Cost-effectiveness of an influenza vaccination program offering intramuscular and intradermal vaccines versus intramuscular vaccine alone for elderly

BackgroundIntradermal (ID) injection is an alternative route for influenza vaccine administration in elderly with potential improvement of vaccine coverage. This study aimed to investigate the cost-effectiveness of an influenza vaccination program offering ID vaccine to elderly who had declined intramuscular (IM) vaccine from the perspective of Hong Kong public healthcare provider.MethodsA decision analytic model was used to simulate outcomes of two programs: IM vaccine alone (IM program), and IM or ID vaccine (IM/ID program) in a hypothetic cohort of elderly aged 65 years. Outcome measures included influenza-related direct medical cost, infection rate, mortality rate, quality-adjusted life years (QALYs) loss, and incremental cost per QALY saved (ICER). Model inputs were derived from literature. Sensitivity analyses evaluated the impact of uncertainty of model variables.ResultsIn base-case analysis, the IM/ID program was more costly (USD52.82 versus USD47.59 per individual to whom vaccine was offered) with lower influenza infection rate (8.71% versus 9.65%), mortality rate (0.021% versus 0.024%) and QALYs loss (0.00336 versus 0.00372) than the IM program. ICER of IM/ID program was USD14,528 per QALY saved. One-way sensitivity analysis found ICER of IM/ID program to exceed willingness-to-pay threshold (USD39,933) when probability of influenza infection in unvaccinated elderly decreased from 10.6% to 5.4%. In 10,000 Monte Carlo simulations of elderly populations of Hong Kong, the IM/ID program was the preferred option in 94.7% of time.ConclusionsAn influenza vaccination program offering ID vaccine to elderly who had declined IM vaccine appears to be a highly cost-effective option.     

Measuring the inappropriate utilization of accident and emergency services?

Accident and Emergency (A&E) departments are increasingly popular venues for primary care, causing a serious threat to healthcare quality. This paper reports the development of a comprehensive research method for identifying primary care patients attending A&E. Patients were randomly selected from the four A&E departments across different time periods and different regions in Hong Kong. The definition of GP cases was based on a retrospective record review conducted by a panel of emergency physicians using the standard laid down by the Hong Kong College of Family Physicians. The patients sampled were similar in sex and age distribution to A&E attendees for the whole territory. The level of GP cases was found to be 57 per cent, with a significantly higher proportion of patients in the younger age group. The high level of use reflects the lack of a well co-ordinated development of primary care services and interfacing with secondary care.     

Length of hospital stay and associated costs for olanzapine vs. haloperidol in the treatment of schizophrenia relapse in Germany

We examined the number of days spent in hospital due to a relapse of schizophrenia and the associated costs for patients treated with olanzapine or haloperidol. Twenty-one German psychiatric hospitals participated in this retrospective study. Data on the last hospitalisation following a relapse of schizophrenia were documented for equal numbers of patients on olanzapine and haloperidol. Matching for time since diagnosis and severity of symptoms was performed. Data were collected on 136 matched pairs. Total length of time spent in hospital was the same on average for patients in both groups (median about 5 weeks), but olanzapine patients spent nearly 1 week less in the in-patient setting than haloperidol patients, resulting in a saving of Euro 411 per patient. Our findings are consistent with those of randomised clinical trials in concluding that olanzapine is preferable to haloperidol in terms of the direct cost of treating schizophrenia. Andrea Spannheimer Kendle GmbH & Co. GMI KG, Stefan-George-Ring 6, 81929 Munich, Germany, e-mail: spannheimer.andrea@kendle.com     

Potential cost-effectiveness of adjuvanted herpes zoster subunit vaccine for older adults in Hong Kong

