Cost-effectiveness of the addition of acarbose to the treatment of patients with type-2 diabetes in Spain

OBJECTIVES: To assess the cost-effectiveness of the addition of acarbose to existing treatment in patients with type 2 diabetes mellitus (DM2) in Spain. METHODS: The CORE Diabetes Model (a published and validated computer simulation model) was used to project long-term clinical and cost outcomes in DM2. Transition probabilities and risk adjustments were derived from published sources. Treatment effects and baseline cohort characteristics were based on a meta-analysis. Direct costs were retrieved from published sources and projected over patient lifetimes from the perspective of the Spanish National Health Service. Costs and clinical benefits were discounted at 3% per year. Sensitivity analyses were performed. RESULTS: Acarbose treatment was associated with improved life expectancy (0.23 years) and quality-adjusted life years (QALY) (0.21 years). Direct costs were on average euro 468 per patient more expensive with acarbose than with placebo. The incremental cost-effectiveness ratios were euro 2,002 per life year gained and euro 2,199 per QALY gained. An acceptability curve showed that with a willingness to pay euro 20,000, which is generally accepted to represent very good value for money, acarbose treatment was associated with a 93.5% probability of being cost-effective. CONCLUSIONS: This long-term economic study showed that the addition of acarbose to existing therapy for DM2 was associated with improvements in life expectancy and QALYs in these patients.     

Long-Term Cost-Effectiveness of Pioglitazone versus Placebo in Addition to Existing Diabetes Treatment: A US Analysis Based on PROactive

Objective:  To estimate the long-term cost-effectiveness of adding pioglitazone versus placebo to standard treatment in high-risk patients with type 2 diabetes.
Methods:  The validated CORE Diabetes Model was modified to project long-term clinical and cost outcomes associated with pioglitazone versus placebo, based on results from PROactive. The model retained basic structure and functionality, with interdependent Markov submodels, Monte Carlo simulation and user interface. Adjustments to submodels were made to accommodate the PROactive primary end points. The analysis was from the perspective of a third party US health-care payer perspective, projected over a lifetime horizon using a 3% annual discount.
Results:  Over a lifetime horizon, addition of pioglitazone was associated with increased life expectancy (0.237 life-years) and quality-adjusted life expectancy (QALE) [0.166 quality-adjusted life-years (QALYs)] versus placebo. Estimated long-term complication rates showed that pioglitazone reduced the number of events versus placebo for most outcomes. Lifetime total direct costs were marginally higher with pioglitazone versus placebo ($272,694 vs. $265,390, difference $7,305). The incremental cost-effectiveness ratio for pioglitazone versus placebo was $44,105 per QALY gained. Probabilistic sensitivity analysis indicated a 55% likelihood that pioglitazone would be considered cost-effective in the United States, with a willingness to pay of $50,000 per QALY gained.
Conclusions:  The addition of pioglitazone to existing therapy in high-risk patients with type 2 diabetes was projected to improve life expectancy, QALE and complication rates compared with placebo. Addition of pioglitazone was in the range generally considered acceptable.     

Cost-Effectiveness of Interferon Beta-1a, Interferon Beta-1b, and Glatiramer Acetate in Newly Diagnosed Non-primary Progressive Multiple Sclerosis

