The cost and cost-effectiveness of an enhanced intervention for people with substance abuse problems at risk for HIV.

OBJECTIVE: To estimate the costs, effectiveness, and cost-effectiveness of prevention interventions for out-of-treatment substance abusers at risk for HIV. This is the first cost-effectiveness study of an AIDS intervention that focuses on drug use as an outcome. STUDY DESIGN: We examined data from the North Carolina Cooperative Agreement site (NC CoOp). All individuals in the study were given the revised NIDA standard intervention and randomly assigned to either a longer, more personalized enhanced intervention or no additional intervention. We estimated the cost of each intervention and, using simple means analysis and multiple regression models, estimated the incremental effectiveness of the enhanced intervention relative to the standard intervention. Finally, we computed cost-effectiveness ratios for several drug use outcomes and compared them to a "back-of-the-envelope" estimate of the benefit of reducing drug use. PRINCIPAL FINDINGS: The estimated cost of implementing the standard intervention is $187.52, and the additional cost of the enhanced intervention is $124.17. Cost-effectiveness ratios range from $35.68 to $139.52 per reduced day of drug use, which are less than an estimate of the benefit per reduced drug day. CONCLUSIONS: The additional cost of implementing the enhanced intervention is relatively small and compares favorably to a rough estimate of the benefits of reduced days of drug use. Thus, the enhanced intervention should be considered an important additional component of an AIDS prevention strategy for out-of-treatment substance abusers.     

Do HEDIS measures reflect cost-effective practices?

PURPOSE: Whether the Health Plan Employer Data and Information Set (HEDIS) performance measures for managed care plans encourage a cost-effective use of society's resources has not been quantified. Our study objectives were to examine the cost-effectiveness evidence for the clinical practices underlying HEDIS 2000 measures and to develop a list of practices not reflected in HEDIS that have evidence of cost effectiveness. DATA SOURCES: Two databases of economic evaluations (Harvard School of Public Health Cost-Utility Registry and the Health Economics Evaluation Database) and two published lists of cost-effectiveness ratios in health and medicine. STUDY SELECTION: For each of the 15 "effectiveness of care" measures in HEDIS 2000, we searched the data through 1998 for cost-effectiveness ratios of similar interventions and target populations. We also searched for important interventions with evidence of cost-effectiveness (<$20,000 per life-year [LY] or quality-adjusted life year [QALY] gained), which are not included in HEDIS. All ratios were standardized to 1998 dollars. The data were collected and analyzed during fall 2000 to summer 2001. DATA EXTRACTION: Cost-effectiveness ratios reporting outcomes in terms of cost/LY or cost/QALY gained were included if they matched the intervention and population covered by the HEDIS measure. DATA SYNTHESIS: Evidence was available for 11 of the 15 HEDIS measures. Cost-effectiveness ranges from cost saving to $660,000/LY gained. There are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors. CONCLUSIONS: HEDIS measures generally reflect cost-effective practices; however, in a number of cases, practices may not be cost effective for certain subgroups. Data quality and availability as well as study perspective remain key challenges in judging cost effectiveness. Opportunities exist to refine existing measures and to develop additional measures, which may promote a more efficient use of societal resources, although more research is needed on whether these measures would also satisfy other desirable attributes of HEDIS.     

Informing Balanced Investment in Services and Health Systems: A Case Study of Priority Setting for Tuberculosis Interventions in South Africa

ObjectivesHealth systems face nonfinancial constraints that can influence the opportunity cost of interventions. Empirical methods to explore their impact, however, are underdeveloped. We develop a conceptual framework for defining health system constraints and empirical estimation methods that rely on routine data. We then present an empirical approach for incorporating nonfinancial constraints in cost-effectiveness models of health benefit packages for the health sector.MethodsWe illustrate the application of this approach through a case study of defining a package of services for tuberculosis case-finding in South Africa. An economic model combining transmission model outputs with unit costs was developed to examine the cost-effectiveness of alternative screening and diagnostic algorithms. Constraints were operationalized as restrictions on achievable coverage based on: (1) financial resources; (2) human resources; and (3) policy constraints around diagnostics purchasing. Cost-effectiveness of the interventions was assessed under one “unconstrained” and several “constrained” scenarios. For the unconstrained scenario, incremental cost-effectiveness ratios were estimated with and without the costs of “relaxing” constraints.ResultsWe find substantial differences in incremental cost-effectiveness ratios across scenarios, leading to variations in the decision rules for prioritizing interventions. In constrained scenarios, the limiting factor for most interventions was not financial, but rather the availability of human resources.ConclusionsWe find that optimal prioritization among different tuberculosis control strategies in South Africa is influenced by whether and how constraints are taken into consideration. We thus demonstrate both the importance and feasibility of considering nonfinancial constraints in health sector resource allocation models.     

