Systematic Review of the Cost and Cost-Effectiveness of Rapid Endovascular Therapy for Acute Ischemic Stroke.

PubMed

Sevick, Laura K; Ghali, Sarah; Hill, Michael D; Danthurebandara, Vishva; Lorenzetti, Diane L; Noseworthy, Tom; Spackman, Eldon; Clement, Fiona

2017-09-01

Rapid endovascular therapy (EVT) is an emerging treatment option for acute ischemic stroke. Several economic evaluations have been published examining the cost-effectiveness of EVT, and many international bodies are currently making adoption decisions. The objective of this study was to establish the cost-effectiveness of EVT for ischemic stroke patients and to synthesize all the publicly available economic literature. A systematic review of the published literature was conducted to identify economic evaluations and cost analyses of EVT for acute ischemic stroke patients. Systematic review best practices were followed, and study quality was assessed. Four-hundred sixty-three articles were identified from electronic databases. After deduplication, abstract review, and full-text review, 17 studies were included. Seven of the studies were cost analyses, and 10 were cost-effectiveness studies. Generally, the cost analyses reported on the cost of the approach/procedure or the hospitalization costs associated with EVT. All of the cost-effectiveness studies reported a cost per quality-adjusted life year as the primary outcomes. Studies varied in regards to the costs considered, the perspective adopted, and the time horizon used. All the studies reported a cost per quality-adjusted life year of <$50 000 as the primary outcome. There is a robust body of evidence for the cost and cost-effectiveness of EVT. The cost analyses suggested that although EVT was associated with higher costs, it also resulted in improved patient outcomes. From the cost-effectiveness studies, EVT seems to be good value for money when a threshold of $50 000 per quality-adjusted life year gained is adopted. © 2017 American Heart Association, Inc.

The cost-effectiveness of an intensive treatment protocol for severe dyslexia in children.

PubMed

Hakkaart-van Roijen, Leona; Goettsch, Wim G; Ekkebus, Michel; Gerretsen, Patty; Stolk, Elly A

2011-08-01

Studies of interventions for dyslexia have focused entirely on outcomes related to literacy. In this study, we considered a broader picture assessing improved quality of life compared with costs. A model served as a tool to compare costs and effects of treatment according to a new protocol and care as usual. Quality of life was measured and valued by proxies using a general quality-of-life instrument (EQ-5D). We considered medical cost and non-medical cost (e.g. remedial teaching). The model computed cost per successful treatment and cost per quality adjusted life year (QALY) in time. About 75% of the total costs was related to diagnostic tests to distinguish between children with severe dyslexia and children who have reading difficulties for other reasons. The costs per successful treatment of severe dyslexia were €36 366. Successful treatment showed a quality-of-life gain of about 11%. At primary school, the average cost per QALY for severe dyslexia amounted to €58 647. In the long term, the cost per QALY decreased to €26 386 at secondary school and €17 663 thereafter. The results of this study provide evidence that treatment of severe dyslexia is cost-effective when the investigated protocol is followed. Copyright © 2011 John Wiley & Sons, Ltd.

A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis

PubMed Central

Barasa, Edwine W.; Ayieko, Philip; Cleary, Susan; English, Mike

2012-01-01

Background To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale. Methods and Findings Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3. Conclusion Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions. Please see later in the article for the Editors' Summary PMID:22719233

A multifaceted intervention to improve the quality of care of children in district hospitals in Kenya: a cost-effectiveness analysis.

PubMed

Barasa, Edwine W; Ayieko, Philip; Cleary, Susan; English, Mike

2012-01-01

To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale. Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26-67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67-47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19-2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A "what-if" analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3. Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions.

The costs, effects and cost-effectiveness of strategies to increase coverage of routine immunizations in low- and middle-income countries: systematic review of the grey literature.

PubMed

Batt, Katherine; Fox-Rushby, J A; Castillo-Riquelme, Marianela

2004-09-01

Evidence-based reviews of published literature can be subject to several biases. Grey literature, however, can be of poor quality and expensive to access. Effective search strategies also vary by topic and are rarely known in advance. This paper complements a systematic review of the published literature on the costs and effects of expanding immunization services in developing countries. The quality of data on the effectiveness and cost-effectiveness of strategies to increase immunization coverage is shown to be similar across literatures, but the quality of information on costing is much lower in the grey literature. After excluding poorer quality studies from this review we found the quantity of available evidence almost doubled, particularly for more complex health-system interventions and cost or cost-effectiveness analyses. Interventions in the grey literature are more up to date and cover a different geographical spread. Consequently the conclusions of the published and grey literatures differ, although the number of papers is still too low to account for differences across types of interventions. We recommend that in future researchers consider using non-English keywords in their searches.

The costs, effects and cost-effectiveness of strategies to increase coverage of routine immunizations in low- and middle-income countries: systematic review of the grey literature.

PubMed Central

Batt, Katherine; Fox-Rushby, J. A.; Castillo-Riquelme, Marianela

2004-01-01

Evidence-based reviews of published literature can be subject to several biases. Grey literature, however, can be of poor quality and expensive to access. Effective search strategies also vary by topic and are rarely known in advance. This paper complements a systematic review of the published literature on the costs and effects of expanding immunization services in developing countries. The quality of data on the effectiveness and cost-effectiveness of strategies to increase immunization coverage is shown to be similar across literatures, but the quality of information on costing is much lower in the grey literature. After excluding poorer quality studies from this review we found the quantity of available evidence almost doubled, particularly for more complex health-system interventions and cost or cost-effectiveness analyses. Interventions in the grey literature are more up to date and cover a different geographical spread. Consequently the conclusions of the published and grey literatures differ, although the number of papers is still too low to account for differences across types of interventions. We recommend that in future researchers consider using non-English keywords in their searches. PMID:15628207

[Threshold value for reimbursement of costs of new drugs: cost-effectiveness research and modelling are essential links].

PubMed

Frederix, Geert W J; Hövels, Anke M; Severens, Johan L; Raaijmakers, Jan A M; Schellens, Jan H M

2015-01-01

There is increasing discussion in the Netherlands about the introduction of a threshold value for the costs per extra year of life when reimbursing costs of new drugs. The Medicines Committee ('Commissie Geneesmiddelen'), a division of the Netherlands National Healthcare Institute ('Zorginstituut Nederland'), advises on reimbursement of costs of new drugs. This advice is based upon the determination of therapeutic value of the drug and the results of economic evaluations. Mathematical models that predict future costs and effectiveness are often used in economic evaluations; these models can vary greatly in transparency and quality due to author assumptions. Standardisation of cost-effectiveness models is one solution to overcome the unwanted variation in quality. Discussions about the introduction of a threshold value can only be meaningful if all involved are adequately informed, and by high quality in cost-effectiveness research and, particularly, economic evaluations. Collaboration and discussion between medical specialists, patients or patient organisations, health economists and policy makers, both in development of methods and in standardisation, are essential to improve the quality of decision making.

Do the potential benefits of metal-on-metal hip resurfacing justify the increased cost and risk of complications?

PubMed

Bozic, Kevin J; Pui, Christine M; Ludeman, Matthew J; Vail, Thomas P; Silverstein, Marc D

2010-09-01

Metal-on-metal hip resurfacing arthroplasty (MoM HRA) may offer potential advantages over total hip arthroplasty (THA) for certain patients with advanced osteoarthritis of the hip. However, the cost effectiveness of MoM HRA compared with THA is unclear. The purpose of this study was to compare the clinical effectiveness and cost-effectiveness of MoM HRA to THA. A Markov decision model was constructed to compare the quality-adjusted life-years (QALYs) and costs associated with HRA versus THA from the healthcare system perspective over a 30-year time horizon. We performed sensitivity analyses to evaluate the impact of patient characteristics, clinical outcome probabilities, quality of life and costs on the discounted incremental costs, incremental clinical effectiveness, and the incremental cost-effectiveness ratio (ICER) of HRA compared to THA. MoM HRA was associated with modest improvements in QALYs at a small incremental cost, and had an ICER less than $50,000 per QALY gained for men younger than 65 and for women younger than 55. MoM HRA and THA failure rates, device costs, and the difference in quality of life after conversion from HRA to THA compared to primary THA had the largest impact on costs and quality of life. MoM HRA could be clinically advantageous and cost-effective in younger men and women. Further research on the comparative effectiveness of MoM HRA versus THA should include assessments of the quality of life and resource use in addition to the clinical outcomes associated with both procedures. Level I, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.

Cost-effectiveness of lobectomy versus genetic testing (Afirma®) for indeterminate thyroid nodules: Considering the costs of surveillance.

PubMed

Balentine, Courtney J; Vanness, David J; Schneider, David F

2018-01-01

We evaluated whether diagnostic thyroidectomy for indeterminate thyroid nodules would be more cost-effective than genetic testing after including the costs of long-term surveillance. We used a Markov decision model to estimate the cost-effectiveness of thyroid lobectomy versus genetic testing (Afirma®) for evaluation of indeterminate (Bethesda 3-4) thyroid nodules. The base case was a 40-year-old woman with a 1-cm indeterminate nodule. Probabilities and estimates of utilities were obtained from the literature. Cost estimates were based on Medicare reimbursements with a 3% discount rate for costs and quality-adjusted life-years. During a 5-year period after the diagnosis of indeterminate thyroid nodules, lobectomy was less costly and more effective than Afirma® (lobectomy: $6,100; 4.50 quality-adjusted life- years vs Afirma®: $9,400; 4.47 quality-adjusted life-years). Only in 253 of 10,000 simulations (2.5%) did Afirma® show a net benefit at a cost-effectiveness threshold of $100,000 per quality- adjusted life-years. There was only a 0.3% probability of Afirma® being cost saving and a 14.9% probability of improving quality-adjusted life-years. Our base case estimate suggests that diagnostic lobectomy dominates genetic testing as a strategy for ruling out malignancy of indeterminate thyroid nodules. These results, however, were highly sensitive to estimates of utilities after lobectomy and living under surveillance after Afirma®. Published by Elsevier Inc.

