Prevention and treatment of cardiovascular disease in Ethiopia: a cost-effectiveness analysis

Background

The coverage of prevention and treatment strategies for ischemic heart disease and stroke is very low in Ethiopia. In view of Ethiopia’s meager healthcare budget, it is important to identify the most cost-effective interventions for further scale-up. This paper’s objective is to assess cost-effectiveness of prevention and treatment of ischemic heart disease (IHD) and stroke in an Ethiopian setting.

Methods

Fifteen single interventions and sixteen intervention packages were assessed from a healthcare provider perspective. The World Health Organization’s Choosing Interventions that are Cost-Effective model for cardiovascular disease was updated with available country-specific inputs, including demography, mortality and price of traded and non-traded goods. Costs and health benefits were discounted at 3 % per year. Incremental cost-effectiveness ratios are reported in US$ per disability adjusted life year (DALY) averted. Sensitivity analysis was undertaken to assess robustness of our results.

Results

Combination drug treatment for individuals having >35 % absolute risk of a CVD event in the next 10 years is the most cost-effective intervention. This intervention costs US$67 per DALY averted and about US$7 million annually. Treatment of acute myocardial infarction (AMI) (costing US$1000–US$7530 per DALY averted) and secondary prevention of IHD and stroke (costing US$1060–US$10,340 per DALY averted) become more efficient when delivered in integrated packages. At an annual willingness-to-pay (WTP) level of about US$3 million, a package consisting of aspirin, streptokinase, ACE-inhibitor and beta-blocker for AMI has the highest probability of being most cost-effective, whereas as WTP increases to > US$7 million, combination drug treatment to individuals having >35 % absolute risk stands out as the most cost-effective strategy. Cost-effectiveness ratios were relatively more sensitive to halving the effectiveness estimates as compared with doubling the price of drugs and laboratory tests.

Conclusions

In Ethiopia, the escalating burden of CVD and its risk factors warrants timely action. We have demonstrated that selected CVD intervention packages could be scaled up at a modest budget increase. The level of willingness-to-pay has important implications for interventions’ probability of being cost-effective. The study provides valuable evidence for setting priorities in an essential healthcare package for CVD in Ethiopia.

     

Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care

Background

Glaucoma is the leading cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma.

Objectives

The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence.

Methods

This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios.

Results

Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04–1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08–1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56.

Conclusions

A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

     

Possible Impact of Incremental Cost-Effectiveness Ratio (ICER) on Decision Making for Cancer Screening in Hong Kong: A Systematic Review

Objectives

The aim of this paper was to critically review the literature on the cost effectiveness of cancer screening interventions, and examine the incremental cost-effectiveness ratios (ICERs) that may influence government recommendations on cancer screening strategies and funding for mass implementation in the Hong Kong healthcare system.

Methods

We conducted a literature review of cost-effectiveness studies in the Hong Kong population related to cancer screening published up to 2015, through a hand search and database search of PubMed, Web of Science, Embase, and OVID Medline. Binary data on the government’s decisions were obtained from the Cancer Expert Working Group, Department of Health. Mixed-effect logistic regression analysis was used to examine the impact of ICERs on decision making. Using Youden’s index, an optimal ICER threshold value for positive decisions was examined by area under receiver operating characteristic curve (AUC).

Results

Eight studies reporting 30 cost-effectiveness pairwise comparisons of population-based cancer screening were identified. Most studies reported an ICER for a cancer screening strategy versus a comparator with outcomes in terms of cost per life-years (55.6 %), or cost per quality-adjusted life-years (55.6 %). Among comparisons with a mean ICER of US$102,931 (range 800–715,137), the increase in ICER value by 1000 was associated with decreased odds (odds ratio 0.990, 0.981–0.999; p = 0.033) of a positive recommendation. An optimal ICER value of US$61,600 per effectiveness unit yielded a high sensitivity of 90 % and specificity of 85 % for a positive recommendation. A lower ICER threshold value of below US$8044 per effectiveness unit was detected for a positive funding decision.

Conclusions

Linking published evidence to Government recommendations and practice on cancer screening, ICERs influence decisions on the adoption of health technologies in Hong Kong. The potential ICER threshold for recommendation in Hong Kong may be higher than those of developed countries.