Development of WHO guidelines on generalized cost-effectiveness analysis

The growing use of cost-effectiveness analysis (CEA) to evaluate specific interventions is dominated by studies of prospective new interventions compared with current practice. This type of analysis does not explicitly take a sectoral perspective in which the costs and effectiveness of all possible interventions are compared, in order to select the mix that maximizes health for a given set of resource constraints. WHO guidelines on generalized CEA propose the application of CEA to a wide range of interventions to provide general information on the relative costs and health benefits of different interventions in the absence of various highly local decision constraints. This general approach will contribute to judgements on whether interventions are highly cost-effective, highly cost-ineffective, or something in between. Generalized CEAs require the evaluation of a set of interventions with respect to the counterfactual of the null set of the related interventions, i.e. the natural history of disease. Such general perceptions of relative cost-effectiveness, which do not pertain to any specific decision-maker, can be a useful reference point for evaluating the directions for enhancing allocative efficiency in a variety of settings. The proposed framework allows the identification of current allocative inefficiencies as well as opportunities presented by new interventions.     

The cost-effectiveness of home assessment and modification to reduce falls in the elderly

Injury sustained through falling is a significant risk for the elderly and a significant burden on the health service. Although many risk factors have been detected and interventions proposed, there remains limited evidence concerning the cost-effectiveness of fall prevention. This study addressed the cost-effectiveness of a home assessment and modification program hypothesised to reduce risk of falling for the independent elderly. Due to a lack of direct clinical trial evidence concerning such an intervention, a decision analytic model was developed to simulate the potential costs and outcomes of the intervention. The model was developed using available published literature concerning injury in the elderly, focusing on Australian data where possible. Cost-effectiveness was estimated as the cost per fall prevented and cost per injury prevented. Over a one-year period, the incremental cost of introducing the intervention was $172 per person, resulting in an incremental cost per fall prevented of $1,721 and cost per injury prevented of $17,208. Over a 10-year period, the intervention resulted in a cost saving of $92 per person (i.e. dominance, with cost savings in addition to reduced falls and injuries). This analysis indicates that there is potential for considerable benefit to be gained from this intervention, in terms of less morbidity, fewer hospitalisations and, possibly, improved quality of life. However, these results are based on a model constructed from various data sources and assumptions so, although results are indicative, further research is required to provide firm data before definitive policy conclusions and recommendations may be made.     

Cost-effectiveness analysis of a family physician delivered smoking cessation program

OBJECTIVES: The objectives were to present a cost-effectiveness analysis of a smoking cessation program delivered by physicians and compare results to other smoking cessation interventions. METHODS: Retrospective effectiveness figures from a previous evaluation of the smoking cessation program were supplemented with estimates based on researched assumptions. Net abstinence rates were determined for smokers, depending on their stage of readiness to quit, that is, "prepared," "contemplative," and "precontemplative," leading to an assessment of the number of smokers achieving abstinence as a result of the Smokescreen intervention. Costs were calculated from the perspectives of smokers, family physicians, organizers, trainers, and all parties combined. Assumptions were varied with a sensitivity analysis. RESULTS: Baseline costs per additional abstainer were $183 based on physicians' intervention costs at 1995 prices. This is the figure most comparable to previously conducted economic evaluations of smoking cessation interventions. Sensitivity analysis varying the perspective and under optimistic and pessimistic assumptions about effectiveness produced a wide variety of estimates. The decision to include or exclude training costs had a particularly important bearing on the estimates. However, under reasonable assumptions the cost per additional quitter compares favorably to smoking and other medical and health care interventions worldwide. CONCLUSIONS: The program appears cost-effective when compared to other smoking cessation and health promotion interventions and illustrates the potential for retrospective cost-effectiveness analysis of interventions.     

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.     