A systematic review of quality and cost-effectiveness derived from Markov models evaluating smoking cessation interventions in patients with chronic obstructive pulmonary disease.

PubMed

Kirsch, Florian

2015-04-01

Smoking cessation is the only strategy that has shown a lasting reduction in the decline of lung function in patients with chronic obstructive pulmonary disease. This study aims to evaluate the cost-effectiveness of smoking cessation interventions in patients with chronic obstructive pulmonary disease, to assess the quality of the Markov models and to estimate the consequences of model structure and input data on cost-effectiveness. A systematic literature search was conducted in PubMed, Embase, BusinessSourceComplete and Econlit on June 11, 2014. Data were extracted, and costs were inflated. Model quality was evaluated by a quality appraisal, and results were interpreted. Ten studies met the inclusion criteria. The results varied widely from cost savings to additional costs of €17,004 per quality adjusted life year. The models scored best in the category structure, followed by data and consistency. The quality of the models seems to rise over time, and regarding the results there is no economic reason to refuse the reimbursement of any smoking cessation intervention.

Analyses of Blood Bank Efficiency, Cost-Effectiveness and Quality

NASA Astrophysics Data System (ADS)

Lam, Hwai-Tai Chen

In view of the increasing costs of hospital care, it is essential to investigate methods to improve the labor efficiency and the cost-effectiveness of the hospital technical core in order to control costs while maintaining the quality of care. This study was conducted to develop indices to measure efficiency, cost-effectiveness, and the quality of blood banks; to identify factors associated with efficiency, cost-effectiveness, and quality; and to generate strategies to improve blood bank labor efficiency and cost-effectiveness. Indices developed in this study for labor efficiency and cost-effectiveness were not affected by patient case mix and illness severity. Factors that were associated with labor efficiency were identified as managerial styles, and organizational designs that balance workload and labor resources. Medical directors' managerial involvement was not associated with labor efficiency, but their continuing education and specialty in blood bank were found to reduce the performance of unnecessary tests. Surprisingly, performing unnecessary tests had no association with labor efficiency. This suggested the existence of labor slack in blood banks. Cost -effectiveness was associated with workers' benefits, wages, and the production of high-end transfusion products by hospital-based donor rooms. Quality indices used in this study included autologous transfusion rates, platelet transfusion rates, and the check points available in an error-control system. Because the autologous transfusion rate was related to patient case mix, severity of illness, and possible inappropriate transfusion, it was not recommended to be used for quality index. Platelet-pheresis transfusion rates were associated with the transfusion preferences of the blood bank medical directors. The total number of check points in an error -control system was negatively associated with government ownership and workers' experience. Recommendations for improving labor efficiency and cost-effectiveness were focused on an incentive system that encourages team effort, and the use of appropriate measurements for laboratory efficiency and operational system designs.

A Cost-effectiveness Analysis of Ferric Carboxymaltose in Patients With Iron Deficiency and Chronic Heart Failure in Spain.

PubMed

Comín-Colet, Josep; Rubio-Rodríguez, Darío; Rubio-Terrés, Carlos; Enjuanes-Grau, Cristina; Gutzwiller, Florian S; Anker, Stefan D; Ponikowski, Piotr

2015-10-01

Treatment with ferric carboxymaltose improves symptoms, functional capacity, and quality of life in patients with chronic heart failure and iron deficiency. The aim of this study was to assess the cost-effectiveness of ferric carboxymaltose treatment vs no treatment in these patients. We used an economic model based on the Spanish National Health System, with a time horizon of 24 weeks. Patient characteristics and ferric carboxymaltose effectiveness (quality-adjusted life years) were taken from the Ferinject® Assessment in patients with IRon deficiency and chronic Heart Failure trial. Health care resource use and unit costs were taken either from Spanish sources, or from the above mentioned trial. In the base case analysis, patients treated with and without ferric carboxymaltose treatment acquired 0.335 and 0.298 quality-adjusted life years, respectively, representing a gain of 0.037 quality-adjusted life years for each treated patient. The cost per patient was €824.17 and €597.59, respectively, resulting in an additional cost of €226.58 for each treated patient. The cost of gaining 1 quality adjusted life year with ferric carboxymaltose was €6123.78. Sensitivity analyses confirmed the robustness of the model. The probability of ferric carboxymaltose being cost-effective (< €30 000 per quality-adjusted life year) and dominant (more effective and lower cost than no treatment) was 93.0% and 6.6%, respectively. Treatment with ferric carboxymaltose in patients with chronic heart failure and iron deficiency, with or without anemia, is cost-effective in Spain. Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

A cost-effectiveness analysis of hormone replacement therapy in the menopause.

PubMed

Cheung, A P; Wren, B G

1992-03-02

To evaluate the cost-effectiveness of hormone replacement therapy in the menopause with particular reference to osteoporotic fracture and myocardial infarction. The multiple-decrement form of the life table was the mathematical model used to follow women of age 50 through their lifetime under the "no hormone replacement" and "hormone replacement" assumptions. Standard demographic and health economic techniques were used to calculate the corresponding lifetime differences in direct health care costs (net costs in dollars) and health effects ("net effectiveness" in terms of life expectancy and quality, in "quality-adjusted life-years"). This was then expressed as a cost-effectiveness ratio or the cost ($) per quality-adjusted life-year (QALY) for each of the chosen hormone replacement regimens. All women of age 50 in New South Wales, Australia (n = 27,021). The analysis showed that the lifetime net increments in direct medical care costs were largely contributed by hormone drug and consultation costs. Hormone replacement was associated with increased quality-adjusted life expectancy, a large percentage of which was attributed to a relief of menopausal symptoms. Cost-effectiveness ratios ranged from under 10,000 to over a million dollars per QALY. Factors associated with improved cost-effectiveness were prolonged treatment duration, the presence of menopausal symptoms, minimum progestogen side effects (in the case of oestrogen with progestogen regimens), oestrogen use after hysterectomy and the inclusion of cardiac benefits in addition to fracture prevention. Hormone replacement therapy for symptomatic women is cost-effective when factors that enhance its efficiency are considered. Short-term treatment of asymptomatic women for prevention of osteoporotic fractures and myocardial infarction is an inefficient use of health resources. Cost-effectiveness of hormone replacement in asymptomatic women is dependent on the magnitude of cardiac benefits associated with hormone use and the treatment duration.

Economic Assessment and Budgetary Impact of a Telemedicine Procedure and Spirometry Quality Control in the Primary Care Setting.

PubMed

Marina, Nuria; Bayón, Juan Carlos; López de Santa María, Elena; Gutiérrez, Asunción; Inchausti, Marta; Bustamante, Victor; Gáldiz, Juan B

2016-01-01

To evaluate the economic impact of a telemedicine procedure designed to improve the quality of lung function testing (LFT) in primary care in a public healthcare system, compared with the standard method. The economic impact of 9,039 LFTs performed in 51 health centers (2010-2013) using telespirometry (TS) compared to standard spirometry (SS) was studied. TS costs more per unit than SS (€47.80 vs. €39.70) (2013), but the quality of the TS procedure is superior (84% good quality, compared to 61% using the standard procedure). Total cost of TS was €431,974 (compared with €358,306€ for SS), generating an economic impact of €73,668 (2013). The increase in cost for good quality LFT performed using TS was €34,030 (2010) and €144,295 (2013), while the costs of poor quality tests fell by €15,525 (2010) and 70,627€ (2013). The cost-effectiveness analysis concludes that TS is 23% more expensive and 46% more effective. Healthcare costs consequently fall as the number of LFTs performed by TS rises. Avoiding poor quality, invalid LFTs generates savings that compensate for the increased costs of performing LFTs with TS, making it a cost-effective method. Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.

Cost-effectiveness of a quality improvement collaborative for obstetric and newborn care in Niger.

PubMed

Broughton, Edward; Saley, Zakari; Boucar, Maina; Alagane, Dondi; Hill, Kathleen; Marafa, Aicha; Asma, Yaroh; Sani, Karimou

2013-01-01

The purpose of this paper is to describe a quality improvement collaborative conducted in 33 Nigerian facilities to improve maternal and newborn care outcomes by increasing compliance with high-impact, evidence-based care standards. Intervention costs and cost-effectiveness were examined and costs to the Niger Health Ministry (MoH) were estimated if they were to scale-up the intervention to additional sites. Facility-based maternal care outcomes and costs from pre-quality improvement collaborative baseline monitoring data in participating facilities from January to May 2006 were compared with outcomes and costs from the same facilities from June 2008 to September 2008. Cost data were collected from project accounting records. The MoH costs were determined from interviews with clinic managers and quality improvement teams. Effectiveness data were obtained from facilities' records. The average delivery-cost decreased from $35 before to $28 after the collaborative. The USAID/HCI project's incremental cost was $2.43/delivery. The collaborative incremental cost-effectiveness was $147/disability-adjusted life year averted. If the MoH spread the intervention to other facilities, substantive cost-savings and improved health outcomes can be predicted. The intervention achieved significant positive health benefits for a low cost. The Niger MoH can expect approximately 50 per cent return on its investment if it implements the collaborative in new facilities. The improvement collaborative approach can improve health and save health care resources. This is one of the first studies known to examine collaborative quality improvement and economic efficiency in a developing country.

The cost-effectiveness of semi-rigid ankle brace to facilitate return to work following first-time acute ankle sprains.