BackgroundAdjuvanted herpes zoster (HZ) subunit vaccine is recommended for adults aged ≥50 years. This study aimed to investigate cost-effectiveness of HZ subunit vaccine for older adults at different age in Hong Kong.MethodsA life-long Markov model was designed to simulate outcomes of four alternatives: Vaccination at model entry (age 50 years); deferring vaccination to 60 years; deferring vaccination to 70 years; and no vaccination. Outcome measures included direct cost, indirect cost, HZ and post-herpetic neuralgia incidences, quality-adjusted life years (QALYs) loss, and incremental cost per QALY saved (ICER). Model clinical inputs were derived from literature. HZ treatment costs were collected from a cohort of HZ patients (n = 218). One-way and probabilistic sensitivity analyses were performed.ResultsIn base-case analysis, vaccination at 50 years showed highest QALYs saved and increment cost (0.00258; USD166), followed by deferring to 60 years (0.00215 QALYs saved; USD102) and deferring to 70 years (0.00134 QALYs; USD62) when comparing to no vaccination. ICERs of vaccination arms versus no vaccine (46,267–64,341 USD/QALY) were between 1–3 × gross domestic product (GPD) per capita in Hong Kong (USD43,530–USD130,590). One-way sensitivity analyses found vaccine cost to be the common and most influential parameter for ICER of each vaccination strategy to become <1 × GDP per capita. In probabilistic sensitivity analysis, vaccination at 50 years, deferring to 60 years and 70 years were accepted as cost-effective in 90% of time at willingness-to-pay (WTP) of 78,400 USD/QALY, 57,680 USD/QALY and 53,760 USD/QALY, respectively.ConclusionsCost-effectiveness of each strategy is highly subject to the vaccine cost and WTP threshold per QALY saved.     

Resisting the ‘gaze’ ?: Nurses' perceptions of the role of accident and emergency departments in responding to alcohol-related attendances

Accident and emergency (A&E) departments are increasingly being viewed as possible sites for monitoring and intervention in a broad range of alcohol-related problems.¹ A study of alcohol-related attendances was conducted in two London hospitals. One of the aims was to explore the feasibility of routine monitoring in A&E departments and possible methods of screening. The process of carrying out the research and the results of the study raised a number of questions about the practicalities of monitoring in the A&E setting, which will be explored in this paper. Furthermore, nursing staff did not seem to embrace the new public health approach to alcohol² that underpins the calls for A&E departments to adopt a prevention role. On the whole, staff did not regard alcohol as their ‘business’; the focus was on the treatment of the presenting condition and for the most part alcohol was viewed as irrelevant or a ‘sideline’. Some nurses were uncomfortable with the concept of routine surveillance and what they saw as the problematization of ‘normal’ behaviour. Intervention, in the form of a referral, was reserved for those patients who were thought to be dependent on alcohol. This study highlights the problematic interface between research, policy and practice. Research evidence appears to have influenced the direction of policy but not its implementation.     

Cost-effectiveness analysis of vaccinations and decision makings on vaccination programmes in Hong Kong: A systematic review

ObjectivesTo describe and systematically review the modelling and reporting of cost-effectiveness analysis of vaccination in Hong Kong, and to identify areas for quality enhancement in future cost-effectiveness analyses.MethodsWe conducted a comprehensive and systematic review of cost-effectiveness studies related to vaccination and government immunisation programmes in Hong Kong published from 1990 to 2015, through database search of Pubmed, Web of Science, Embase, and OVID Medline. Methodological quality of selected studies was assessed using Consolidated Health Economic Evaluation Reporting Standards checklist (CHEERS). Decision making of vaccination was obtained from Scientific Committee on Vaccine Preventable Diseases (SCVPD) and Department of Health in Hong Kong.ResultsNine eligible studies reporting twelve comparative cost-effectiveness comparisons of vaccination programme for influenza (n = 2), pneumococcal disease (n = 3), influenza plus pneumococcal disease (n = 1), chickenpox (n = 2), Haemophilus influenzae b (n = 1), hepatitis A (n = 1), cervical cancer (n = 1) and rotavirus (n = 1) were identified. Ten comparisons (83.3%) calculated the incremental cost-effectiveness ratio (ICER) of a vaccination strategy versus status quo as outcomes in terms of cost in USD per life-years, cost per quality-adjusted life-years, or cost per disability-adjusted life-years. Among those 10 comparisons in base-case scenario, 4 evaluated interventions were cost-saving relative to status quo while the ICER estimates in 3 of the 6 remaining comparisons were far below commonly accepted threshold and WHO willingness-to-pay threshold, suggestive of very cost-effective. Seven studies were of good quality based on the CHEERS checklist; one was of moderate quality; and one was of excellent quality. The common methodological problems were characterisation of heterogeneity and reporting of study parameters.ConclusionsThere was a paucity of cost-effectiveness models evaluating vaccination targeted to the Hong Kong population. All evaluated vaccinations and immunisation interventions in Hong Kong, except for Haemophilus influenzae b, hepatitis A and HPV vaccinations, were considered either cost-saving or very cost-effective when compared to status quo.     