Reporting the cost-effectiveness of interventions with nonsignificant effect differences: example from a trial of secondary prevention of coronary heart disease

OBJECTIVES: This study reports the cost-effectiveness of interventions with nonsignificant differences in effect, and considers reporting of cost-effectiveness in situations where nonsignificant differences arise in some but not all end points. METHODS: Data on costs and effects associated with three end points (adequate assessment, risk factors, and life-years) were derived from a trial of methods to promote secondary prevention of coronary heart disease. Incremental cost per life-year gained figures were calculated, and the uncertainty around these was displayed on cost-effectiveness planes in the form of ellipses. RESULTS: There was a significant difference in one of the intermediate end points (adequate assessment) but nonsignificant differences in the other intermediate end point (risk factors) and the final end point (life-years). Estimation of cost per life-year figures revealed the cost-effectiveness of the interventions to be unfavorable. CONCLUSIONS: Cost-effectiveness ratios based on final end points should be calculated even in situations where nonsignificant differences in life-years arise, to avoid publication bias and to provide decision makers with useful information. Uncertainty in the incremental cost-effectiveness ratios should be estimated and presented graphically.     

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

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

Uncertainty in cost-effectiveness analysis. Probabilistic uncertainty analysis and stochastic league tables

Interest is growing in the application of standard statistical inferential techniques to the calculation of cost-effectiveness ratios (CER), but individual level data will not be available in many cases because it is very difficult to undertake prospective controlled trials of many public health interventions. We propose the application of probabilistic uncertainty analysis using Monte Carlo simulations, in combination with nonparametric bootstrapping techniques where appropriate. This paper also discusses how decision makers should interpret the CER of interventions where uncertainty intervals overlap. We show how the incorporation of uncertainty around costs and effects of interventions into a stochastic league table provides additional information to decision makers for priority setting. Stochastic league tables inform decision makers about the probability that a specific intervention would be included in the optimal mix of interventions for different resource levels, given the uncertainty surrounding the interventions.     

Achievable Cost Saving and Cost-Effective Thresholds for Diabetes Prevention Lifestyle Interventions in People Aged 65 Years and Older: A Single-Payer Perspective

BackgroundMore than 75% of people older than 65 years of age in the United States have prediabetes or diabetes. Diabetes is a burden on Medicare, the US health care payer. Intensive lifestyle interventions have successfully prevented diabetes cases, and medical nutrition therapy has also significantly reduced diabetes risk factors. Including medical nutrition therapy coverage for prediabetes is a policy decision to be made by Medicare, and cost-effectiveness data must support that decision.ObjectiveThe aims of this study were to determine the thresholds of diabetes cases that need to be averted by prediabetes lifestyle interventions in order to be cost saving and/or cost-effective to a single health care insurance payer, such as Medicare; and to compare those thresholds with published intervention data to determine the feasibility of cost savings and/or cost-effectiveness.DesignThis analysis used standard methods of cost-effectiveness and cost saving analysis. A health system perspective was used. Cost estimates for diabetes treatment and lifestyle interventions were based on published data. Costs for 3-, 6-, and 10-year lifestyle interventions were calculated. Sensitivity analyses were performed using least and most-conservative published data for health care and intervention costs.ResultsThe number of cases averted needed for base-case cost savings ranged from 882,883 to 2,443,686, and in sensitivity analysis from 394,148 to 6,738,678. Cost savings are likely in the base and least-conservative scenarios. The number of cases averted needed for base-case cost-effectiveness ranged from 454,755 to 1,258,692, and in sensitivity analysis from 212,225 to 4,843,262. Cost-effectiveness is likely in all interventions, except the 10-year interventions in the most-conservative scenario.ConclusionsPrediabetes lifestyle interventions for people aged 65 years or older are highly cost-effective and possibly cost saving to a health care insurance payer such as Medicare. It is likely that medical nutrition therapy could be even more cost saving and/or cost-effective than intensive lifestyle interventions. These results suggest that Medicare would receive financial benefit from providing coverage for these services.     