PubMed

Fatoye, Francis; Haigh, Carol

2016-05-01

To examine the cost-effectiveness of semi-rigid ankle brace to facilitate return to work following first-time acute ankle sprains. Economic evaluation based on cost-utility analysis. Ankle sprains are a source of morbidity and absenteeism from work, accounting for 15-20% of all sports injuries. Semi-rigid ankle brace and taping are functional treatment interventions used by Musculoskeletal Physiotherapists and Nurses to facilitate return to work following acute ankle sprains. A decision model analysis, based on cost-utility analysis from the perspective of National Health Service was used. The primary outcomes measure was incremental cost-effectiveness ratio, based on quality-adjusted life years. Costs and quality of life data were derived from published literature, while model clinical probabilities were sourced from Musculoskeletal Physiotherapists. The cost and quality adjusted life years gained using semi-rigid ankle brace was £184 and 0.72 respectively. However, the cost and quality adjusted life years gained following taping was £155 and 0.61 respectively. The incremental cost-effectiveness ratio for the semi-rigid brace was £263 per quality adjusted life year. Probabilistic sensitivity analysis showed that ankle brace provided the highest net-benefit, hence the preferred option. Taping is a cheaper intervention compared with ankle brace to facilitate return to work following first-time ankle sprains. However, the incremental cost-effectiveness ratio observed for ankle brace was less than the National Institute for Health and Care Excellence threshold and the intervention had a higher net-benefit, suggesting that it is a cost-effective intervention. Decision-makers may be willing to pay £263 for an additional gain in quality adjusted life year. The findings of this economic evaluation provide justification for the use of semi-rigid ankle brace by Musculoskeletal Physiotherapists and Nurses to facilitate return to work in individuals with first-time ankle sprains. © 2016 John Wiley & Sons Ltd.

When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature.

PubMed

Talmor, Daniel; Shapiro, Nathan; Greenberg, Dan; Stone, Patricia W; Neumann, Peter J

2006-11-01

Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources. To identify published original CEAs presenting cost/quality-adjusted life year or cost/life-year ratios for treatments used in intensive care units, to summarize the results in an accessible format, and to identify areas in critical care medicine that merit further economic evaluation. We conducted a systematic search of the English-language literature for original CEAs of critical care interventions published from 1993 through 2003. We collected data on the target population, therapy or program, study results, analytic methods employed, and the cost-effectiveness ratios presented. We identified 19 CEAs published through 2003 with 48 cost-effectiveness ratios pertaining to treatment of severe sepsis, acute respiratory failure, and general critical care interventions. These ratios ranged from cost saving to 958,423 US dollars/quality-adjusted life year and from 1,150 to 575,054 US dollars/life year gained. Many studies reported favorable cost-effectiveness profiles (i.e., below 50,000 US dollars/life year or quality-adjusted life year). Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.

Cost-effectiveness of negative pressure wound therapy in patients with many comorbidities and severe wounds of various etiology.

PubMed

Driver, Vickie R; Eckert, Kristen A; Carter, Marissa J; French, Michael A

2016-11-01

This study analyzed a cross-section of patients with severe chronic wounds and multiple comorbidities at an outpatient wound clinic, with regard to the cost-effectiveness and cost-benefit of negative pressure wound therapy (intervention) vs. no negative pressure wound therapy (control) at 1 and 2 years. Medicare reimbursement charges for wound care were used to calculate costs. Amputation charges were assessed using diagnosis-related groups. Cost-benefit analysis was based on ulcer-free months and cost-effectiveness on quality-adjusted life-years. Undiscounted costs, benefits, quality-adjusted life-years, undiscounted and discounted incremental net health benefits, and incremental cost-effectiveness ratios were calculated for unmatched and matched cohorts. There were 150 subjects in the intervention group and 154 controls before matching and 103 subjects in each of the matched cohorts. Time to heal for the intervention cohort was significantly shorter compared to the controls (270 vs. 635 days, p = 1.0 × 10 -7 , matched cohorts). The intervention cohort had higher benefits and quality-adjusted life-year gains compared to the control cohort at years 1 and 2; by year 2, the gains were 68-73% higher. In the unmatched cohorts, the incremental net health benefit was $9,933 per ulcer-free month at year 2 for the intervention; the incremental cost-effectiveness ratio was -825,271 per quality-adjusted life-year gained (undiscounted costs and benefits). For the matched cohorts, the incremental net health benefits was only $1,371 per ulcer-free month for the intervention, but the incremental cost-effectiveness ratio was $366,683 per quality-adjusted life-year gained for year 2 (discounted costs and benefits). In a patient population with severe chronic wounds and serious comorbidities, negative pressure wound therapy resulted in faster healing wounds and was more cost-effective with greater cost-benefits than not using negative pressure wound therapy. Regarding overall cost-effectiveness, the intervention was still expensive, but that is the reality amidst limited treatment options for such serious cases of chronic wounds. © 2016 by the Wound Healing Society.

Cost-effectiveness of a pressure ulcer quality collaborative.

PubMed

Makai, Peter; Koopmanschap, Marc; Bal, Roland; Nieboer, Anna P

2010-06-01

A quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective. We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained. Incidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by euro2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained. During the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.

Cost-effectiveness of biological treatment sequences for fistulising Crohn’s disease across Europe

PubMed Central

Baji, Petra; Gulácsi, László; Brodszky, Valentin; Végh, Zsuzsanna; Danese, Silvio; Irving, Peter M; Peyrin-Biroulet, Laurent; Schreiber, Stefan; Rencz, Fanni; Lakatos, Péter L; Péntek, Márta

2017-01-01

Background In clinical practice, treatment sequences of biologicals are applied for active fistulising Crohn’s disease, however underlying health economic analyses are lacking. Objective The purpose of this study was to analyse the cost-effectiveness of different biological sequences including infliximab, biosimilar-infliximab, adalimumab and vedolizumab in nine European countries. Methods A Markov model was developed to compare treatment sequences of one, two and three biologicals from the payer’s perspective on a five-year time horizon. Data on effectiveness and health state utilities were obtained from the literature. Country-specific costs were considered. Calculations were performed with both official list prices and estimated real prices of biologicals. Results Biosimilar-infliximab is the most cost-effective treatment against standard care across the countries (with list prices: €34684–€72551/quality adjusted life year; with estimated real prices: €24364–€56086/quality adjusted life year). The most cost-effective two-agent sequence, except for Germany, is the biosimilar-infliximab–adalimumab therapy compared with single biosimilar-infliximab (with list prices: €58533–€133831/quality adjusted life year; with estimated prices: €45513–€105875/quality adjusted life year). The cost-effectiveness of the biosimilar-infliximab–adalimumab–vedolizumab three-agent sequence compared wit biosimilar-infliximab –adalimumab is €87214–€152901/quality adjusted life year. Conclusions The suggested first-choice biological treatment is biosimilar-infliximab. In case of treatment failure, switching to adalimumab then to vedolizumab provides meaningful additional health gains but at increased costs. Inter-country differences in cost-effectiveness are remarkable due to significant differences in costs. PMID:29511561

Vaccination versus treatment of influenza in working adults: a cost-effectiveness analysis.

PubMed

Rothberg, Michael B; Rose, David N

2005-01-01

To determine the cost-effectiveness of influenza vaccination, antiviral therapy, or no intervention for healthy working adults, accounting for annual variation in vaccine efficacy. We conducted a cost-effectiveness analysis based on published clinical trials of influenza vaccine and antiviral drugs, incorporating 10 years of surveillance data from the World Health Organization. We modeled influenza vaccination, treatment of influenza-like illness with antiviral drugs, or both, as compared with no intervention, targeting healthy working adults under age 50 years in the general community or workplace. Outcomes included costs, illness days, and quality-adjusted days gained. In the base case analysis, the majority of costs incurred for all strategies were related to lost productivity from influenza illness. The least expensive strategy varied from year to year. For the 10-year period, antiviral therapy without vaccination was associated with the lowest overall costs (234 US dollars per person per year). Annual vaccination cost was 239 US dollars per person, and was associated with 0.0409 quality-adjusted days saved, for a marginal cost-effectiveness ratio of 113 US dollars per quality-adjusted day gained or 41,000 US dollars per quality-adjusted life-year saved compared with antiviral therapy. No intervention was the most expensive and least effective option. In sensitivity analyses, lower vaccination costs, higher annual probabilities of influenza, and higher numbers of workdays lost to influenza made vaccination more cost-effective than treatment. If vaccination cost was less than 16 US dollars or time lost from work exceeded 2.4 days per episode of influenza, then vaccination was cost saving compared with all other strategies. Influenza vaccination for healthy working adults is reasonable economically, and under certain circumstances is cost saving. Antiviral therapy is consistently cost saving.

Economic evaluation of enhanced asthma management: a systematic review

PubMed Central

Yong, Yee V.; Shafie, Asrul A.

2014-01-01

Objectives: To evaluate and compare full economic evaluation studies on the cost-effectiveness of enhanced asthma management (either as an adjunct to usual care or alone) vs. usual care alone. Methods: Online databases were searched for published journal articles in English language from year 1990 to 2012, using the search terms ‘“asthma” AND (“intervene” OR “manage”) AND (“pharmacoeconomics” OR “economic evaluation” OR “cost effectiveness” OR “cost benefit” OR “cost utility”)’. Hand search was done for local publishing. Only studies with full economic evaluation on enhanced management were included (cost consequences (CC), cost effectiveness (CE), cost benefit (CB), or cost utility (CU) analysis). Data were extracted and assessed for the quality of its economic evaluation design and evidence sources. Results: A total of 49 studies were included. There were 3 types of intervention for enhanced asthma management: education, environmental control, and self-management. The most cost-effective enhanced management was a mixture of education and self-management by an integrated team of healthcare and allied healthcare professionals. In general, the studies had a fair quality of economic evaluation with a mean QHES score of 73.7 (SD=9.7), and had good quality of evidence sources. Conclusion: Despite the overall fair quality of economic evaluations but good quality of evidence sources for all data components, this review showed that the delivered enhanced asthma managements, whether as single or mixed modes, were overall effective and cost-reducing. Whilst the availability and accessibility are an equally important factor to consider, the sustainability of the cost-effective management has to be further investigated using a longer time horizon especially for chronic diseases such as asthma. PMID:25580173

Economic evaluation of a bio-psycho-social intervention for comorbid disorders in a traumatized population in post-war Kosovo.