     

Cost-Effectiveness Analyses of Lung Cancer Screening Strategies Using Low-Dose Computed Tomography: a Systematic Review

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.

Objective

The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.

Methods

We searched MEDLINE, EMBASE, EBM Reviews—Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).

Results

The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.

Conclusions

The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.

     

Cost and Budget Impact Analysis of an Accurate Intraoperative Sentinel Lymph Node Diagnosis for Breast Cancer Metastasis

Background

Conventional intraoperative sentinel lymph node biopsy (SLNB) in breast cancer (BC) has limitations in establishing a definitive diagnosis of metastasis intraoperatively, leading to an unnecessary second operation. The one-step nucleic amplification assay (OSNA) provides accurate intraoperative diagnosis and avoids further testing. Only five articles have researched the cost and cost effectiveness of this diagnostic tool, although many hospitals have adopted it, and economic evaluation is needed for budget holders.

Objective

We aimed to measure the budget impact in Japanese BC patients after the introduction of OSNA, and assess the certainty of the results.

Methods

Budget impact analysis of OSNA on Japanese healthcare expenditure from 2015 to 2020. Local governments, society-managed health insurers, and Japan health insurance associations were the budget holders. In order to assess the cost gap between the gold standard (GS) and OSNA in intraoperative SLNB, a two-scenario comparative model that was structured using the clinical pathway of a BC patient group who received SLNB was applied. Clinical practice guidelines for BC were cited for cost estimation.

Results

The total estimated cost of all BC patients diagnosed by GS was US$1,023,313,850. The budget impact of OSNA in total health expenditure was ?US$24,413,153 (?US$346 per patient). Two-way sensitivity analysis between survival rate (SR) of the GS and OSNA was performed by illustrating a cost-saving threshold: y ? 1.14x ? 0.16 in positive patients, and y ? 0.96x + 0.029 in negative patients (x = SR–GS, y = SR–OSNA). Base inputs of the variables in these formulas demonstrated a cost saving.

Conclusion

OSNA reduces healthcare costs, as confirmed by sensitivity analysis.

     

Cost Implications for Subsequent Perinatal Outcomes After IVF Stratified by Number of Embryos Transferred: A Five Year Analysis of Vermont Data

Background

In states in the USA without in vitro fertilzation coverage (IVF) insurance coverage, more embryos are transferred per cycle leading to higher risks of multi-fetal pregnancies and adverse pregnancy outcomes.

Objective

To determine frequency and cost of selected adverse perinatal complications based on number of embryos transferred during IVF, and calculate incremental cost per IVF live birth.

Methods

Medical records of patients who conceived with IVF (n = 116) and delivered at >20 weeks gestational age between 2007 and 2011 were evaluated. Gestational age at delivery, low birth weight (LBW) term births, and delivery mode were tabulated. Healthcare costs per cohort, extrapolated costs assuming 100 patients per cohort, and incremental costs per infant delivered were calculated.

Results

The highest prematurity and cesarean section rates were recorded after double embryo transfers (DET), while the lowest rates were found in single embryo transfers (SET). Premature singleton deliveries increased directly with number of transferred embryos [6.3 % (SET), 9.1 % (DET) and 10.0 % for ≥3 embryos transferred]. This trend was also noted for rate of cesarean delivery [26.7 % (SET), 36.6 % (DET), and 47.1 % for ≥3 embryos transferred]. The proportion of LBW infants among deliveries after DET and for ≥3 embryos transferred was 3.9 and 9.1 %, respectively. Extrapolated costs per cohort were US$718,616, US$1,713,470 and US$1,227,396 for SET, DET, and ≥3 embryos transferred, respectively.

Conclusion

Attempting to improve IVF pregnancy rates by permitting multiple embryo transfers results in sharply increased rates of multiple gestation and preterm delivery. This practice yields a greater frequency of adverse perinatal outcomes and substantially increased healthcare spending. Better efforts to encourage SET are necessary to normalize healthcare expenditures considering the frequency of very high cost sequela associated with IVF where multiple embryo transfers occur.