OBJECTIVE: To perform a cost-effectiveness analysis of three immunomodulatory treatments for newly diagnosed nonprimary progressive MS: interferon beta-1a, interferon beta-1b, and glatiramer acetate. METHODS: We developed a state-transition model to estimate the health effects and costs associated with interferon beta-1a, interferon beta-1b, glatiramer acetate, and no treatment for hypothetical cohorts of men and women with non-primary progressive MS. We used the Expanded Disability Status Scale as the measure of disability and included both relapses and disease progression in the model. We evaluated treatment strategies assuming a 10-year treatment duration using the societal perspective. We elicited preferences for disability and treatment states using standard-gamble questions and modeled the disutility associated with treatment administration and side effects explicitly. Main outcome measures were net gains in quality-adjusted life expectancy and incremental cost-effectiveness ratios in dollars per quality-adjusted life year (QALY) gained. RESULTS: For treatment duration of 10 years for newly diagnosed non-primary progressive MS, interferon beta-1a yielded the largest gain in quality-adjusted life expectancy with an incremental cost-effectiveness ratio of $2,200,000/QALY for women and $1,800,000/QALY for men, compared with no treatment. For a 5-year treatment duration, a "no treatment" strategy yielded more quality-adjusted life years than any of the treatment strategies. Cost-effectiveness ratios were similar for all three immunomodulatory treatments evaluated. CONCLUSIONS: Cost-effectiveness results for all three immunomodulatory treatments for MS were unfavorable in the simulated study population under a wide range of assumptions. For treatment duration less than or equal to 5 years, expected benefits of treatment may not outweigh disutility associated with side effects and treatment discomfort.     

The cost effectiveness of health insurance

BACKGROUND: Although studies have examined both the adverse consequences of lacking health insurance and the costs of insuring the uninsured, there are no estimates of the value of providing health insurance to those currently uninsured. OBJECTIVE: To examine the value associated with providing insurance to those currently uninsured through an incremental cost-effectiveness analysis. METHODS: People aged 25 to 64 in both the National Health Interview Survey (with 2-year mortality follow-up) and the Medical Expenditure Panel Survey were examined to estimate the contribution of sociodemographic, health, and health behavior characteristics on insured persons' quality-adjusted life years (QALYs) and healthcare costs. Parameter estimates from these regression models were used to predict QALYs and costs associated with insuring the uninsured, given their characteristics for 1996. Markov decision-analysis modeling was then employed to calculate incremental cost-effectiveness ratios. RESULTS: The incremental cost-effectiveness of insurance for the average 25-year-old adult (through age 64) is approximately $35,000 per QALY gained (range $21,000 to $48,000). The incremental cost-effectiveness ratio becomes more favorable as people approach age 65. CONCLUSIONS: The additional health care purchased with health insurance provides gains in quality-adjusted life at costs that compare favorably to those of other programs and medical interventions society now chooses to fund.     

Cost-effectiveness of a potential vaccine for human papillomavirus

Human papillomavirus (HPV) infection, usually a sexually transmitted disease, is a risk factor for cervical cancer. Given the substantial disease and death associated with HPV and cervical cancer, development of a prophylactic HPV vaccine is a public health priority. We evaluated the cost-effectiveness of vaccinating adolescent girls for high-risk HPV infections relative to current practice. A vaccine with a 75% probability of immunity against high-risk HPV infection resulted in a life-expectancy gain of 2.8 days or 4.0 quality-adjusted life days at a cost of $246 relative to current practice (incremental cost effectiveness of $22,755/quality-adjusted life year [QALY]). If all 12-year-old girls currently living in the United States were vaccinated, >1,300 deaths from cervical cancer would be averted during their lifetimes. Vaccination of girls against high-risk HPV is relatively cost effective even when vaccine efficacy is low. If the vaccine efficacy rate is 35%, the cost effectiveness increases to $52,398/QALY. Although gains in life expectancy may be modest at the individual level, population benefits are substantial.     