PubMed

Chang, Wei-Lun; Andersen, Carit Jacques; Berisha, Besa Shatri; Estrup, Olena; Wang, Shr-Jie

2018-05-08

Post-hoc economic evaluation of a bio-psycho-social intervention in post-war Kosovo from a societal perspective. Cost-effectiveness analysis, cost-utility analysis, and partial cost-benefit analysis using data from a randomized controlled trial. Thirty-four torture/war victims with comorbid conditions enrolled in 2012-2013. Participants were randomly assigned to an "intervention" and a "waiting-list" group. Changes in mental, emotional and physical health and functional impairment were assessed before and after treatment, along with increase in labour income as a proxy for productivity gain. The cost of an extra unit of effectiveness and an additional quality-adjusted life year were calculated. The total cost per participant was €1,322 including, or €1,019 excluding, research costs. Wide variations in costs of changes in mental, emotional and physical effectiveness were demonstrated. Multidisciplinary intervention resulted in functional improvement at a cost of €10,508 per quality-adjusted life year gained. With a mean monthly income increase to €133 (18%) after intervention, the intervention cost per participant would be equal to the total increase in monthly income after 4-5 years, assuming the increased level is maintained. Socio-economic benefit associated with quality-adjusted life year gain is shown, although the cost of an additional quality-adjusted life year is above the World Health Organization cost-effectiveness threshold.

The Kaiser Permanente implant registries: effect on patient safety, quality improvement, cost effectiveness, and research opportunities.

PubMed

Paxton, Elizabeth W; Inacio, Maria Cs; Kiley, Mary-Lou

2012-01-01

Considering the high cost, volume, and patient safety issues associated with medical devices, monitoring of medical device performance is critical to ensure patient safety and quality of care. The purpose of this article is to describe the Kaiser Permanente (KP) implant registries and to highlight the benefits of these implant registries on patient safety, quality, cost effectiveness, and research. Eight KP implant registries leverage the integrated health care system's administrative databases and electronic health records system. Registry data collected undergo quality control and validation as well as statistical analysis. Patient safety has been enhanced through identification of affected patients during major recalls, identification of risk factors associated with outcomes of interest, development of risk calculators, and surveillance programs for infections and adverse events. Effective quality improvement activities included medical center- and surgeon-specific profiles for use in benchmarking reports, and changes in practice related to registry information output. Among the cost-effectiveness strategies employed were collaborations with sourcing and contracting groups, and assistance in adherence to formulary device guidelines. Research studies using registry data included postoperative complications, resource utilization, infection risk factors, thromboembolic prophylaxis, effects of surgical delay on concurrent injuries, and sports injury patterns. The unique KP implant registries provide important information and affect several areas of our organization, including patient safety, quality improvement, cost-effectiveness, and research.

Quality of Life and Cost Effectiveness of Prostate Cancer Treatment

DTIC Science & Technology

2008-03-01

Study objective is to assess the effects of different treatments for prostate cancer on quality of life and cost of care for two ethnic groups. It...across ethnic groups; and (3) analyze resource utilization patterns, treatment modalities and quality of life of men with prostate cancer between non-VA

Cost-effectiveness of allopurinol and febuxostat for the management of gout.

PubMed

Jutkowitz, Eric; Choi, Hyon K; Pizzi, Laura T; Kuntz, Karen M

2014-11-04

Gout is the most common inflammatory arthritis in the United States. To evaluate the cost-effectiveness of urate-lowering treatment strategies for the management of gout. Markov model. Published literature and expert opinion. Patients for whom allopurinol or febuxostat is a suitable initial urate-lowering treatment. Lifetime. Health care payer. 5 urate-lowering treatment strategies were evaluated: no treatment; allopurinol- or febuxostat-only therapy; allopurinol-febuxostat sequential therapy; and febuxostat-allopurinol sequential therapy. Two dosing scenarios were investigated: fixed dose (80 mg of febuxostat daily, 0.80 success rate; 300 mg of allopurinol daily, 0.39 success rate) and dose escalation (≤120 mg of febuxostat daily, 0.82 success rate; ≤800 mg of allopurinol daily, 0.78 success rate). Discounted costs, discounted quality-adjusted life-years, and incremental cost-effectiveness ratios. In both dosing scenarios, allopurinol-only therapy was cost-saving. Dose-escalation allopurinol-febuxostat sequential therapy was more costly but more effective than dose-escalation allopurinol therapy, with an incremental cost-effectiveness ratio of $39 400 per quality-adjusted life-year. The relative rankings of treatments did not change. Our results were relatively sensitive to several potential variations of model assumptions; however, the cost-effectiveness ratios of dose escalation with allopurinol-febuxostat sequential therapy remained lower than the willingness-to-pay threshold of $109 000 per quality-adjusted life-year. Long-term outcome data for patients with gout, including medication adherence, are limited. Allopurinol single therapy is cost-saving compared with no treatment. Dose-escalation allopurinol-febuxostat sequential therapy is cost-effective compared with accepted willingness-to-pay thresholds. Agency for Healthcare Research and Quality.

[Cost-effectiveness analysis and diet quality index applied to the WHO Global Strategy].

PubMed

Machado, Flávia Mori Sarti; Simões, Arlete Naresse

2008-02-01

To test the use of cost-effectiveness analysis as a decision making tool in the production of meals for the inclusion of the recommendations published in the World Health Organization's Global Strategy. Five alternative options for breakfast menu were assessed previously to their adoption in a food service at a university in the state of Sao Paulo, Southeastern Brazil, in 2006. Costs of the different options were based on market prices of food items (direct cost). Health benefits were estimated based on adaptation of the Diet Quality Index (DQI). Cost-effectiveness ratios were estimated by dividing benefits by costs and incremental cost-effectiveness ratios were estimated as cost differential per unit of additional benefit. The meal choice was based on health benefit units associated to direct production cost as well as incremental effectiveness per unit of differential cost. The analysis showed the most simple option with the addition of a fruit (DQI = 64 / cost = R$ 1.58) as the best alternative. Higher effectiveness was seen in the options with a fruit portion (DQI1=64 / DQI3=58 / DQI5=72) compared to the others (DQI2=48 / DQI4=58). The estimate of cost-effectiveness ratio allowed to identifying the best breakfast option based on cost-effectiveness analysis and Diet Quality Index. These instruments allow easy application easiness and objective evaluation which are key to the process of inclusion of public or private institutions under the Global Strategy directives.

The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review.

PubMed

Kilpatrick, Kelley; Kaasalainen, Sharon; Donald, Faith; Reid, Kim; Carter, Nancy; Bryant-Lukosius, Denise; Martin-Misener, Ruth; Harbman, Patricia; Marshall, Deborah Anne; Charbonneau-Smith, Renee; DiCenso, Alba

2014-12-01

Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles. We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes. Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak. Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness. © 2014 John Wiley & Sons, Ltd.

Opportunities for reproductive tourism: cost and quality advantages of Turkey in the provision of in-vitro Fertilization (IVF) services.

PubMed

Yildiz, M Said; Khan, M Mahmud

2016-08-12

The scale and scope of medical tourism have expanded rapidly over the last few decades. Turkey is becoming an important player in this market because of its relatively better service quality and large comparative cost advantage. This paper compares cost, quality and effectiveness of in-vitro fertilization (IVF) in the USA and in Turkey. The data from Turkey were obtained from a hospital specializing in IVF services and the US data came from secondary sources. Package price offered by the dominant IVF-service provider to international patients in Turkey was used as a measure of cost for Turkey while IVF-specific service prices were used to estimate the cost for USA. To compare quality and effectiveness of IVF services, a number of general clinical quality indicators and IVF success rate were used. Indicators of quality, cost and success rate in the Turkish hospital were found to be better than the corresponding indicators in US hospitals. The cost difference of IVF services between USA and Turkey is so significant that the overall cost of obtaining the service from Turkey remains lower even with additional expenses for travel and accommodation. Cost-effectiveness ratio of IVF treatment per successful clinical pregnancy was much lower in Turkey than in the USA. It appears that cost and quality are the two most important factors affecting demand for health care services by international patients in Turkey. Like other important players in the medical tourism market, Turkey should be able to take advantage of its success in IVF, a highly specialized niche market, to transform its health system into an important exporter of general health services.

Cost-effectiveness analysis of a patient-centered care model for management of psoriasis.

PubMed

Parsi, Kory; Chambers, Cindy J; Armstrong, April W

2012-04-01

Cost-effectiveness analyses help policymakers make informed decisions regarding funding allocation of health care resources. Cost-effectiveness analysis of technology-enabled models of health care delivery is necessary to assess sustainability of novel online, patient-centered health care models. We sought to compare cost-effectiveness of conventional in-office care with a patient-centered, online model for follow-up treatment of patients with psoriasis. Cost-effectiveness analysis was performed from a societal perspective on a randomized controlled trial comparing a patient-centered online model with in-office visits for treatment of patients with psoriasis during a 24-week period. Quality-adjusted life expectancy was calculated using the life table method. Costs were generated from the original study parameters and national averages for salaries and services. No significant difference existed in the mean change in Dermatology Life Quality Index scores between the two groups (online: 3.51 ± 4.48 and in-office: 3.88 ± 6.65, P value = .79). Mean improvement in quality-adjusted life expectancy was not significantly different between the groups (P value = .93), with a gain of 0.447 ± 0.48 quality-adjusted life years for the online group and a gain of 0.463 ± 0.815 quality-adjusted life years for the in-office group. The cost of follow-up psoriasis care with online visits was 1.7 times less than the cost of in-person visits ($315 vs $576). Variations in travel time existed among patients depending on their distance from the dermatologist's office. From a societal perspective, the patient-centered online care model appears to be cost saving, while maintaining similar effectiveness to standard in-office care. Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.

Cost-effectiveness analysis of online hemodiafiltration versus high-flux hemodialysis.