     

Task shifting in the management of hypertension in Kinshasa,Democratic Republic of Congo: a cross-sectional study

Background

The Democratic Republic of the Congo (DRC) is characterized by a high prevalence of hypertension (HTN) and a high proportion of uncontrolled HTN, which is indicative of poor HTN management. Effective management of HTN in the African region is challenging due to limited resources, particularly human resources for health. To address the shortage of health workers, the World Health Organization (WHO) recommends task shifting for better disease management and treatment. Although task shifting from doctors to nurses is being implemented in the DRC, there are no studies, to the best of our knowledge, that document the association between task shifting and HTN control. The aim of this study was to investigate the association between task shifting and HTN control in Kinshasa, DRC.

Methods

We conducted a cross-sectional study in Kinshasa from December 2015 to January 2016 in five general referral hospitals (GRHs) and nine health centers (HCs). A total of 260 hypertensive patients participated in the study. Sociodemographic, clinical, health care costs and perceived health care quality assessment data were collected using a structured questionnaire. To examine the association between task shifting and HTN control, we assessed differences between GRH and HC patients using bivariate and multivariate analyses.

Results

Almost half the patients were female (53.1%), patients’ mean age was 59.5 ± 11.4 years. Over three-fourths of patients had uncontrolled HTN. There was no significant difference in the proportion of GRH and HC patients with uncontrolled HTN (76.2% vs 77.7%, p = 0.771). Uncontrolled HTN was associated with co-morbidity (OR = 10.3; 95% CI: 3.8–28.3) and the type of antihypertensive drug used (OR = 4.6; 95% CI: 1.3–16.1). The mean healthcare costs in the GRHs were significantly higher than costs in the HCs (US$ 34.2 ± US$3.34 versus US$ 7.7 ± US$ 0.6, respectively).

Conclusion

Uncontrolled HTN was not associated with the type of health facility. This finding suggests that the management of HTN at primary healthcare level might be just as effective as at secondary level. However, the high proportion of patients with uncontrolled HTN underscores the need for HTN management guidelines at all healthcare levels.

     

The economic burden of childhood pneumococcal diseases in The Gambia

Background

Streptococcus pneumoniae is a common cause of child death. However, the economic burden of pneumococcal disease in low-income countries is poorly described. We aimed to estimate from a societal perspective, the costs incurred by health providers and families of children with pneumococcal diseases.

Methods

We recruited children less than 5 years of age with outpatient pneumonia, inpatient pneumonia, pneumococcal sepsis and bacterial meningitis at facilities in rural and urban Gambia. We collected provider costs, out of pocket costs and productivity loss for the families of children. For each disease diagnostic category, costs were collected before, during, and for 1 week after discharge from hospital or outpatient visit.

Results

A total of 340 children were enrolled; 100 outpatient pneumonia, 175 inpatient pneumonia 36 pneumococcal sepsis, and 29 bacterial meningitis cases. The mean provider costs per patient for treating outpatient pneumonia, inpatient pneumonia, pneumococcal sepsis and meningitis were US$8, US$64, US$87 and US$124 respectively and the mean out of pocket costs per patient were US$6, US$31, US$44 and US$34 respectively. The economic burden of outpatient pneumonia, inpatient pneumonia, pneumococcal sepsis and meningitis increased to US$15, US$109, US$144 and US$170 respectively when family members’ time loss from work was taken into account.

Conclusion

The economic burden of pneumococcal disease in The Gambia is substantial, costs to families was approximately one-third to a half of the provider costs, and accounted for up to 30 % of total societal costs. The introduction of pneumococcal conjugate vaccine has the potential to significantly reduce this economic burden in this society.

     

Long-Term Cost-Effectiveness of Insulin Glargine Versus Neutral Protamine Hagedorn Insulin for Type 2 Diabetes in Thailand

Background

Even though Insulin glargine (IGlar) has been available and used in other countries for more than a decade, it has not been adopted into Thai national formulary. This study aimed to evaluate the long-term cost effectiveness of IGlar versus neutral protamine Hagedorn (NPH) insulin in type 2 diabetes from the perspective of Thai Health Care System.