The cost-effectiveness of prophylaxis for Mycobacterium avium complex in AIDS

OBJECTIVE: To develop a simulation model to project costs, life expectancy, and cost-effectiveness in discounted dollars per quality-adjusted life-year (QALY) saved for clinical strategies to prevent Mycobacterium avium complex (MAC) in patients with AIDS. METHODS: We used natural history data from the Multicenter AIDS Cohort Study, efficacy and toxicity data from randomized clinical trials, and cost data from the AIDS Cost and Services Utilization Survey. The model permits timing of prophylaxis to be stratified by CD4 count (201-300, 101-200, 51-100, and < or = 50/mm3), and allows combinations of prophylaxis, crossover to second- and third-line agents for toxicity, and consideration of adherence, resistance, and quality of life. RESULTS: The model projects that the average HIV-infected patient with a beginning CD4 count between 201 and 300/mm3 has total lifetime costs of approximately $43,150 and a quality-adjusted life expectancy of 42.35 months. If azithromycin prophylaxis for M. avium complex is begun after the CD4 declines to 50/mm3, costs and quality-adjusted survival increase to approximately $44,040 and 42.78 months, respectively, for an incremental cost-effectiveness ratio of $25,000/QALY compared with no M. avium complex prophylaxis. Other prophylaxis options (i.e., rifabutin, clarithromycin, and combination therapies) either cost more but offer shorter survival, or have cost-effectiveness ratios above $260,000/QALY. Sensitivity analysis reveals that, for reasonable assumptions about quality of life, risk of infection, prophylaxis cost, adherence, and resistance, azithromycin remains the most cost-effective prophylaxis option. CONCLUSIONS: Azithromycin prophylaxis, begun after the CD4 count has declined to 50/mm3, is the most cost-effective M. avium complex prophylaxis strategy. Consistent with new United States Public Health Service guidelines, it should be the first-line prophylaxis option.     

Cost-effectiveness of a mobile-phone text messaging intervention on type 2 diabetes—A randomized-controlled trial

AimsTo evaluate the cost-effectiveness of a mobile phone text messaging program for people with type 2 diabetes mellitus.MethodsWe performed a generalized cost-effectiveness analysis in a randomized controlled trial in Bangladesh. Patients with type 2 diabetes were randomized (1:1) to a text messaging intervention plus standard-care or standard-care alone. Intervention participants received a text message daily for 6 months encouraging healthy lifestyles. Costs to users and the health systems were measured. The EQ-5D-3L was used to measure improvements in health-related quality-adjusted life years (QALYs). Intervention costs were expressed as average cost-effectiveness ratios (cost-per 1% unit-reduction in glycated haemoglobin HbA1c and cost per QALY gained), based on the World Health Organization cost effectiveness and strategic planning (WHO-CHOICE) method.ResultsIn 236 patients [mean age 48 (SD9.6) years] the adjusted difference in accumulated QALYs between the intervention and the control group over the 6-month period was 0.010 (95%CI: 0.000; 0.021). Additional costs per-patient averaged 24 international dollars (Intl.$), resulting in incremental cost-effectiveness ratios of 38 Intl.$ per % glycated haemoglobin (HbA1c) reduction and 2406 Intl.$ per QALY gained. The total intervention costs for the mobile phone text messaging program was 2842 Int.$.ConclusionText messaging might be a valuable addition to standard treatment for diabetes care in low-resource settings and predicted to lead an overall saving in health systems costs. Studies with longer follow-up and larger samples are needed to draw reliable conclusions.     

Evaluating the benefits of increasing measles immunization rates

OBJECTIVE: To calculate the cost-effectiveness, expressed in dollars per quality-adjusted life years (QALY), of increasing measles immunization rates. DATA SOURCES/STUDY DESIGN: Published data were supplemented by expert opinion. We determined the cost savings and value of the health benefits from averting a single case of measles. Next we examined the U. S. data regarding the relationship between pre-school measles immunization and incidence rates. Finally, we calculated the cost-effectiveness of a program that would increase a locality's immunization rate to the point of disease elimination. PRINCIPAL FINDINGS: Averting a single case of measles, using "base case" assumptions, yields societal cost savings of $2,089 and an increase of 0.086 QALYs. Using a very low discount rate increases the total benefits to $2,251 in societal cost savings and 0.150 QALYs in health benefits. In general, programs to raise measles immunization rates are not cost-effective, except possibly during an outbreak of the disease or in areas with very low immunization rates. The extremely low measles incidence rates in the mid-1990s result in such programs having extremely high costs per QALY gained. CONCLUSIONS: Programs that are narrowly designed to increase immunization rates alone are not likely to be cost-effective. Yet these programs do have the potential to be cost-effective if the program design and evaluation also recognize the benefits associated with the primary and preventive care that can accompany immunizations. Such programs may also be cost-effective if they are components of a global eradication of measles.     