Time studies in A&E departments--a useful tool for management

A time and motion study was conducted in an accident and emergency (A&E) department in a Hong Kong Government hospital in order to suggest solutions for severe queuing problems found in A&E. The study provided useful information about the patterns of arrival and service; the throughput; and the factors that influence the length of the queue at the A&E department. Plans for building a computerized simulation model were dropped as new intelligence generated by the study enabled problem solving using simple statistical analysis and common sense. Demonstrates some potential benefits for management in applying operations research methods in busy clinical working environments. The implementation of the recommendations made by this study successfully eliminated queues in A&E.     

'Inappropriate' attenders at accident and emergency departments II: health service responses

BACKGROUND: Health services have responded to perceived 'inappropriate' attenders at accident and emergency (A&E) departments in three ways. Firstly, they have responded by attempting to decrease the numbers of patients attending A&E departments. There is little evidence supporting the efficacy of such policies. Secondly, they have responded by referring inappropriate attenders to another site. Research indicates that whilst such referral may be feasible, resultant decreases in departmental workloads have yet to be demonstrated. Patient outcome has also to be determined. Thirdly, by performing triage of attenders they provide care appropriate to their needs. Sessional GPs working in A&E departments manage non-emergency A&E attenders safely and use fewer resources than do usual A&E staff. Long-term effects on health-seeking behaviour and patient perception of the distinction between primary care services have yet to be determined. CONCLUSIONS: Rather than vainly attempting to make the patients appropriate to the service, future initiatives should concentrate on making the A&E service more appropriate to the patient.      

Towards integration of general practitioner posts and accident and emergency departments: a case study of two integrated emergency posts in the Netherlands

Background  

Accident and emergency (A&E) departments and general practitioner (GP) posts are often used inappropriately, leading to overcrowding. In the Netherlands, increasingly more integrated emergency posts (IEPs) are being created, integrating the care provided by GP posts and A&E departments, in order to improve the provision of the emergency care.     

Programme costs for introducing age/gestation-based universal influenza vaccine schedules for young children and pregnant women in Hong Kong

BackgroundHong Kong experiences year-round influenza activity with winter and summer peaks. The government’s Vaccination Subsidy Scheme (VSS) provides vaccine to high-risk groups prior to the larger winter peak. The VSS is predominantly administered through the private sector. This study aimed to cost the two theoretical routine influenza vaccination schedules using both northern and southern hemisphere vaccines, administered according to child’s age and women’s gestation, from a governmental perspective; and compare these costs to the costs of government’s seasonal VSS assuming equivalent coverage estimates to determine the budget impacts of these influenza vaccination programmes in Hong Kong.MethodsWe used the World Health Organization’s Flutool Plus to estimate the incremental annual costs for immunising young children aged 6 months to 2 years and pregnant women with influenza vaccine during 2021, assuming the latter group accesses the public system for some antenatal care. Inputs were based on literature review, publicly available data and expert opinions. Sensitivity analyses were done with various coverage rates and vaccine costs.ResultsThe annual incremental cost (including vaccine price) to vaccinate young children with three doses of influenza vaccine during the first two years of life was estimated at USD 1,175,146 (per-dose-cost of USD 10.55) at 75% coverage while that to vaccinate pregnant women with one dose at 60% coverage was estimated at USD 398,555 (per-dose-cost of USD 13.39). Across a range of sensitivity analyses we predict that routine year-round schedules could be cost-saving to the government compared to the VSS. Implementing routine immunisation to both risk groups equates to USD 1,573,701, i.e., 0.012% of Hong Kong’s annual healthcare spending.ConclusionProposed year-round universal schedules providing influenza immunisation according to the child’s age or the woman’s gestation are predicted to be cost-saving compared to the current seasonally administered subsidised vaccine programme.     