Methods

A validated computer simulation model (the IMS CORE Diabetes Model) was used to estimate the long-term projection of costs and clinical outcomes. The model was populated with published characteristics of Thai patients with type 2 diabetes. Baseline risk factors were obtained from Thai cohort studies, while relative risk reduction was derived from a meta-analysis study conducted by the Canadian Agency for Drugs and Technology in Health. Only direct costs were taken into account. Costs of diabetes management and complications were obtained from hospital databases in Thailand. Both costs and outcomes were discounted at 3 % per annum and presented in US dollars in terms of 2014 dollar value. Incremental cost-effectiveness ratio (ICER) was calculated. One-way and probabilistic sensitivity analyses were also performed.

Results

IGlar is associated with a slight gain in quality-adjusted life years (0.488 QALYs), an additional life expectancy (0.677 life years), and an incremental cost of THB119,543 (US$3522.19) compared with NPH insulin. The ICERs were THB244,915/QALY (US$7216.12/QALY) and THB176,525/life-year gained (LYG) (US$5201.09/LYG). The ICER was sensitive to discount rates and IGlar cost. At the acceptable willingness to pay of THB160,000/QALY (US$4714.20/QALY), the probability that IGlar was cost effective was less than 20 %.

Conclusions

Compared to treatment with NPH insulin, treatment with IGlar in type 2 diabetes patients who had uncontrolled blood glucose with oral anti-diabetic drugs did not represent good value for money at the acceptable threshold in Thailand.

     

The cost-effectiveness of interventions targeting lifestyle change for the prevention of diabetes in a Swedish primary care and community based prevention program

Background

Policymakers need to know the cost-effectiveness of interventions to prevent type 2 diabetes (T2D). The objective of this study was to estimate the cost-effectiveness of a T2D prevention initiative targeting weight reduction, increased physical activity and healthier diet in persons in pre-diabetic states by comparing a hypothetical intervention versus no intervention in a Swedish setting.

Methods

A Markov model was used to study the cost-effectiveness of a T2D prevention program based on lifestyle change versus a control group where no prevention was applied. Analyses were done deterministically and probabilistically based on Monte Carlo simulation for six different scenarios defined by sex and age groups (30, 50, 70 years). Cost and quality adjusted life year (QALY) differences between no intervention and intervention and incremental cost-effectiveness ratios (ICERs) were estimated and visualized in cost-effectiveness planes (CE planes) and cost-effectiveness acceptability curves (CEA curves).

Results

All ICERs were cost-effective and ranged from 3833 €/QALY gained (women, 30 years) to 9215 €/QALY gained (men, 70 years). The CEA curves showed that the probability of the intervention being cost-effective at the threshold value of 50,000 € per QALY gained was very high for all scenarios ranging from 85.0 to 91.1%.

Discussion/conclusion

The prevention or the delay of the onset of T2D is feasible and cost-effective. A small investment in healthy lifestyle with change in physical activity and diet together with weight loss are very likely to be cost-effective.

     

Economic evaluation of a telephone- and face-to-face-delivered counseling intervention for smoking cessation in patients with coronary heart disease

Objective

This study examined the cost-effectiveness and cost-utility of two smoking cessation counseling interventions differing in their modality for patients diagnosed with coronary heart disease from a societal perspective.

Methods

In a randomized controlled trial conducted in Dutch hospital wards, cardiac patients who smoked prior to admission were allocated to usual care (n = 245), telephone counseling (n = 223) or face-to-face counseling (n = 157). The counseling interventions lasted for 3 months and were complemented by nicotine patches. Baseline histories were obtained, and interviews took place 6 months after hospitalization to assess self-reported smoking status and quality adjusted life years (QALYs). Incremental cost-effectiveness ratios per quitter and cost-utility ratios per QALY were calculated and presented in acceptability curves. Uncertainty was accounted for by sensitivity analysis.

Results

Using continued abstinence as the outcome measure showed that telephone counseling had the highest probability of being cost-effective. Face-to-to-face counseling was also more cost-effective than usual care. No significant improvements and differences in QALYs between the three conditions were found. Varying costs and effect estimations revealed that the results of the primary analyses were robust.

Conclusions

Assuming a willingness-to-pay of €20,000 per abstinent patient, telephone counseling would be a highly cost-effective smoking cessation intervention assisting cardiac patients to quit. However, the lack of consensus concerning the willingness-to-pay per quitter impedes drawing firm conclusions. Moreover, studies with extended follow-up periods are needed to capture late relapses and possible differences in QALYs.