PubMed

Ramponi, Francesco; Ronco, Claudio; Mason, Giacomo; Rettore, Enrico; Marcelli, Daniele; Martino, Francesca; Neri, Mauro; Martin-Malo, Alejandro; Canaud, Bernard; Locatelli, Francesco

2016-01-01

Clinical studies suggest that hemodiafiltration (HDF) may lead to better clinical outcomes than high-flux hemodialysis (HF-HD), but concerns have been raised about the cost-effectiveness of HDF versus HF-HD. Aim of this study was to investigate whether clinical benefits, in terms of longer survival and better health-related quality of life, are worth the possibly higher costs of HDF compared to HF-HD. The analysis comprised a simulation based on the combined results of previous published studies, with the following steps: 1) estimation of the survival function of HF-HD patients from a clinical trial and of HDF patients using the risk reduction estimated in a meta-analysis; 2) simulation of the survival of the same sample of patients as if allocated to HF-HD or HDF using three-state Markov models; and 3) application of state-specific health-related quality of life coefficients and differential costs derived from the literature. Several Monte Carlo simulations were performed, including simulations for patients with different risk profiles, for example, by age (patients aged 40, 50, and 60 years), sex, and diabetic status. Scatter plots of simulations in the cost-effectiveness plane were produced, incremental cost-effectiveness ratios were estimated, and cost-effectiveness acceptability curves were computed. An incremental cost-effectiveness ratio of €6,982/quality-adjusted life years (QALY) was estimated for the baseline cohort of 50-year-old male patients. Given the commonly accepted threshold of €40,000/QALY, HDF is cost-effective. The probabilistic sensitivity analysis showed that HDF is cost-effective with a probability of ~81% at a threshold of €40,000/QALY. It is fundamental to measure the outcome also in terms of quality of life. HDF is more cost-effective for younger patients. HDF can be considered cost-effective compared to HF-HD.

Cost-effectiveness of nurse-led disease management for heart failure in an ethnically diverse urban community.

PubMed

Hebert, Paul L; Sisk, Jane E; Wang, Jason J; Tuzzio, Leah; Casabianca, Jodi M; Chassin, Mark R; Horowitz, Carol; McLaughlin, Mary Ann

2008-10-21

Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. Less is known about the cost-effectiveness of these interventions. To estimate the cost-effectiveness of a nurse-led disease management intervention over 12 months, implemented in a randomized, controlled effectiveness trial. Cost-effectiveness analysis conducted alongside a randomized trial. Medical costs from administrative records, and self-reported quality of life and nonmedical costs from patient surveys. Patients with systolic dysfunction recruited from ambulatory clinics in Harlem, New York. 12 months. Societal and payer. 12-month program that involved 1 face-to-face encounter with a nurse and regular telephone follow-up. Quality of life as measured by the Health Utilities Index Mark 3 and EuroQol-5D and cost-effectiveness as measured by the incremental cost-effectiveness ratio (ICER). Costs and quality of life were higher in the nurse-managed group than the usual care group. The ICERs over 12 months were $17,543 per EuroQol-5D-based quality-adjusted life-year (QALY) and $15,169 per Health Utilities Index Mark 3-based QALY (in 2001 U.S. dollars). From a payer perspective, the ICER ranged from $3673 to $4495 per QALY. Applying national prices in place of New York City prices yielded a societal ICER of $13,460 to $15,556 per QALY. Cost-effectiveness acceptability curves suggest that the intervention was most likely cost-effective for patients with less severe (New York Heart Association classes I to II) heart failure. The trial was conducted in an ethnically diverse, inner-city neighborhood; thus, results may not be generalizable to other communities. Over 12 months, the nurse-led disease management program was a reasonably cost-effective way to reduce the burden of heart failure in this community.

The use of cost per life year gained as a measurement of cost-effectiveness in Spain: a systematic review of recent publications.

PubMed

Rodríguez Barrios, José Manuel; Pérez Alcántara, Ferran; Crespo Palomo, Carlos; González García, Paloma; Antón De Las Heras, Enrique; Brosa Riestra, Max

2012-12-01

The objective of this study was to evaluate the methodological characteristics of cost-effectiveness evaluations carried out in Spain, since 1990, which include LYG as an outcome to measure the incremental cost-effectiveness ratio. A systematic review of published studies was conducted describing their characteristics and methodological quality. We analyse the cost per LYG results in relation with a commonly accepted Spanish cost-effectiveness threshold and the possible relation with the cost per quality adjusted life year (QALY) gained when they both were calculated for the same economic evaluation. A total of 62 economic evaluations fulfilled the selection criteria, 24 of them including the cost per QALY gained result as well. The methodological quality of the studies was good (55%) or very good (26%). A total of 124 cost per LYG results were obtained with a mean ratio of 49,529 and a median of 11,490 (standard deviation of 183,080). Since 2003, a commonly accepted Spanish threshold has been referenced by 66% of studies. A significant correlation was found between the cost per LYG and cost per QALY gained results (0.89 Spearman-Rho, 0.91 Pearson). There is an increasing interest for economic health care evaluations in Spain, and the quality of the studies is also improving. Although a commonly accepted threshold exists, further information is needed for decision-making as well as to identify the relationship between the costs per LYG and per QALY gained.

Costs, quality of life and cost-effectiveness of arthroscopic and open repair for rotator cuff tears: an economic evaluation alongside the UKUFF trial.

PubMed

Murphy, J; Gray, A; Cooper, C; Cooper, D; Ramsay, C; Carr, A

2016-12-01

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial. Using data from 273 patients, healthcare-related use of resources, costs and quality-adjusted life years (QALYs) were estimated at 12 months and 24 months after surgery on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for arthroscopic versus open management at 24 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. There were no significant differences between the arthroscopic and open groups in terms of total mean use and cost of resources or QALYs at any time post-operatively. Open management dominated arthroscopic management in 59.8% of bootstrapped cost and effect differences. The probability that arthroscopic management was cost-effective compared with open management at a willingness-to-pay threshold of £20 000 per QALY gained was 20.9%. There was no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management in the trial. There was uncertainty about which strategy was most cost-effective. Cite this article: Bone Joint J 2016;98-B:1648-55. ©2016 Gray et al.

Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review.

PubMed

Watson, Samuel I; Sahota, Harvir; Taylor, Celia A; Chen, Yen-Fu; Lilford, Richard J

2018-01-01

Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs. We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist. Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as "changing by whom and where care was provided", specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings. There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.

Cost effectiveness of novel oral anticoagulants for stroke prevention in atrial fibrillation depending on the quality of warfarin anticoagulation control.

PubMed

Janzic, Andrej; Kos, Mitja

2015-04-01

Vitamin K antagonists, such as warfarin, are standard treatments for stroke prophylaxis in patients with atrial fibrillation. Patient outcomes depend on quality of warfarin management, which includes regular monitoring and dose adjustments. Recently, novel oral anticoagulants (NOACs) that do not require regular monitoring offer an alternative to warfarin. The aim of this study was to evaluate whether cost effectiveness of NOACs for stroke prevention in atrial fibrillation depends on the quality of warfarin control. We developed a Markov decision model to simulate warfarin treatment outcomes in relation to the quality of anticoagulation control, expressed as percentage of time in the therapeutic range (TTR). Standard treatment with adjusted-dose warfarin and improved anticoagulation control by genotype-guided dosing were compared with dabigatran, rivaroxaban, apixaban and edoxaban. The analysis was performed from the Slovenian healthcare payer perspective using 2014 costs. In the base case, the incremental cost-effectiveness ratio for apixaban, dabigatran and edoxaban was below the threshold of €25,000 per quality-adjusted life-years compared with adjusted-dose warfarin with a TTR of 60%. The probability that warfarin was a cost-effective option was around 1%. This percentage rises as the quality of anticoagulation control improves. At a TTR of 70%, warfarin was the preferred treatment in half the iterations. The cost effectiveness of NOACs for stroke prevention in patients with nonvalvular atrial fibrillation who are at increased risk for stroke is highly sensitive to warfarin anticoagulation control. NOACs are more likely to be cost-effective options in settings with poor warfarin management than in settings with better anticoagulation control, where they may not represent good value for money.

Contract management using cause-effect clues in service worksheets.

PubMed

Chen, J H

1996-01-01

Sophisticated equipment often needs intensive technical resources to maintain its system availability. Service contracts can be an easy channel to outside technical resources. Usually, a service contract purchaser only sees its cost instead of its maintenance quality. A system's needs, however, depend on the trade-off between the cost paid and the quality received. If a clinical engineer can actively interpret and integrate the cause-effect consequences on the compiled service worksheets, those clues can serve as a criterion to justify the quality and the cost-effectiveness of a service contract. Through the analysis of the service labor consumed, the justification of the parts replaced, and the assessment of the "fit" to system availability, this paper provides a cost-effective tool for equipment management.

The cost-effectiveness of infliximab in Crohn's disease.

PubMed

Smart, Claire; Selinger, Christian P

2014-10-01

Crohn's disease (CD) is a chronic inflammatory condition that can affect any part of the gastrointestinal tract. It leads to severe symptoms and reduced quality of life. Infliximab is a monoclonal antibody against TNF-α and is effective in treating moderate to severe CD. It is associated with high treatment costs, but subsequent reductions in hospitalisation and surgery have been reported. This review examines the evidence for the cost-effectiveness of infliximab for the treatment of CD. Studies have been found to be very heterogeneous depending on setting, costs assumed and clinical data. Within the UK setting infliximab has been found to be cost effective with increased costs of around £25,000 per quality adjusted life year gained.

Costs and cost-effectiveness analysis of treatment in children with eczema by nurse practitioner vs. dermatologist: results of a randomized, controlled trial and a review of international costs.

PubMed

Schuttelaar, M L A; Vermeulen, K M; Coenraads, P J

2011-09-01

In a randomized, controlled trial (RCT) on childhood eczema we reported that substituting nurse practitioners (NPs) for dermatologists resulted in similar outcomes of eczema severity and in the quality of life, and higher patient satisfaction. To determine costs and cost-effectiveness of care provided by NPs vs. dermatologists and to compare our results with those in studies from other countries. We estimated the healthcare costs, family costs and the costs in other sectors alongside the RCT. All the costs were linked to quality of life [Infants' Dermatitis Quality of Life Index (IDQOL), Children's Dermatology Life Quality Index (CDLQI)] and to patient satisfaction (Client Satisfaction Questionnaire-8) to determine the incremental cost-effectiveness ratio (ICER). We also examined all the reported studies on the costs of childhood eczema. The mean annual healthcare costs, family costs and costs in other sectors were €658, €302 and €21, respectively, in the NP group and €801, €608 and €0·93, respectively, in the dermatologist group. The ICER in the NP group compared with the dermatologist group indicated €925 and €751 savings per one point less improvement in IDQOL and CDLQI, respectively, and €251 savings per one point more satisfaction in the NP group at 12 months. The mean annual healthcare costs and family costs varied considerably in the six identified studies. Substituting NPs for dermatologists is both cost-saving and cost-effective. The treatment of choice is that provided by the NPs as it is similarly effective to treatment provided by a dermatologist with a higher parent satisfaction. International comparisons are difficult because the types of costs determined, the units and unit prices, and eczema severity all differ between studies. © 2011 The Authors. BJD © 2011 British Association of Dermatologists.