Using queuing theory to analyse the Government’s 4-h completion time target in Accident and Emergency departments

This paper uses a queuing model to evaluate completion times in Accident and Emergency (A&E) departments in the light of the Government target of completing and discharging 98% of patients inside 4 h. It illustrates how flows though an A&E can be accurately represented as a queuing process, how outputs can be used to visualise and interpret the 4-h Government target in a simple way and how the model can be used to assess the practical achievability of A&E targets in the future. The paper finds that A&E targets have resulted in significant improvements in completion times and thus deal with a major source of complaint by users of the National Health Service in the UK. It suggests that whilst some of this improvement is attributable to better management, some is also due to the way some patients in A&E are designated and therefore counted through the system. It finds for example that the current target would not have been possible without some form of patient re-designation or re-labelling taking place. Further it finds that the current target is so demanding that the integrity of reported performance is open to question. Related incentives and demand management issues resulting from the target are also briefly discussed.     

PERCEPTIONS OF ALCOHOL-RELATED ATTENDANCES IN ACCIDENT AND EMERGENCY DEPARTMENTS IN ENGLAND: A NATIONAL SURVEY

The results from a survey, conducted in February and March 1997,of all Accident and Emergency (A&E) departments in Englandare presented. The survey examined staff perceptions of thepreventive role of A&E departments in screening and interventionin alcohol-related attendances. Perceptions of the prevalenceof alcohol-related attendances were also included. Attitudestowards developing a preventive response were positive. Fewdepartments currently screen or offer intervention and considerablebarriers to the implementation of a preventive response werereported.     

'Inappropriate' attenders at accident and emergency departments I: definition, incidence and reasons for attendance

BACKGROUND AND OBJECTIVES: Significant numbers of patients refer themselves to A&E departments for conditions which are neither accidents nor emergencies, relatively few of which require specific hospital treatment. These patients and their conditions have been described as 'inappropriate'. The objective of this paper is to review research relating to the definition, incidence and reasons for attendance of 'inappropriate' attenders. There is no accepted practical definition of what constitutes an 'appropriate' attender to an A&E department nor of what constitutes an 'emergency'. It is therefore not surprising that there is enormous variability (from 6 to 80%) regarding the proportion of visits judged to be inappropriate. All definitions rely completely on implicit and subjective judgements to determine appropriateness. The decision making of patients in opting to attend accident and emergency departments in preference to consulting their GP is complex, involving an interplay of social, psychological and medical factors. CONCLUSIONS: An analysis of reported work suggests that the most important factors are the perceived appropriateness of the condition for A&E, A&E accessibility and GP availability. A major deficiency in the available research is that patients have been retrospectively labelled as 'inappropriate' by medical personnel on the basis of the results of patient assessment and treatment. This review suggests that definitions and putative management strategies must consider the social and psychological context of the patients' decisions to attend.      

General Practitioner Appointment Systems, Patient Satisfaction, and use of Accident and Emergency Services--a Study in One Geographical Area