     

Cost-effectiveness analysis of EGFR mutation testing in patients with non-small cell lung cancer (NSCLC) with gefitinib or carboplatin–paclitaxel

Objective

Assess the cost-effectiveness of an EGFR-mutation testing strategy for advanced NSCLC in first-line therapy with either gefitinib or carboplatin–paclitaxel in Mexican institutions.

Methods

Cost-effectiveness analysis using a discrete event simulation (DES) model to simulate two therapeutic strategies in patients with advanced NSCLC. Strategy one included patients tested for EGFR-mutation and therapy given accordingly. Strategy two included chemotherapy for all patients without testing. All results are presented in 2014 US dollars. The analysis was made with data from the Mexican frequency of EGFR-mutation. A univariate sensitivity analysis was conducted on EGFR prevalence. Progression-free survival (PFS) transition probabilities were estimated on data from the IPASS and simulated with a Weibull distribution, run with parallel trials to calculate a probabilistic sensitivity analysis.

Results

PFS of patients in the testing strategy was 6.76 months (95 % CI 6.10–7.44) vs 5.85 months (95 % CI 5.43–6.29) in the non-testing group. The one-way sensitivity analysis showed that PFS has a direct relationship with EGFR-mutation prevalence, while the ICER and testing cost have an inverse relationship with EGFR-mutation prevalence. The probabilistic sensitivity analysis showed that all iterations had incremental costs and incremental PFS for strategy 1 in comparison with strategy 2.

Conclusion

There is a direct relationship between the ICER and the cost of EGFR testing, with an inverse relationship with the prevalence of EGFR-mutation. When prevalence is >10 % ICER remains constant. This study could impact Mexican and Latin American health policies regarding mutation detection testing and treatment for advanced NSCLC.

     

Sustained quality of life improvement after intracoronary injection of autologous bone marrow cells in the setting of acute myocardial infarction: results from the BONAMI trial

Purpose

Cardiac cell therapy is a promising treatment for acute myocardial infarction (AMI), leading to cardiac function improvement. However, whether it translates into quality of life (QoL) improvement is unclear. We hypothesized that administration of bone marrow cells (BMC) to patients with AMI improves QoL.

Methods

In the multicenter BONAMI trial (NCT00200707), patients with reperfused AMI and decreased myocardial viability were randomized to intracoronary autologous BMC infusion (n = 52) or state-of-the-art therapy (n = 49). QoL data, derived from the Minnesota Living with Heart Failure questionnaire (MLHFQ), were obtained 1, 3, and 12 months after AMI and analyzed using a Rasch-family model.

Results

Using this model, QoL improved over time in the BMC group (p = 0.025) but not in the control group. Furthermore, the BMC-group patients displayed a better QoL than the control-group patients at 3 and 12 months post-AMI (p = 0.034 and p = 0.003, respectively). These findings were not detected when analyzing MLHFQ data using a standard method. Cardiac function, myocardial viability, mortality, and number of major adverse cardiac events did not differ between treatment groups.

Conclusion

Our results suggest that BMC therapy can improve QoL, stressing the need for confirmation trials and for systematic QoL assessment in cardiac cell therapy trials .

     

The impact of waiting for intervention on costs and effectiveness: the case of transcatheter aortic valve replacement

Objectives

The economic crisis in Europe might have limited access to some innovative technologies implying an increase of waiting time. The purpose of the study is to evaluate the impact of waiting time on the costs and benefits of transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis.

Methods

This is a cost-utility analysis from the perspective of the Spanish National Health Service. Results of two prospective hospital registries (158 and 273 consecutive patients) were incorporated into a probabilistic Markov model to compare quality adjusted life years (QALYs) and costs for TAVR after waiting for 3–12 months, relative to immediate TAVR. We simulated a cohort of 1000 patients, male, and 80 years old; other patient profiles were assessed in sensitivity analyses.

Results

As waiting time increased, costs decreased at the expense of lower survival and loss of QALYs, leading to incremental cost-effectiveness ratios for eliminating waiting lists of about 12,500 € per QALY. In subgroup analyses prioritization of patients for whom higher benefit was expected led to a smaller loss of QALYs. Concerning budget impact, long waiting lists reduced spending considerably and permanently.