An Empiric Estimate of the Value of Life: Updating the Renal Dialysis Cost-Effectiveness Standard

ObjectivesProposals to make decisions about coverage of new technology by comparing the technology's incremental cost-effectiveness with the traditional benchmark of dialysis imply that the incremental cost-effectiveness ratio of dialysis is seen a proxy for the value of a statistical year of life. The frequently used ratio for dialysis has, however, not been updated to reflect more recently available data on dialysis.MethodsWe developed a computer simulation model for the end-stage renal disease population and compared cost, life expectancy, and quality-adjusted life expectancy of current dialysis practice relative to three less costly alternatives and to no dialysis. We estimated incremental cost-effectiveness ratios for these alternatives relative to the next least costly alternative and no dialysis and analyzed the population distribution of the ratios. Model parameters and costs were estimated using data from the Medicare population and a large integrated health-care delivery system between 1996 and 2003. The sensitivity of results to model assumptions was tested using 38 scenarios of one-way sensitivity analysis, where parameters informing the cost, utility, mortality and morbidity, etc. components of the model were by perturbed +/?50%.ResultsThe incremental cost-effectiveness ratio of dialysis of current practice relative to the next least costly alternative is on average $129,090 per quality-adjusted life-year (QALY) ($61,294 per year), but its distribution within the population is wide; the interquartile range is $71,890 per QALY, while the 1st and 99th percentiles are $65,496 and $488,360 per QALY, respectively. Higher incremental cost-effectiveness ratios were associated with older age and more comorbid conditions. Sensitivity to model parameters was comparatively small, with most of the scenarios leading to a change of less than 10% in the ratio.ConclusionsThe value of a statistical year of life implied by dialysis practice currently averages $129,090 per QALY ($61,294 per year), but is distributed widely within the dialysis population. The spread suggests that coverage decisions using dialysis as the benchmark may need to incorporate percentile values (which are higher than the average) to be consistent with the Rawlsian principles of justice of preserving the rights and interests of society's most vulnerable patient groups.     

The benefits and costs of tamoxifen for breast cancer prevention

OBJECTIVE: To estimate the effects of key uncertainties on the effectiveness and cost-effectiveness of breast cancer prevention with tamoxifen. METHODS: The incremental cost-effectiveness ratio of tamoxifen therapy relative to placebo was estimated using decision analysis with Markov modelling of health states, outcomes and costs for a simulated cohort of women at high risk for breast cancer. Relative effects of tamoxifen's benefits and harms were estimated from meta-analyses of randomised controlled trials. Cost estimates were based on Australian treatment patterns and costs. The main outcome measure was cost per quality-adjusted life year (QALY) gained with costs and effects discounted at a 5% annual rate. RESULTS: Tamoxifen therapy over five years reduces the incidence of breast cancer by approximately 1.4%, which is offset by an increase in endometrial cancer of 0.7% and pulmonary embolism of 0.2%. If the reduction is permanent (preventing new breast cancers emerging over five years and no further treatment effect thereafter), the model estimates an increase in life expectancy of 0.057 QALYs and an extra cost of $2,193; or $38,271/QALY gained. A model assuming further treatment effects of tamoxifen preventing new breast cancers emerging for up to 10 years results in an incremental cost of $19,354/QALY. However, if five years of tamoxifen therapy merely delays when these breast cancers appear (such that by 10 years there is no longer a reduced incidence), the incremental cost per QALY saved is estimated to be $199,149. CONCLUSIONS: Tamoxifen is potentially cost-effective in preventing breast cancer in women at high risk. However, its cost-effectiveness as a preventive therapy is highly sensitive to whether these cancers are permanently prevented or their clinical presentation is only delayed. Long-term follow-up in randomised controlled trials is therefore crucial in forming health policy.     