The cost-effectiveness of forty health interventions in Guinea

Addressing diseases of a high burden with the most cost-effective interventions could do much to reduce disease in the population. We conducted a cost-effectiveness analysis of 40 health interventions in Guinea, a low-income country in sub-Saharan Africa, using local data. Interventions were selected from treatment protocols at health centres, first referral hospitals and national programmes in Guinea, based upon consultation with health care providers and government plans. For each intervention, we calculated the costs (comprising labour, drugs, supplies, equipment, and overhead) in relation to years of life saved, discounted at 3%. The results show that the per capita costs and effectiveness of any intervention vary considerably. Average costs show no clear pattern by level of care, but effectiveness is generally highest for curative hospital interventions. Several interventions have a cost-effectiveness of US$100 per year of life saved (LYS) or less, and address more than 5% of total years of life lost. These include health centre interventions such as: treatment of childhood pneumonia ($3/LYS); rehydration therapy for diarrhoea ($7/LYS); integrated management of childhood pneumonia, malaria and diarrhoea ($8/LYS); short-course treatment of tuberculosis ($12/LYS); treatment of childhood malaria ($13/LYS), and childhood vaccination ($25/LYS). Outreach programmes for impregnated bed nets against malaria cost $43/LYS. Maternal and perinatal diseases, have slightly less cost-effective interventions: integrated family planning, prenatal and delivery care at health centres ($109/LYS) or outreach programmes to provide prenatal and delivery care ($283/LYS). A minimum package of health services would cost approximately $13 per capita, and would address a large proportion (69%) of major causes of premature mortality. This minimum package would cost about three times the current public spending on health, suggesting that health spending needs to rise to achieve good health outcomes.     

Breastfeeding promotion and priority setting in health

An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost-effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost-effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost-effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each.     

Cost-effectiveness of a supplementary class-based exercise program in the treatment of knee osteoarthritis

OBJECTIVES: The aim of this study was to assess the cost-effectiveness of a class-based exercise program supplementing a home-based program when compared with a home-based program alone. In addition, we estimated the probability that the supplementary class program is cost-effective over a range of values of a decision maker's willingness to pay for an additional quality-adjusted life-year (QALY). METHODS: The resource use and effectiveness data were collected as part of the clinical trial detailed elsewhere. Unit costs were estimated from published sources. The net benefit approach to cost-effectiveness analysis is used to estimate the probability of the intervention being cost-effective. RESULTS: The addition of a supplementary class-based group results in an increase in QALYs and lower costs. For all plausible values of a decision maker's willingness to pay for a QALY, the supplementary class group is likely to be cost-effective. CONCLUSIONS: The addition of a class-based exercise program is likely to be cost-effective and, on current evidence, should be implemented.     

DM3 Outcomes Research in Medication use: Hcfa''s Health Care Quality Improvement Program

The objective of public policy decision making is to choose the set of interventions that maximize the net benefit to society. Given a set of mutually exclusive interventions, the one with the lowest cost-effectiveness ratio is not necessarily the one that maximizes net benefit. Thus, a treatment with a higher cost-effectiveness ratio compared to baseline may result in higher net benefits if its incremental cost-effectiveness is less than the dollar value of the outcome. In this presentation we describe how to use cost-effectiveness results to determine the intervention that maximizes net benefit. We also show how cost-effectiveness results can be used to determine threshold values for the benefit than another. We then examine the effect of budget constraints on this decision making problem. We also present a graphical means of representing cost-effectiveness results that allow for easy interpretation and use of the results. We describe a simple rule for identifying the net benefit maximizing intervention from this graph. We will illustrate the issue discussed using examples from the medical literature. This workshop should be beneficial to health care decision makers who have to interpret cost-effectiveness results and incorporate them in their decision making process.     

Cost-utility analyses of clinical preventive services: published ratios, 1976-1997

BACKGROUND: Cost-effectiveness analyses of clinical preventive services are a potential means to aid public health resource allocation. Cost-utility analysis (CUA) is a specific form of cost-effectiveness analysis where results are expressed in terms of cost per quality-adjusted life year (QALY) gained. To increase the transparency and comparability of CUAs, standardization of methods has been recommended. OBJECTIVES: The purposes of this study were as follows: (1) identify published articles with original CUAs of primary and secondary clinical preventive services, (2) summarize the ratios found in these analyses, (3) identify articles employing comparable methods, and (4) explore analytic methods employed over time. METHODS: As part of a larger study we conducted a comprehensive search of published CUAs in the area of clinical preventive services and systematically collected data on the results of the analyses and analytic methods employed. Cost-effectiveness ratios were standardized and organized into a table.Results: We found 50 CUAs pertaining to clinical preventive services (primary, n=22, 44%; and secondary, n=28, 56%) and 174 cost-effectiveness ratios. These ratios ranged from cost-savings up to $27,000,000/QALY, with a median of $14,000/QALY. Only three (6%) of the CUAs met minimum reference case requirements. There was no apparent improvement of methods over time. CONCLUSIONS: Immunizations and chemoprophylaxis have the most favorable cost-effectiveness ratios, and preventive services are more cost-effective when targeted at high-risk populations. However, there is wide variation in the methods used in these analyses. This study allows us to define where improvements in methodologic rigor need to occur, provides a base-line for future audits, and highlights disease areas in clinical preventive services that have been omitted or underevaluated.     