Conclusions

A shorter waiting time is likely to be cost-effective (considering commonly accepted willingness-to-pay thresholds in Europe) relative to 3 months or longer waiting periods. If waiting lists are nevertheless seen as unavoidable due to severe but temporary budgetary restrictions, prioritizing patients for whom higher benefit is expected appears to be a way of postponing spending without utterly sacrificing patients’ survival and quality of life.

     

Estimating the cost-effectiveness of daclatasvir + sofosbuvir versus sofosbuvir + ribavirin for patients with genotype 3 hepatitis C virus

Background

As treatments for chronic hepatitis C are moving away from interferon-containing regimens, the most appropriate allocation of resources to higher cost, interferon-free, direct-acting antiviral (DAA) regimens needs to be assessed. Hepatitis C virus (HCV) genotype 3 is associated with faster disease progression and has fewer treatment options, historically, than other HCV genotypes. This analysis aims to estimate the comparative cost-effectiveness of two recently licenced interferon-free regimens for the treatment of HCV genotype 3.

Methods

Utilising a published Markov model and results of a matching-adjusted indirect comparison of recently published clinical trial data (ALLY-3 and VALENCE, respectively), 12 weeks of treatment with daclatasvir + sofosbuvir (DCV + SOF) was compared to 24 weeks of treatment with sofosbuvir + ribavirin (SOF + RBV). UK-specific model inputs were used to inform a cost-utility analysis of these regimens.

Results

In the base case analysis, DCV + SOF was found to be dominant over SOF + RBV in treatment-naïve patients, patients that had previously been treated, and patients that are intolerant to, or ineligible for, interferon-containing regimens. Given the low rates of treatment currently observed in the UK, DCV + SOF was also compared to no treatment in the interferon-ineligible/intolerant patients, and may be considered cost-effective with an incremental cost-effectiveness ratio of £8817.

Conclusions

When compared to 24 weeks of SOF + RBV, 12 weeks of treatment with DCV + SOF results in improved quality of life and reduced total costs, and therefore is likely to represent significant clinical and economic value as a treatment option for genotype 3 HCV infection.

     

Psychological distress between chronic hemodialysis patients with and without low back pain

Objective

The aim of this study was to compare psychological distress between patients on chronic hemodialysis with and without chronic low back pain (CLBP).

Subjects and methods

A total of 72 patients on chronic hemodialysis, aged 72.9 ± 10.8 years, were enrolled in this cross-sectional study. Psychological distress using the K6, questionnaire for CLBP, and physical activity using the tri-accelerometer were evaluated.

Results

Twenty-nine patients (40.3 %) were having CLBP. The K6 scores were 4.0 ± 4.6 and physical activity (n = 55) was 1.0 ± 1.0 METs h/day. K6 scores in patients on chronic hemodialysis with CLBP were significantly higher than those in patients on chronic hemodialysis without CLBP even after adjusting for sex, age, duration of hemodialysis and physical activity.

Conclusion

These results suggest that higher psychological distress was a fundamental feature in patients on chronic hemodialysis with CLBP.

     

Cost-Effectiveness Analysis of Iodine-123 Meta-Iodobenzylguanidine Imaging for Screening Heart Failure Patients Eligible for an Implantable Cardioverter Defibrillator in the USA

Background

Many guideline-eligible heart failure (HF) patients do not receive a survival benefit from implantable cardioverter defibrillators (ICDs). Improved risk stratification may help to reduce costs and improve the cost effectiveness of ICDs.

Objective

To estimate the potential outcomes, costs, and cost effectiveness of using iodine-123 meta-iodobenzylguanidine (I-mIBG) to screen HF patients eligible for an ICD.

Methods

A decision-analytic model was developed to compare screening with I-mIBG imaging and no screening over 2-year and 10-year time horizons from a US payer perspective. Data on I-mIBG imaging and risk stratification were obtained from the ADMIRE-HF/HFX (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) trial. Data on ICD effectiveness for prevention of sudden cardiac death (SCD) were obtained from a meta-analysis. Costs of ICDs and costs of generator and lead procedures were obtained from the Agency for Healthcare Research and Quality National Inpatient Sample. Age-specific mortality was modeled using US life tables and data from the ACT (Advancements in ICD Therapy) Registry on risks of SCD and non-SCD mortality. Sensitivity analyses were conducted.

