used. The accuracy of mammography and breast MRI was estimated from published data in high-risk women. Breast cancer survival in the absence of screening was based on the Surveillance, Epidemiology and End Results database of breast cancer patients diagnosed in the prescreening period (1975-1981), adjusted for the current use of adjuvant therapy. Utilization rates and costs of diagnostic and treatment interventions were based on a combination of published literature and Medicare payments for 2005. Main Outcome Measures  The survival benefit, incremental costs, and cost-effectiveness of MRI screening strategies, which varied by ages of starting and stopping MRI screening, were computed separately for BRCA1 and BRCA2 mutation carriers. Results  Screening strategies that incorporate annual MRI as well as annual mammography have a cost per quality-adjusted life-year (QALY) gained ranging from less than $45 000 to more than $700 000, depending on the ages selected for MRI screening and the specific BRCA mutation. Relative to screening with mammography alone, the cost per QALY gained by adding MRI from ages 35 to 54 years is $55 420 for BRCA1 mutation carriers, $130 695 for BRCA2 mutation carriers, and $98 454 for BRCA2 mutation carriers who have mammographically dense breasts. Conclusions  Breast MRI screening is more cost-effective for BRCA1 than BRCA2 mutation carriers. The cost-effectiveness of adding MRI to mammography varies greatly by age.      

Cost-effectiveness Analysis for Technology Acquisition

Background

In a developing country with limited resources, it is important to utilize the total cost visibility approach over the entire life-cycle of the technology and then analyse alternative options for acquiring technology.

Methods

The present study analysed cost-effectiveness of an “In-house” magnetic resonance imaging (MRI) scan facility of a large service hospital against outsourcing possibilities. Cost per unit scan was calculated by operating costing method and break-even volume was calculated. Then life-cycle cost analysis was performed to enable total cost visibility of the MRI scan in both “In-house” and “outsourcing of facility” configuration. Finally, cost-effectiveness analysis was performed to identify the more acceptable decision option.

Result

Total cost for performing unit MRI scan was found to be Rs 3,875 for scans without contrast and Rs 4,129 with contrast. On life-cycle cost analysis, net present value (NPV) of the “In-house” configuration was found to be Rs-(4,09,06,265) while that of “outsourcing of facility” configuration was Rs-(5,70,23,315). Subsequently, cost-effectiveness analysis across eight Figures of Merit showed the “In-house” facility to be the more acceptable option for the system.

Conclusion

Every decision for acquiring high-end technology must be subjected to life-cycle cost analysis.Key Words: Technology assessment, Cost benefit analysis, Cost-effectiveness analysis     

Cost-effectiveness analysis for technology acquisition

Background: In a developing country with limited resources, it is important to utilize the total cost visibility approach over the entire life-cycle of the technology and then analyse alternative options for acquiring technology.     

蛋白尿的中西医治疗方法概述

蛋白尿是肾脏病常见的临床表现,既是肾脏受损的标志,又是加重肾脏病进展的因素.西医治疗主要以饮食调控,控制血压、血糖、血脂,应用抗血小板或抗凝药物,或使用激素及免疫抑制剂等为主.中医治疗可分为专方治疗、中成药治疗及单味药治疗等几个方面.传统观点认为脾肾功能失调为产生蛋白尿的基本病机,以益气健脾、补肾固精为基本治疗原则,但这种治疗方法在临床应用时具有一定的局限性,故而有专家提出和解少阳及清热解毒、活血化瘀通络等其他治疗方法.常用的中成药如黄葵胶囊、百令胶囊、雷公藤制剂、肾康注射液及肾炎康复片等在降低蛋白尿方面都取得了较好的临床疗效.黄芪、大黄、白茅根等多种单味药也经现代药理研究证实有降低蛋白尿的作用.