Cost-utility Analysis of Supported Self-management with Motiva-tional Interviewing for Patients with Psoriasis.

PubMed

Larsen, Marie H; Wahl, Astrid K; Krogstad, Anne-Lene; Aas, Eline

2016-06-15

There are few studies evaluating the cost-effectiveness of self-management interventions for patients with psoriasis. Motivational interviewing (MI) as a telephone follow-up after climate-heliotherapy was effective on several clinical parameters, but its cost-effectiveness is unknown. A cost-utility analysis was conducted alongside a randomized controlled trial (RCT) comparing MI with usual care. A total of 169 Norwegian patients were included. A within-trial analysis compared the costs and quality-adjusted life years (QALYs). Utilities were measured with the 15D instrument, supplemented with Dermatological Life Quality Index (DLQI). A time-integrated summary score defined the clinical effects. QALYs were adjusted for baseline differences. MI provided equivalent quality of life and utility (15D: -0.0022 QALYs (95% Cl -0.02, 0.01), p = 0.77, and DLQI: -0.62 QALYs (95%CI -0.65, 0.41), p = 0.24, at lower costs €-1103 (-2293, 87), p = 0.058, compared with treatment-as-usual. The MI intervention was thus cost-effective. This result was more evident when using the DLQI as outcome measure compared with 15D.

Lake Erie Wastewater Management Study.

DTIC Science & Technology

1982-09-01

quality problems, the causes of these problems, and a cost- effective strategy to improve Lake Erie’s water quality.Numerous questions remain...unanswered about the exact relationship between land use and water quality and about the effectiveness of the proposed management strategy. However, enough...Dr. Terry J. Logan of Ohio State University who wrote the biological availa- bility section and developed cost effectiveness of different Best

Food cost disparities in rural communities.

PubMed

Hardin-Fanning, Frances; Rayens, Mary Kay

2015-05-01

Promotion of healthy eating is an effective public health strategy to prevent chronic disease incidence and progression. However, food prices can impede healthy eating, especially in rural communities. The purpose of this study was to determine whether food costs are associated with nutritional quality, geographic location, and month of year. The Overall Nutritional Quality Index and cost of 92 foods were assessed four times over a 10-month period in the primary grocery stores in four Kentucky counties, two rural and two urban. Repeated measures analysis of variance was used to assess differences in food costs by nutritional quality, county, and month. Among more nutritious food items, costs were lower in urban areas. This was particularly true among foods in the highest quartile of nutritional quality. Across all counties, there was a pattern of highest per-serving costs in the second quartile of nutritional quality, whereas more nutritious foods were less expensive. Strategies that help individuals improve the ability to identify and prepare less costly foods with high nutritional value may be effective in improving dietary habits, particularly in rural, impoverished food deserts. © 2014 Society for Public Health Education.

Food Cost Disparities in Rural Communities

PubMed Central

Hardin-Fanning, Frances; Rayens, Mary Kay

2015-01-01

Promotion of healthy eating is an effective public health strategy to prevent chronic disease incidence and progression. However, food prices can impede healthy eating, especially in rural communities. The purpose of this study was to determine whether food costs are associated with nutritional quality, geographic location, and month of year. The Overall Nutritional Quality Index and cost of 92 foods were assessed four times over a 10-month period in the primary grocery stores in four Kentucky counties, two rural and two urban. Repeated measures analysis of variance was used to assess differences in food costs by nutritional quality, county, and month. Among more nutritious food items, costs were lower in urban areas. This was particularly true among foods in the highest quartile of nutritional quality. Across all counties, there was a pattern of highest per-serving costs in the second quartile of nutritional quality, whereas more nutritious foods were less expensive. Strategies that help individuals improve the ability to identify and prepare less costly foods with high nutritional value may be effective in improving dietary habits, particularly in rural, impoverished food deserts. PMID:25305093

Treating Type 1 Diabetes Mellitus with a Rapid-Acting Analog Insulin Regimen vs. Regular Human Insulin in Germany: A Long-Term Cost-Effectiveness Evaluation.

PubMed

Valentine, William J; Van Brunt, Kate; Boye, Kristina S; Pollock, Richard F

2018-06-01

The aim of the present study was to evaluate the cost effectiveness of rapid-acting analog insulin relative to regular human insulin in adults with type 1 diabetes mellitus in Germany. The PRIME Diabetes Model, a patient-level, discrete event simulation model, was used to project long-term clinical and cost outcomes for patients with type 1 diabetes from the perspective of a German healthcare payer. Simulated patients had a mean age of 21.5 years, duration of diabetes of 8.6 years, and baseline glycosylated hemoglobin of 7.39%. Regular human insulin and rapid-acting analog insulin regimens reduced glycosylated hemoglobin by 0.312 and 0.402%, respectively. Compared with human insulin, hypoglycemia rate ratios with rapid-acting analog insulin were 0.51 (non-severe nocturnal) and 0.80 (severe). No differences in non-severe diurnal hypoglycemia were modeled. Discount rates of 3% were applied to future costs and clinical benefits accrued over the 50-year time horizon. In the base-case analysis, rapid-acting analog insulin was associated with an improvement in quality-adjusted life expectancy of 1.01 quality-adjusted life-years per patient (12.54 vs. 11.53 quality-adjusted life-years). Rapid-acting analog insulin was also associated with an increase in direct costs of €4490, resulting in an incremental cost-effectiveness ratio of €4427 per quality-adjusted life-year gained vs. human insulin. Sensitivity analyses showed that the base case was driven predominantly by differences in hypoglycemia; abolishing these differences reduced incremental quality-adjusted life expectancy to 0.07 quality-adjusted life-years, yielding an incremental cost-effectiveness ratio of €74,622 per quality-adjusted life-year gained. Rapid-acting analog insulin is associated with beneficial outcomes in patients with type 1 diabetes and is likely to be considered cost effective in the German setting vs. regular human insulin.

Cost-effectiveness of a vaccine to prevent herpes zoster and postherpetic neuralgia in older adults.

PubMed

Hornberger, John; Robertus, Katherine

2006-09-05

The Shingles Prevention Study showed that a varicella-zoster virus (VZV) vaccine administered to adults 60 years of age or older reduced the incidence of herpes zoster from 11.12 to 5.42 cases per 1000 person-years. Median follow-up was 3.1 years, and relative risk reduction was 51.3% (95% CI, 44.2% to 57.6%). To assess the extent to which clinical and cost variables influence the cost-effectiveness of VZV vaccination for preventing herpes zoster in immunocompetent older adults. Decision theoretical model. English-language data published to March 2006 identified from MEDLINE on herpes zoster rates, vaccine effectiveness, quality of life, medical resource use, and unit costs. Immunocompetent adults 60 years of age or older with a history of VZV infection. Lifetime. U.S. societal. Varicella-zoster virus vaccination versus no vaccination. Incremental quality-adjusted survival and cost per quality-adjusted life-year (QALY) gained. By reducing incidence and severity of herpes zoster, vaccination can increase quality-adjusted survival by 0.6 day compared with no vaccination. One scenario in which vaccination costs less than 100,000 dollars per QALY gained is when 1) the unit cost of vaccination is less than 200 dollars, 2) the age at vaccination is less than 70 years, and 3) the duration of vaccine efficacy is more than 30 years. Vaccination would be more cost-effective in "younger" older adults (age 60 to 64 years) than in "older" older adults (age > or =80 years). Longer life expectancy and a higher level of vaccine efficacy offset a lower risk for herpes zoster in the younger group. Other factors influencing cost-effectiveness include quality-of-life adjustments for acute zoster, unit cost of the vaccine, risk for herpes zoster, and duration of vaccine efficacy. The effectiveness of VZV vaccination remains uncertain beyond the median 3.1-year duration of follow-up in the Shingles Prevention Study. Varicella-zoster virus vaccination to prevent herpes zoster in older adults would increase QALYs compared with no vaccination. Resolution of uncertainties about the average quality-of-life effects of acute zoster and the duration of vaccine efficacy is needed to better determine the cost-effectiveness of zoster vaccination in older adults.

Can disease management reduce health care costs by improving quality?

PubMed

Fireman, Bruce; Bartlett, Joan; Selby, Joe

2004-01-01

Disease management (DM) promises to achieve cost savings by improving the quality of care for chronic diseases. During the past decade the Permanente Medical Group in Northern California has implemented extensive DM programs. Examining quality indicators, utilization, and costs for 1996-2002 for adults with four conditions, we find evidence of substantial quality improvement but not cost savings. The causal pathway--from improved care to reduced morbidity to cost savings--has not produced sufficient savings to offset the rising costs of improved care. We conclude that the rationale for DM programs, like the rationale for any medical treatments, should rest on their effectiveness and value.

Cost-effectiveness analyses in orthopaedic sports medicine: a systematic review.