Results

In the analysis, screening with I-mIBG imaging was associated with a reduction in ICD utilization of 21 %, resulting in a number needed to screen to prevent 1 ICD implantation of 5. Screening reduced the costs per patient by US$5500 and US$13,431 (in 2013 dollars) over 2 and 10 years, respectively, in comparison with no screening and resulted in losses of 0.001 and 0.040 life-years, respectively, over 2 and 10 years. Screening was decrementally cost effective, with savings of US$5,248,404 and US$513,036 per quality-adjusted life-year lost over 2 and 10 years, respectively. In subgroup analyses, cost savings were greater for patients with an ejection fraction (EF) of 25–35 % than for those with an EF <25 %.

Conclusions

According to the model, screening of guideline-eligible patients selected for ICDs with I-mIBG imaging may be cost effective and may help reduce costs associated with implantation of ICDs, with a minimal impact on survival.

     

A cost-utility analysis of ingenol mebutate gel for the treatment of actinic keratosis: a Scottish perspective

Background

Actinic keratosis (AK) is a UV-induced, pre-malignant skin condition that is common in adults over 60 years of age with fair skin in Scotland. The most commonly prescribed first-line treatment for AK in Scotland is currently diclofenac gel (3 %). Ingenol mebutate gel is a recently developed topical therapy available in two strengths for the treatment of AK lesions on the face and scalp (150 mcg/g once daily for 3 consecutive days) or trunk and extremities (500 mcg/g once daily for 2 consecutive days).

Objective

To compare the cost-effectiveness of two strengths of ingenol mebutate gel developed to treat AK lesions on the face and scalp (150 mcg/g once daily for 3 consecutive days) or trunk and extremities (500 mcg/g once daily for 2 consecutive days) with other first-line AK therapies including diclofenac gel, 5-FU, 5-FU/salicylic acid, and cryotherapy for the first-line treatment of AK in adult patients, from the perspective of the National Health Service (NHS) in Scotland.

Methods

A cost-utility analysis was conducted using a decision-tree approach to calculate the costs and benefits of different treatment strategies for AK on the face and scalp or trunk and limbs over a 12-month time horizon. Data on the relative efficacy of treatments were obtained from a systematic literature review and meta-analysis. Utility scores and resource-use data were obtained from published sources.

Results

Over 12 months, ingenol mebutate 150 mcg/g gel and 500 mcg/g gel were cost-effective compared with the most commonly used topical therapy in Scotland, diclofenac (3 %) gel, at a willingness-to-pay threshold of £20,000 per QALY, with a minimal additional cost of £43 and £105, respectively per QALY gained.

Conclusions

Ingenol mebutate gel is a cost-effective therapy for the first-line treatment of AK from a Scottish NHS perspective.

     

Comparative analysis of decision maker preferences for equity/efficiency attributes in reimbursement decisions in three European countries

Background

In addition to cost-effectiveness, national guidelines often include other factors in reimbursement decisions. However, weights attached to these are rarely quantified, thus decisions can depend strongly on decision-maker preferences.

Objective

To explore the preferences of policymakers and healthcare professionals involved in the decision-making process for different efficiency and equity attributes of interventions and to analyse cross-country differences.

Method

Discrete choice experiments (DCEs) were carried out in Austria, Hungary, and Norway with policymakers and other professionals working in the health industry (N = 153 respondents). Interventions were described in terms of different efficiency and equity attributes (severity of disease, target age of the population and willingness to subsidise others, potential number of beneficiaries, individual health benefit, and cost-effectiveness). Parameter estimates from the DCE were used to calculate the probability of choosing a healthcare intervention with different characteristics, and to rank different equity and efficiency attributes according to their importance.

Results

In all three countries, cost-effectiveness, individual health benefit and severity of the disease were significant and equally important determinants of decisions. All countries show preferences for interventions targeting young and middle aged populations compared to those targeting populations over 60. However, decision-makers in Austria and Hungary show preferences more oriented to efficiency than equity, while those in Norway show equal preferences for equity and efficiency attributes.

Conclusion

We find that factors other than cost-effectiveness seem to play an equally important role in decision-making. We also find evidence of cross-country differences in the weight of efficiency and equity attributes.