The Modeled Lifetime Cost-Effectiveness of Published Adherence-Improving Interventions for Antihypertensive and Lipid-Lowering Medications

ObjectiveWe sought to compare the cost-effectiveness of different interventions that have been shown to improve adherence with antihypertensive and lipid-lowering therapy, by combining a burden of nonadherence model framework with literature-based data on adherence-improving interventions.MethodsMEDLINE was reviewed for studies that evaluated ≥1 adherence intervention compared with a control, used an adherence measure other than self-report, and followed patients for ≥6 months. Effectiveness was assessed as Relative Improvement, ratio of adherence with an intervention versus control. Costs, standardized to 12 months and adjusted to 2007 US$, and effectiveness estimates for each intervention were entered into a previously published model designed to measure the burden of nonadherence with antihypertensive and lipid-lowering medications, in a hypertensive population. Outputs included direct medical costs and incremental costs per quality-adjusted life-year (QALY) gained.ResultsAfter screening, 23 eligible adherence-improving interventions were identified from 18 studies. Relative Improvement ranged from 1.13 to 3.60. After eliminating more costly/less effective interventions, two remained. Self-monitoring, reminders, and educational materials incurred total health-care costs of $17,520, and compared with no adherence intervention, had an incremental cost-effectiveness ratio (ICER) of $4984 per QALY gained. Pharmacist/nurse management incurred total health-care costs of $17,896, and versus self-monitoring, reminders, and education had an ICER of $6358 per QALY gained.ConclusionsOf published interventions shown to improve adherence, reminders and educational materials, and a pharmacist/nurse management program, appear to be cost-effective and should be considered before other interventions. Understanding relative cost-effectiveness of adherence interventions may guide design and implementation of efficient adherence-improving programs     

The Potential Clinical and Economic Outcomes of Pharmacogenomic Approaches to EGFR-Tyrosine Kinase Inhibitor Therapy in Non–Small-Cell Lung Cancer

Objectives:  Pharmacogenomic applications in oncology offer significant promise, but the clinical and economic implications remain unclear. The objective of this study was to evaluate the potential cost-utility of implementing epidermal growth factor receptor (EGFR) testing before initiating second-line therapy for advanced refractory non–small-cell lung cancer (NSCLC).
Methods:  We developed a decision analytic model to evaluate the cost-utility of EGFR protein expression or gene copy number testing compared to standard care with erlotinib in refractory advanced NSCLC patients. Costs and utilities were obtained from publicly available sources. We performed sensitivity analyses to evaluate uncertainty in the results.
Results:  The quality-adjusted life expectancies for erlotinib, EGFR protein expression testing, and gene copy number testing were: 0.44, 0.48, and 0.50 quality-adjusted life years (QALYs); and the costs were: $57,238, $63,512, and $66,447, respectively. The most cost-effective testing option, EGFR gene copy number testing, produced an incremental cost-effectiveness ratio of $162,018/QALY compared to no testing (erlotinib). The results were most sensitive to the survival estimates, health state utilities, and cost of disease progression. In the probabilistic sensitivity analyses, erlotinib without testing was the optimal treatment strategy until the $150,000/QALY willingness-to-pay threshold, after which gene copy testing was optimal. The discounted expected value of perfect information at a $100,000/QALY threshold in the USA over 5 years was $31.4 million.
Conclusions:  The study results suggest that EGFR pharmacogenomic testing has the potential to improve quality-adjusted life expectancy in the treatment of refractory NSCLC by a clinically meaningful margin at a value commensurate with the approved therapies in this setting. Additional research in this area is warranted.     