PubMed

Nwachukwu, Benedict U; Schairer, William W; Bernstein, Jaime L; Dodwell, Emily R; Marx, Robert G; Allen, Answorth A

2015-06-01

As increasing attention is paid to the cost of health care delivered in the United States (US), cost-effectiveness analyses (CEAs) are gaining in popularity. Reviews of the CEA literature have been performed in other areas of medicine, including some subspecialties within orthopaedics. Demonstrating the value of medical procedures is of utmost importance, yet very little is known about the overall quality and findings of CEAs in sports medicine. To identify and summarize CEA studies in orthopaedic sports medicine and to grade the quality of the available literature. Systematic review. A systematic review of the literature was performed to compile findings and grade the methodological quality of US-based CEA studies in sports medicine. The Quality of Health Economic Studies (QHES) instrument and the checklist by the US Panel on Cost-effectiveness in Health and Medicine were used to assess study quality. One-sided Fisher exact testing was performed to analyze the predictors of high-quality CEAs. Twelve studies met inclusion criteria. Five studies examined anterior cruciate ligament reconstruction, 3 studies examined rotator cuff repair, 2 examined autologous chondrocyte implantation, 1 study examined hip arthroscopic surgery, and 1 study examined the operative management of shoulder dislocations. Based on study findings, operative intervention in sports medicine is highly cost-effective. The quality of published evidence is good, with a mean quality score of 81.8 (range, 70-94). There is a trend toward higher quality in more recent publications. No significant predictor of high-quality evidence was found. The CEA literature in sports medicine is good; however, there is a paucity of studies, and the available evidence is focused on a few procedures. More work needs to be conducted to quantify the cost-effectiveness of different techniques and procedures within sports medicine. The QHES tool may be useful for the evaluation of future CEAs. © 2014 The Author(s).

Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice.

PubMed

Aboagye, Emmanuel; Karlsson, Malin Lohela; Hagberg, Jan; Jensen, Irene

2015-02-01

To evaluate the cost-effectiveness of medical yoga as an early intervention compared with evidence-based exercise therapy and self-care advice for non-specific low back pain. Randomized controlled trial with a cost-effectiveness analysis. A total of 159 participants randomized into the medical yoga group (n = 52), the exercise therapy group (n = 52) and the self-care advice group (n = 55). The health outcome measure EQ-5D was applied to measure quality of life data combined with cost data collected from treatment groups from baseline to 12 months follow-up. Outcome measure was health-related quality of life (HRQL). Incremental cost per quality adjusted life year (QALY) was also calculated. Cost-effectiveness analysis was conducted primarily from the societal and employer perspectives. Medical yoga is cost-effective compared with self-care advice if an employer considers the significant improvement in the HRQL of an employee with low back pain justifies the additional cost of treatment (i.e. in this study EUR 150). From a societal perspective, medical yoga is a cost-effective treatment compared with exercise therapy and self-care advice if an additional QALY is worth EUR 11,500. Sensitivity analysis suggests that medical yoga is more cost-effective than its alternatives. Six weeks of uninterrupted medical yoga thera-py is a cost-effective early intervention for non-specific low back pain, when treatment recommendations are adhered to.

Cost-effectiveness of a combined physical exercise and psychosocial training intervention for children with cancer: Results from the quality of life in motion study.

PubMed

Braam, K I; van Dijk-Lokkart, E M; van Dongen, J M; van Litsenburg, R R L; Takken, T; Huisman, J; Merks, J H M; Bosmans, J E; Hakkenbrak, N A G; Bierings, M B; van den Heuvel-Eibrink, M M; Veening, M A; van Dulmen-den Broeder, E; Kaspers, G J L

2017-11-01

This study was performed to estimate the cost-effectiveness of a combined physical exercise and psychosocial intervention for children with cancer compared with usual care. Sixty-eight children, aged 8-18 years old, during or within the first year post-cancer treatment were randomised to the intervention (n = 30) and control group (n = 38). Health outcomes included fitness, muscle strength and quality adjusted life years; all administered at baseline, 4- and 12-month follow-up. Costs were gathered by 1 monthly cost questionnaires over 12 months, supplemented by medication data obtained from pharmacies. Results showed no significant differences in costs and effects between the intervention and control group at 12-month follow-up. On average, societal costs were €299 higher in the intervention group than in the control group, but this difference was not significant. Cost-effectiveness acceptability curves indicated that the intervention needs large societal investments to reach reasonable probabilities of cost-effectiveness for quality of life and lower body muscle strength. Based on the results of this study, the intervention is not cost-effective in comparison with usual care. © 2016 John Wiley & Sons Ltd.

Can aging in place be cost effective? A systematic review.

PubMed

Graybill, Erin M; McMeekin, Peter; Wildman, John

2014-01-01

To systematically review cost, cost-minimization and cost-effectiveness studies for assisted living technologies (ALTs) that specifically enable older people to 'age in place' and highlight what further research is needed to inform decisions regarding aging in place. People aged 65+ and their live-in carers (where applicable), using an ALT to age in place at home opposed to a community-dwelling arrangement. Studies were identified using a predefined search strategy on two key economic and cost evaluation databases NHS EED, HEED. Studies were assessed using methods recommended by the Campbell and Cochrane Economic Methods Group and presented in a narrative synthesis style. Eight eligible studies were identified from North America spread over a diverse geographical range. The majority of studies reported the ALT intervention group as having lower resource use costs than the control group; though the low methodological quality and heterogeneity of the individual costs and outcomes reported across studies must be considered. The studies suggest that in some cases ALTs may reduce costs, though little data were identified and what there were was of poor quality. Methods to capture quality of life gains were not used, therefore potential effects on health and wellbeing may be missed. Further research is required using newer developments such as the capabilities approach. High quality studies assessing the cost-effectiveness of ALTs for ageing in place are required before robust conclusion on their use can be drawn.

Cost-effectiveness of maintenance pemetrexed in patients with advanced nonsquamous-cell lung cancer from the perspective of the Swiss health care system.

PubMed

Matter-Walstra, Klazien; Joerger, Markus; Kühnel, Ursula; Szucs, Thomas; Pestalozzi, Bernhard; Schwenkglenks, Matthias

2012-01-01

A recent randomized study showed switch maintenance with pemetrexed after nonpemetrexed-containing first-line chemotherapy in patients with advanced nonsmall-cell lung cancer to prolong overall survival by 2.8 months. We examined the cost-effectiveness of pemetrexed in this indication, from the perspective of the Swiss health care system, and assessed the influence of the costs of best supportive care (BSC) on overall cost-effectiveness. A Markov model was constructed based on the pemetrexed maintenance study, and the incremental cost-effectiveness ratio (ICER) of adding pemetrexed until disease progression was calculated as cost per quality-adjusted life-year gained. Uncertainties concerning the costs of BSC on the ICER were addressed. The base case ICER for maintenance therapy with pemetrexed plus BSC compared to BSC alone was €106,202 per quality-adjusted life-year gained. Varying the costs for BSC had a marked effect. Assuming a reduction of the costs for BSC by 25% in the pemetrexed arm resulted in an ICER of €47,531 per quality-adjusted life-year, which is below predefined criteria for cost effectiveness in Switzerland. Switch maintenance with pemetrexed in patients with advanced nonsquamous-cell lung cancer after standard first-line chemotherapy is not cost-effective. Uncertainties on the resource use and costs for BSC have a large influence on the cost-effectiveness calculation and should be reported in more detail. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Cost analysis and exploratory cost-effectiveness of youth-friendly sexual and reproductive health services in the Republic of Moldova.

PubMed

Kempers, Jari; Ketting, Evert; Lesco, Galina

2014-07-21

Youth-friendly sexual and reproductive health services (YFHS) have high priority in many countries. Yet, little is known about the cost and cost-effectiveness of good quality YFHS in resource limited settings. This paper analyses retrospectively costs and potential cost-effectiveness of four well performing youth-friendly health centres (YFHC) in Moldova. This study assesses: (1) what were the costs of YFHSs at centre level, (2) how much would scaling-up to a national good quality YFHS programme cost, and (3) was the programme potentially cost-effective? Four well performing YFHCs were selected for the study. YFHS costs were analysed per centre, funding source, service and person reached. The costing results were extrapolated to estimate cost of a good quality national YFHS programme in Moldova. A threshold analysis was carried out to estimate the required impact level for the YFHSs to break-even (become cost saving). Average annual cost of a well performing YFHC was USD 26,000 in 2011. 58% was financed by the National Health Insurance Company and the rest by external donors (42%). Personnel salaries were the largest expense category (47%). The annual implementation costs of a good quality YFHSs in all 38 YFHCs of Moldova were estimated to be USD 1.0 million. The results of the threshold analysis indicate that the annual break-even impact points in a YFHC for: 1) STI services would be >364 averted STIs, 2) early pregnancy and contraceptive services >178 averted unwanted pregnancies, and 3) HIV services only >0.65 averted new HIV infections. The costing results highlight the following: 1) significant additional resources would be required for implementation of a good quality national YFHS programme, 2) the four well performing YFHCs rely heavily on external funding (42%), 3) which raises questions about financial sustainability of the programme. At the same time results of the threshold analysis are encouraging. The result suggest that, together the three SRH components (STI, early pregnancy and contraception, and HIV) are potentially cost saving. High cost savings resulting from averted lifetime treatment cost of HIV infected persons are likely to off-set the costs of STIs and unwanted pregnancies.

Less is more: cost-effectiveness analysis of surveillance strategies for small, nonfunctional, radiographically benign adrenal incidentalomas.

PubMed

Chomsky-Higgins, Kathryn; Seib, Carolyn; Rochefort, Holly; Gosnell, Jessica; Shen, Wen T; Kahn, James G; Duh, Quan-Yang; Suh, Insoo

2018-01-01

Guidelines for management of small adrenal incidentalomas are mutually inconsistent. No cost-effectiveness analysis has been performed to evaluate rigorously the relative merits of these strategies. We constructed a decision-analytic model to evaluate surveillance strategies for <4cm, nonfunctional, benign-appearing adrenal incidentalomas. We evaluated 4 surveillance strategies: none, one-time, annual for 2 years, and annual for 5 years. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2016 US dollars and health outcomes in quality-adjusted life-years. No surveillance has an expected net cost of $262 and 26.22 quality-adjusted life-years. One-time surveillance costs $158 more and adds 0.2 quality-adjusted life-years for an incremental cost-effectiveness ratio of $778/quality-adjusted life-years. The strategies involving more surveillance were dominated by the no surveillance and one-time surveillance strategies less effective and more expensive. Above a 0.7% prevalence of adrenocortical carcinoma, one-time surveillance was the most effective strategy. The results were robust to all sensitivity analyses of disease prevalence, sensitivity, and specificity of diagnostic assays and imaging as well as health state utility. For patients with a < 4cm, nonfunctional, benign-appearing mass, one-time follow-up evaluation involving a noncontrast computed tomography and biochemical evaluation is cost-effective. Strategies requiring more surveillance accrue more cost without incremental benefit. Copyright © 2017 Elsevier Inc. All rights reserved.