This study examines the relationship between (i) measures ofhow appointment systems work; (ii) patients' views of the arrangementsfor seeing their general practitioner; and (iii) practice self-referralrates to accident and emergency departments (A&E). Nineteengeneral practices and one district general hospital A&Edepartment in West Lothian, Scotland formed the setting fora prospective study employing analyses of computerized hospitalrecords, of patients surveys, and of data collected by practicesduring an 8-week study period in 1993. Principal outcome measureswere: (i) measures of appointment system operation correctedfor practice list size [number of unbooked (‘available’)appointments, appointment provision, proportion of patientsseen as ‘extras’]; (ii) patient views on practiceappointment systems (reported dissatisfaction with arrangementsfor being seen, proportion of patients reporting they normallywait in excess of 15 minutes when attending to be seen, theperceived availability of a doctor to deal with (a) urgent and(b) non urgent problems); (iii) practice self-referral ratesto local A&E department. Practices varied widely in theirrate of provision of appointments, in the proportion of appointmentswhich were unbooked at the start of the working day and in theproportion of patients identified as ‘extras’ byreception staff. These measures of appointment system operationcorrelated with patient dissatisfaction with the arrangementsof seeing a doctor in their practice and with the perceivedavailability of a doctor to deal with non urgent problems. Themeasures did not, however, correlate with A&E self-referralrates after they had been corrected for distance between practiceand hospital, or with the perceived availability of a doctorto deal with urgent problems. The proportion of patients seenas extras was related to the proportion of patients reportingthey normally waited in excess of 15 minutes to be seen whenattending their practice. Practices with small list sizes hadfewer respondents reporting dissatisfaction with the arrangementsfor seeing a doctor than had larger practices. Patients attendingA&E reported higher levels of dissatisfaction with the arrangementsfor seeing their general practitioner than did a sample of patientsattending their general practitioner. This finding persistedafter attempting to control for case mix, and was true whetherpatients were referred to A&E by their doctor or self-referred.The crow fly distance between a practice and the hospital isconfirmed as an important predictor of use of A&E servicesby patients who self-refer to such departments. This paper identifiesthree predictors of patient dissatisfaction with access arrangementsfor seeing a doctor. These are patients' perceptions of generalpractitioner availability to deal with non-urgent problems,practice list size, and measures of appointment system operation[the proportion of unbooked (‘available’) appointments,the rate of provision of appointments, and the proportion ofpatients identified as ‘extras’ by reception staff].Distance between practice and hospital is confirmed as an importantpredictor of a practice's self-referral rate to A&E. Thereis no evidence from this study that the variation amongst practicesin A&E serf-referral rates is related to the operation ofgeneral practitioner appointment systems.     

Using out-of-hours services: general practice or A&E?

BACKGROUND: General medical and accident and emergency (A&E) services are the two major providers of open access out-of-hours care, and there are widespread concerns about rising and non-urgent demand presented to both. METHODS: This paper examines the differential use of these services out of hours, in an audit and research study two A&E departments and 21 practices in South London. It focuses on aspects of demand, including time of contact, age-related usage and nature of presenting complaints. Through interviews with a subsample of 82 patients who attended A&E, it also provides a more qualitative focus on differential decision making. RESULTS: Findings show that there are differences in the way A&E and general medical services are used in terms of age-related demand and aspects of presenting complaints. Significantly more families with children aged under 10 contacted a GP, and whilst more digestive, respiratory and viral/non-specific complaints were presented to GPs, musculoskeletal problems constituted the largest category of complaints presented at the A&E departments. However, some usage relating to perceived and actual availability of services appeared to be interchangeable in terms of site-of-help seeking. CONCLUSION: There is a need for a collaborative multi-method approach to respond to and influence demand.      

Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation

ObjectivesTo evaluate the lifetime cost-effectiveness of 3 widely used atrial fibrillation (AF) treatments from the perspectives of Chinese healthcare system: antiarrhythmic drugs (AADs), ThermoCool SmartTouch guided by ablation index (STAI), and second-generation cryoballoon (CB2).MethodsA discrete event simulation (DES) model was implemented to compare the lifetime cost-effectiveness of AADs, STAI, and CB2. AF disease progression was explicitly modeled based on the Atrial Fibrillation Progression Trial clinical study results. The base-case analysis assumed that patients with paroxysmal AF (PAF) entered the model at the age of 55 years and had a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points)-Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), Age 65 to 74 years, and Sex category) score of 2 for males and 3 for females. Model parameter uncertainties were incorporated throughout the DES simulation with full probabilistic model parameterization.ResultsThe lifetime cost-effectiveness evaluations showed that patients treated with AADs gained an average of 4.98 quality-adjusted life-years (QALYs) and 9.63 life-years (LYs) at an average cost of US dollar (USD) 15 374. Patients treated with CB2 gained 5.92 QALYs and 10.74 LYs at an average cost of USD 26 811. The STAI group gained an average of 6.55 QALYs and 11.57 LYs at an average cost of USD 24 722. The incremental cost-effectiveness ratios was USD 5927 and USD 12 167 per QALY for STAI versus AADs and CB2 versus AADs, respectively. Assuming the willingness-to-pay threshold for China is USD 30 390 per QALY, both ablation treatments will be cost-effective compared with AADs for patients with PAF.ConclusionsThe DES model demonstrated that catheter ablations are more cost-effective than AADs for patients with PAF under the healthcare system in China. Among catheter ablation technologies, STAI provides better outcomes at lower costs.     

Uterine evacuation in the setting of transabdominal cerclage

ObjectivePatients with transabdominal cerclage in place present a management challenge in the setting of undesired pregnancy, pregnancy failure, or pre-viable pregnancy complications. Literature that guides safe surgical technique for uterine evacuation is sparse. This study sought to describe the management and safety profile of dilation and curettage (D&C) and dilation and evacuation (D&E) in patients with transabdominal cerclage.Study designWe used hospital billing records to identify patients with history of transabdominal cerclage placed between January 1998 and August 2019. We subsequently described the patient characteristics and surgical techniques of the procedures among those who underwent uterine evacuation.ResultsOf the 142 patients with an abdominal cerclage placed at our institution, fourteen had subsequent uterine aspiration for a total of 19 procedures over the study period. We describe fifteen D&C procedures in 11 patients between 5- and 12-weeks gestation, and four D&E procedures in three patients between 17- and 19-weeks gestation. Surgeons used osmotic dilators for cervical preparation and standard surgical techniques. There was one minor complication and no major complications. Three patients had procedures other than uterine evacuation.ConclusionsDilation and curettage and D&E are reasonable potential methods of uterine evacuation in women with transabdominal cerclage.Implications statementThis chart review suggests D&C and D&E are reasonable management options in the setting of transabdominal cerclage. Current practice guidelines should reflect the utilization of these procedures as potentially less invasive means of uterine evacuation.     

Alcohol and the accident and emergency department: a current review

Alcohol misuse constitutes a major problem in our modern society and both physical and mental alcohol-related harm result in a large number of Accident and Emergency (A&E) attendances, thus imposing a significant burden on the workload and financial resources of the department. The current management of problem drinking by most A&E departments could be further improved. The introduction of a holistic approach that includes efficient screening instruments and effective brief, anti-alcoholic interventions, for the management of these patients must be considered. This should strengthen the preventive role of A&E departments, and, in the long term, may result in a decrease in the number of cases of alcohol misuse and in alcohol-related attendances.     

Primary care consultation skills training: implementing a new training programme for senior house officers in an accident and emergency department

Senior house officers (SHOs) in Accident and Emergency (A&E) departments see many patients who present with primary care problems. Until now, most SHOs have lacked postgraduate training in primary care skills to enable them to meet these patients' needs effectively. This paper describes an innovative training programme that has been developing at King's College Hospital, London. It identifies a new opportunity for general practitioners to contribute to the postgraduate medical education of hospital junior medical staff. The training programme was designed to give A&E SHOs protected time in which to reflect on strengths and weaknesses in relation to primary care consultations and learn from their experiences. Its aim was to improve the assessment and management of patients, and to encourage a problem solving approach within the A&E setting. The programme, established in 1992, was developed through collaboration between the departments of A&E Medicine and General Practice and Primary Care. Evaluation has been a central theme in its development, and has been used to ensure that the training meets the needs of each individual set of SHOs and of the department. It has been used in establishing agreement about the training's value and benefits. The authors discuss some of the methodological difficulties encountered in evaluating this type of educational initiative.     

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.