Cost-effectiveness of prenatal screening for postpartum thyroiditis

Five percent of all pregnant women and 25% of pregnant women with insulin-dependent diabetes mellitus (IDDM) develop postpartum thyroiditis (PPT) during the first year after delivery. PPT has significant morbidity and can be predicted prenatally by the presence of thyroid peroxidase (TPO) antibody. Our objective was to estimate the cost-effectiveness of screening pregnant women for the TPO antibody versus the current strategy of no screening test or an alternative strategy of a thyroid-stimulating hormone (TSH) test 6 weeks postpartum. We performed cost-effectiveness analysis using a decision tree model that accounted for cases of PPT detected, medical outcomes of screening, and costs of screening and care. Hypothetical cohorts of 1000 pregnant women with uncomplicated pregnancies and 1000 pregnant women with IDDM were used to determine direct medical costs, quality-adjusted life years, and cases of PPT detected. The cost of testing 1000 pregnant women for TSH at the 6 week postpartum visit was $75,000, with an effectiveness of 995.2 quality-adjusted life years resulting in a cost-effectiveness ratio of $48,000 per quality-adjusted life year. Checking a TPO antibody was more effective (995.5 quality-adjusted life years) but also more expensive ($93,000). The incremental cost-effectiveness ratio of the TPO antibody strategy was $60,000 per quality-adjusted life year. Results were most sensitive to changes in the test characteristics, incidence of disease, and percentage of women with PPT who were symptomatic. A separate analysis for women with IDDM resulted in an incremental cost-effectiveness ratio of $13,000 per quality-adjusted life year for the TSH strategy and $32,000 per quality-adjusted life year for the TPO strategy. Screening for PPT is likely to be reasonably cost-effective and should be considered for inclusion as part of routine pregnancy care.     

Cost-Effectiveness of the New 2018 American College of Physicians Glycemic Control Guidance Statements Among US Adults With Type 2 Diabetes

ObjectivesThis study aims to estimate the national impact and cost-effectiveness of the 2018 American College of Physicians (ACP) guidance statements compared to the status quo.MethodsSurvey data from the 2011-2016 National Health and Nutrition Examination were used to generate a national representative sample of individuals with diagnosed type 2 diabetes in the United States. Individuals with A1c <6.5% on antidiabetic medications are recommended to deintensify their A1c level to 7.0% to 8.0% (group 1); individuals with A1c 6.5% to 8.0% and a life expectancy of <10 years are recommended to deintensify their A1c level >8.0% (group 2); and individuals with A1c >8.0% and a life expectancy of >10 years are recommended to intensify their A1c level to 7.0% to 8.0% (group 3). We used a Markov-based simulation model to evaluate the lifetime cost-effectiveness of following the ACP recommended A1c level.Results14.41 million (58.1%) persons with diagnosed type 2 diabetes would be affected by the new guidance statements. Treatment deintensification would lead to a saving of $363 600 per quality-adjusted life-year (QALY) lost for group 1 and a saving of $118 300 per QALY lost for group 2. Intensifying treatment for group 3 would lead to an additional cost of $44 600 per QALY gain. Nationally, the implementation of the guidance would add 3.2 million life-years and 1.1 million QALYs and reduce healthcare costs by $47.7 billion compared to the status quo.ConclusionsImplementing the new ACP guidance statements would affect a large number of persons with type 2 diabetes nationally. The new guidance is cost-effective.     

Cost-Effectiveness of Switching to Exemestane after 2 to 3 Years of Therapy with Tamoxifen in Postmenopausal Women with Early-Stage Breast Cancer

OBJECTIVES: Data from the Intergroup Exemestane Study (IES) suggest that switching to the aromatase inhibitor, exemestane, after 2 to 3 years of tamoxifen therapy prolongs disease-free survival versus continuing on tamoxifen therapy. We sought to evaluate the cost-effectiveness of this management strategy. METHODS: A Markov model was developed to predict patients' transitions across various health states based on treatment strategy (continuing tamoxifen vs. switching to exemestane), breast cancer status (no recurrence, local or distant recurrence, contralateral breast cancer), and other related health events (osteoporosis, endometrial cancer, death). Rates of disease-related events (recurrence and contralateral breast cancer) were estimated using data from the IES. Survival and lifetime medical-care costs by type of disease-related event were estimated using SEER-Medicare data. The model was used to estimate direct costs (in 2004 US dollars), life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness. RESULTS: Switching to exemestane versus continuing tamoxifen therapy was associated with increased disease-free survival (181 vs. 172 months), QALYs (12.21 vs. 11.89), and net discounted lifetime costs of cancer care ($12,124 vs. $7724 per patient). The incremental cost-effectiveness ratio of exemestane was $20,100 per QALY gained (95% confidence interval: $12,100, $59,000). Sensitivity analyses showed that results were robust to plausible variations in recurrence rates, costs, and utilities. CONCLUSIONS: Switching postmenopausal early-stage breast cancer patients to exemestane after 2 to 3 years of tamoxifen appears to be a cost-effective treatment strategy versus completing a 5-year course of tamoxifen.     