Health interventions for the metal working industry: which is the most cost-effective? A study from a developing country

This study ranked the cost-effectiveness of health interventions in the metal working industry in a developing country. Data were based on 82 034 workers of the Northern region of Mexico. Effectiveness was measured through 'healthy life years' (HeaLYs) gained. Costs were estimated per worker according to type and appropriate inputs from selected health interventions. 'Hand' was the anatomical region that yielded the most gain of HeaLYs and amputation was the injury that yielded the most gain of HeaLYs. The most effective health intervention corresponded to training, followed by medical care, education, helmets, safety shoes, lumbar supports, safety goggles, gloves and safety aprons. In dollar terms, education presented the best cost-effectiveness ratio (US$637) and safety aprons presented the worst cost-effectiveness ratio (US$1 147 770). Training proved to be a very expensive intervention, but presented the best effectiveness outcome and the second best cost-effectiveness ratio (US$2084). Cost-effectiveness analyses in developing countries are critical. Corporations might not have the same funds and technology as those in developed countries or multinational companies.     

Cost-utility analysis of interferon beta-1b in secondary progressive multiple sclerosis

OBJECTIVES: Interferon beta-1b has recently become available for the treatment of secondary progressive multiple sclerosis (SPMS). This study aims at estimating the cost-effectiveness of this new treatment that has been shown in a clinical trial to reduce the progression of the disease. Effectiveness is measured as the number of quality-adjusted life-years (QALYs) gained from the reduction in progression. Because the clinical trial period will only capture part of the treatment's effect in terms of QALYs gained, since benefits achieved during the trial will have an effect beyond it, the cost-effectiveness analysis involves modeling over the longer term using complementary data. METHODS: A Markov model with states based on disability expressed by EDSS scores was used. Transition probabilities were calculated directly from clinical trial data for the first 3 years and then extrapolated to 10 years. Mean costs and utilities for each Markov state were calculated from a population-based cross-sectional study in Sweden. RESULTS: The incremental cost per QALY is SEK 342,700 (US $39,250; US $1 = SEK 8.73, March 10, 2000) when all costs (direct, informal care, and indirect) are included (discounted 3%). When indirect costs are excluded, the cost per QALY is SEK 542,000 ($62,100). CONCLUSIONS: Cost-effectiveness analysis in SPMS requires that the effect of treatment beyond clinical trials be included. Also, analysis should be done from a societal perspective, since many of the costs occur outside the healthcare system. The cost-utility ratios estimated in this analysis are at or below the mean threshold value indicated in a recent survey of health economists ($60,000).     

Cost-Utility Analyses in Diabetes: A Systematic Review and Implications from Real-World Evidence

ObjectivesTo systematically review the cost-effectiveness of diabetes interventions, identify high-value diabetes services, and estimate potential gains from increasing their utilization.MethodsThe study consisted of two steps. First, we reviewed cost-utility analyses (CUAs) related to diabetes published through the end of 2012, using the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org). We used logistic regression to examine factors independently associated with favorable cost-effective ratios. Second, we used the Humedica electronic medical records to estimate potential savings and health benefits gained by shifting patients currently receiving low-value services to high-value alternatives.ResultsWe identified 196 diabetes CUAs, of which 55% examined pharmaceuticals. Most (70%) diabetes CUAs focused on treatment rather than prevention. Most used a health care payer perspective and were industry-sponsored. Of the 497 published cost-utility ratios, 82% examined an intervention recommended by diabetes guidelines. Approximately 73% of the interventions were cost-saving or below $50,000 per quality-adjusted life-year. Logistic regression analysis showed that higher-quality CUAs, CUAs conducted from the US perspective, surgical interventions, and guideline-recommended interventions were more likely to report favorable ratios. Of the 7907 eligible patients with diabetes in our sample, up to 7117 could in principle be shifted to cost-saving treatments, reducing costs by $12.5 million and gaining more than 1938 quality-adjusted life-years over a lifetime.ConclusionsMost diabetes interventions evaluated by CUAs are recommended by practice guidelines and may provide good value for money. Our results indicate that patients with diabetes and the health care system could potentially benefit from shifting to the greater use of high-value services.     

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.