Cost effectiveness of an internet-delivered lifestyle intervention in primary care patients with high cardiovascular risk

ObjectiveTo assess the cost-effectiveness of an online adaptation of the diabetes prevention program (ODPP) lifestyle intervention.MethodsODPP was a before–after evaluation of a weight loss intervention comprising 16 weekly and 8 monthly lessons, incorporating behavioral tools and regular, brief, web-based individualized counseling in an overweight/obese cohort (mean age 52, 76% female, 92% white, 28% with diabetes). A Markov model was developed to estimate ODPP cost effectiveness compared with usual care (UC) to reduce metabolic risk over 10 years. Intervention costs and weight change outcomes were obtained from the study; other model parameters were based on published reports. In the model, diabetes risk was a function of weight change with and without the intervention.ResultsCompared to UC, the ODPP in our cohort cost $14,351 and $29,331 per quality-adjusted life-year (QALY) gained from the health care system and societal perspectives, respectively. In a hypothetical cohort without diabetes, the ODPP cost $7777 and $18,263 per QALY gained, respectively. Results were robust in sensitivity analyses, but enrolling cohorts with lower annual risk of developing diabetes (≤ 1.8%), enrolling fewer participants (≤ 15), or increasing the hourly cost (≥$91.20) or annual per-participant time (≥ 1.45 h) required for technical support could increase ODPP cost to >$20,000 per QALY gained. In probabilistic sensitivity analyses, ODPP was cost-effective in 20–58% of model iterations using an acceptability threshold of $20,000, 73–92% at $50,000, and 95–99% at $100,000 per QALY gained.ConclusionsThe ODPP may offer an economical approach to combating overweight and obesity.     

A cost-effectiveness analysis of exercise as a health promotion activity.

We used cost-effectiveness analysis to estimate the health and economic implications of exercise in preventing coronary heart disease (CHD). We assumed that nonexercisers have a relative risk of 2.0 for a CHD event. Two hypothetical cohorts (one with exercise and the other without exercise) of 1,000 35-year-old men were followed for 30 years to observe differences in the number of CHD events, life expectancy, and quality-adjusted life expectancy. We used jogging as an example to calculate cost, injury rates, adherence, and the value of time spent. Both direct and indirect costs associated with exercise, injury, and treating CHD were considered. We estimate that exercising regularly results in 78.1 fewer CHD events and 1,138.3 Quality Adjusted Life Years (QALYs) gained over the 30-year study period. Under our base case assumptions, which include indirect costs such as time spent in exercise, exercise does not produce economic savings. However, the cost per QALY gained of $11,313 is favorable when compared with other preventive or therapeutic interventions for CHD. The value of time spent is a crucial factor, influencing whether exercise is a cost-saving activity. In an alternative model, where all members of the cohort exercise for one year, and then only those who like it or are neutral continue, exercise produces net economic savings as well as reducing morbidity.     

Cost effectiveness of a targeted age-based West Nile virus vaccination program

BackgroundWest Nile virus (WNV) is the leading cause of domestically-acquired arboviral disease in the United States. Several WNV vaccines are in various stages of development. We estimate the cost-effectiveness of WNV vaccination programs targeting groups at increased risk for severe WNV disease.MethodsWe used a mathematical model to estimate costs and health outcomes of vaccination with WNV vaccine compared to no vaccination among seven cohorts, spaced at 10 year intervals from ages 10 to 70 years, each followed until 90-years-old. U.S. surveillance data were used to estimate WNV neuroinvasive disease incidence. Data for WNV seroprevalence, acute and long-term care costs of WNV disease patients, quality-adjusted life-years (QALYs), and vaccine characteristics were obtained from published reports. We assumed vaccine efficacy to either last lifelong or for 10 years with booster doses given every 10 years.ResultsThere was a statistically significant difference in cost-effectiveness ratios across cohorts in both models and all outcomes assessed (Kruskal-Wallis test p < 0.0001). The 60-year-cohort had a mean cost per neuroinvasive disease case prevented of $664,000 and disability averted of $1,421,000 in lifelong model and $882,000 and $1,887,000, respectively in 10-year immunity model; these costs were statistically significantly lower than costs for other cohorts (p < 0.0001). Vaccinating 70-year-olds had the lowest cost per death averted in both models at around $4.7 million (95%CI $2–$8 million). Cost per disease case averted was lowest among 40- and 50-year-old cohorts and cost per QALY saved lowest among 60-year cohorts in lifelong immunity model. The models were most sensitive to disease incidence, vaccine cost, and proportion of persons developing disease among infected.ConclusionsAge-based WNV vaccination program targeting those at higher risk for severe disease is more cost-effective than universal vaccination. Annual variation in WNV disease incidence, QALY weights, and vaccine costs impact the cost effectiveness ratios.     

Economic analysis of a school-based obesity prevention program

OBJECTIVE: To assess the cost-effectiveness and cost-benefit of Planet Health, a school-based intervention designed to reduce obesity in youth of middle-school age children. RESEARCH METHODS AND PROCEDURES: Standard cost-effectiveness analysis methods and a societal perspective were used in this study. Three categories of costs were measured: intervention costs, medical care costs associated with adulthood overweight, and costs of productivity loss associated with adulthood overweight. Health outcome was measured as cases of adulthood overweight prevented and quality-adjusted life years (QALYs) saved. Cost-effectiveness ratio was measured as the ratio of net intervention costs to the total number of QALYs saved, and net-benefit was measured as costs averted by the intervention minus program costs. RESULTS: Under base-case assumptions, at an intervention cost of $33,677 or $14 US dollars per student per year, the program would prevent an estimated 1.9% of the female students (5.8 of 310) from becoming overweight adults. As a result, an estimated 4.1 QALYs would be saved by the program, and society could expect to save an estimated $15,887 USD in medical care costs and $25,104 USD in loss of productivity costs. These findings translated to a cost of $4305 USD per QALY saved and a net saving of $7313 USD to society. Results remained cost-effective under all scenarios considered and remained cost-saving under most scenarios. DISCUSSION: The Planet Health program is cost-effective and cost-saving as implemented. School-based prevention programs of this type are likely to be cost-effective uses of public funds and warrant careful consideration by policy makers and program planners.     

A therapeutic HIV vaccine: how good is good enough?

The goal of a therapeutic HIV vaccine is to attenuate HIV disease progression in those already infected. Our objective was to establish comparative efficacy and cost-effectiveness thresholds at which a therapeutic vaccine would make a valuable contribution to HIV care. Using an HIV computer simulation model, we compared therapeutic vaccination with HIV standard of care without vaccination. Input data were obtained from the literature. Base case and sensitivity analyses related to vaccine magnitude, penetrance, durability, and cost. In the base case (0.5 log magnitude, 25% penetrance, 3-year durability, and US$ 4000 per series), vaccination increased quality-adjusted life expectancy (QALE) by 0.50 months compared to no vaccination (cost-effectiveness ratio US$ 89,900 per quality-adjusted life year (QALY)). Increasing vaccine penetrance to 50% increased the projected QALE benefit to 0.91 months (cost-effectiveness ratio US$ 45,500/QALY). Even modestly effective therapeutic HIV vaccines may produce small but meaningful increases in life expectancy and compare favorably to alternative uses of scarce HIV care resources.