Hospital-related cost of sepsis: A systematic review.

PubMed

Arefian, Habibollah; Heublein, Steffen; Scherag, André; Brunkhorst, Frank Martin; Younis, Mustafa Z; Moerer, Onnen; Fischer, Dagmar; Hartmann, Michael

2017-02-01

This article systematically reviews research on the costs of sepsis and, as a secondary aim, evaluates the quality of economic evaluations reported in peer-reviewed journals. We systematically searched the MEDLINE, National Health Service (Abstracts of Reviews of Effects, Economic Evaluation and Health Technology Assessment), Cost-effectiveness Analysis Registry and Web of Knowledge databases for studies published between January 2005 and June 2015. We selected original articles that provided cost and cost-effectiveness analyses, defined sepsis and described their cost calculation method. Only studies that considered index admissions and re-admissions in the first 30 days were published in peer-reviewed journals and used standard treatments were considered. All costs were adjusted to 2014 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist. Overall, 37 studies met our eligibility criteria. The median of the mean hospital-wide cost of sepsis per patient was $32,421 (IQR $20,745-$40,835), and the median of the mean ICU cost of sepsis per patient was $27,461 (IQR $16,007-$31,251). Overall, the quality of economic studies was low. Estimates of the hospital-related costs of sepsis varied considerably across the included studies depending on the method used for cost calculation, the type of sepsis and the population that was examined. A standard model for conducting cost improve the quality of studies on the costs of sepsis. Copyright © 2016 The British Infection Association. All rights reserved.

Cost and quality trends in direct contracting arrangements.

PubMed

Lyles, Alan; Weiner, Jonathan P; Shore, Andrew D; Christianson, Jon; Solberg, Leif I; Drury, Patricia

2002-01-01

This paper presents the first empirical analysis of a 1997 initiative of the Buyers Health Care Action Group (BHCAG) known as Choice Plus. This initiative entailed direct contracts with provider-controlled delivery systems; annual care system bidding; public reports of consumer satisfaction and quality; uniform benefits; and risk-adjusted payment. After case-mix adjustment, hospital costs decreased, ambulatory care costs rose modestly, and pharmacy costs increased substantially. Process-oriented quality indicators were stable or improved. The BHCAG employer-to-provider direct contracting and consumer choice model appeared to perform reasonably well in containing costs, without measurable adverse effects on quality.

Impact of air pollution control costs on the cost and spatial arrangement of cellulosic biofuel production in the U.S.

PubMed

Murphy, Colin W; Parker, Nathan C

2014-02-18

Air pollution emissions regulation can affect the location, size, and technology choice of potential biofuel production facilities. Difficulty in obtaining air pollutant emission permits and the cost of air pollution control devices have been cited by some fuel producers as barriers to development. This paper expands on the Geospatial Bioenergy Systems Model (GBSM) to evaluate the effect of air pollution control costs on the availability, cost, and distribution of U.S. biofuel production by subjecting potential facility locations within U.S. Clean Air Act nonattainment areas, which exceed thresholds for healthy air quality, to additional costs. This paper compares three scenarios: one with air quality costs included, one without air quality costs, and one in which conversion facilities were prohibited in Clean Air Act nonattainment areas. While air quality regulation may substantially affect local decisions regarding siting or technology choices, their effect on the system as a whole is small. Most biofuel facilities are expected to be sited near to feedstock supplies, which are seldom in nonattainment areas. The average cost per unit of produced energy is less than 1% higher in the scenarios with air quality compliance costs than in scenarios without such costs. When facility construction is prohibited in nonattainment areas, the costs increase by slightly over 1%, due to increases in the distance feedstock is transported to facilities in attainment areas.

Preference-based comparative effectiveness and cost–effectiveness: a review and relevance of value-based medicine for vitreoretinal interventions.

PubMed

Brown, Melissa M; Brown, Gary C; Lieske, Heidi B; Lieske, P Alexander

2012-05-01

This analysis discusses the comparative effectiveness and cost-effectiveness of vitreoretinal interventions, measured in quality-adjusted life years (QALYs) and percentage patient value (PPV gain, or improvement in quality of life and/or length of life). The material is relevant since the Patient Protection and Affordable Care Act enacted by Congress with the support of the President has emphasized the critical importance of patient-based preferences. The majority of preference-based, comparative effectiveness and cost-effectiveness vitreoretinal interventions assessed in the US healthcare literature are Value-Based Medicine analyses, thus comparable. These interventions confer a mean patient (human) value gain (improvement in quality of life) of 8.3% [SD 6.3%, 95% confidence interval (CI) + 2.6%]. The average cost-utility of these vitreoretinal interventions is US$23 026/QALY (SD US$24 508, 95% CI + US$8770). Most vitreoretinal interventions are very cost effective using a conventional US standard of US$50 000/QALY as the upper anchor for a very cost-effective intervention, and the World Health Organization of approximately US$142 200/QALY as the upper anchor for a cost-effective intervention. Most vitreoretinal interventions confer considerable patient value and are very cost effective. Further standardization across healthcare is needed in the preference-based, comparative and cost-utility (cost-effectiveness) arena. The metrics of PPV (percentage patient value) gain and US$/PPV (dollars expended per percentage patient value gain) or financial value gain may be more user-friendly than the QALY.

Comparative Cost-Effectiveness of Conservative or Intensive Blood Pressure Treatment Guidelines in Adults Aged 35-74 Years: The Cardiovascular Disease Policy Model.

PubMed

Moise, Nathalie; Huang, Chen; Rodgers, Anthony; Kohli-Lynch, Ciaran N; Tzong, Keane Y; Coxson, Pamela G; Bibbins-Domingo, Kirsten; Goldman, Lee; Moran, Andrew E

2016-07-01

The population health effect and cost-effectiveness of implementing intensive blood pressure goals in high-cardiovascular disease (CVD) risk adults have not been described. Using the CVD Policy Model, CVD events, treatment costs, quality-adjusted life years, and drug and monitoring costs were simulated over 2016 to 2026 for hypertensive patients aged 35 to 74 years. We projected the effectiveness and costs of hypertension treatment according to the 2003 Joint National Committee (JNC)-7 or 2014 JNC8 guidelines, and then for adults aged ≥50 years, we assessed the cost-effectiveness of adding an intensive goal of systolic blood pressure <120 mm Hg for patients with CVD, chronic kidney disease, or 10-year CVD risk ≥15%. Incremental cost-effectiveness ratios <$50 000 per quality-adjusted life years gained were considered cost-effective. JNC7 strategies treat more patients and are more costly to implement compared with JNC8 strategies. Adding intensive systolic blood pressure goals for high-risk patients prevents an estimated 43 000 and 35 000 annual CVD events incremental to JNC8 and JNC7, respectively. Intensive strategies save costs in men and are cost-effective in women compared with JNC8 alone. At a willingness-to-pay threshold of $50 000 per quality-adjusted life years gained, JNC8+intensive had the highest probability of cost-effectiveness in women (82%) and JNC7+intensive the highest probability of cost-effectiveness in men (100%). Assuming higher drug and monitoring costs, adding intensive goals for high-risk patients remained consistently cost-effective in men, but not always in women. Among patients aged 35 to 74 years, adding intensive blood pressure goals for high-risk groups to current national hypertension treatment guidelines prevents additional CVD deaths while saving costs provided that medication costs are controlled. © 2016 American Heart Association, Inc.

Assessing the Quality of Economic Evaluations of FDA Novel Drug Approvals: A Systematic Review.

PubMed

Woersching, Alex L; Borrego, Matthew E; Raisch, Dennis W

2016-12-01

To systematically review and assess the quality of the novel drugs' economic evaluation literature in print during the drugs' early commercial availability following US regulatory approval. MEDLINE and the United Kingdom National Health Service Economic Evaluation Database were searched from 1946 through December 2011 for economic evaluations of the 50 novel drugs approved by the FDA in 2008 and 2009. The inclusion criteria were English-language, peer-reviewed, original economic evaluations (cost-utility, cost-effectiveness, cost-minimization, and cost-benefit analyses). We extracted and analyzed data from 36 articles considering 19 of the 50 drugs. Two reviewers assessed each publication's quality using the Quality of Health Economic Studies (QHES) instrument and summarized study quality on a 100-point scale. Study quality had a mean of 70.0 ± 16.2 QHES points. The only study characteristics associated with QHES score (with P < 0.05) were having used modeling or advanced statistics, 75.1 versus 61.9 without; using quality-adjusted life years as an outcome, 75.9 versus 64.7 without; and cost-utility versus cost-minimization analysis, 75.9 versus 58.7. Studies most often satisfied quality aspects about stating study design choices and least often satisfied aspects about justifying design choices. The reviewed literature considered a minority of the 2008-2009 novel drugs and had mixed study quality. Cost-effectiveness stakeholders might benefit from efforts to improve the quality and quantity of literature examining novel drugs. Editors and reviewers may support quality improvement by stringently imposing economic evaluation guidelines about justifying study design choices. © The Author(s) 2016.

Cost-Effectiveness Comparison of Imaging-Guided Prostate Biopsy Techniques: Systematic Transrectal Ultrasound, Direct In-Bore MRI, and Image Fusion.

PubMed

Venderink, Wulphert; Govers, Tim M; de Rooij, Maarten; Fütterer, Jurgen J; Sedelaar, J P Michiel

2017-05-01

Three commonly used prostate biopsy approaches are systematic transrectal ultrasound guided, direct in-bore MRI guided, and image fusion guided. The aim of this study was to calculate which strategy is most cost-effective. A decision tree and Markov model were developed to compare cost-effectiveness. Literature review and expert opinion were used as input. A strategy was deemed cost-effective if the costs of gaining one quality-adjusted life year (incremental cost-effectiveness ratio) did not exceed the willingness-to-pay threshold of €80,000 (≈$85,000 in January 2017). A base case analysis was performed to compare systematic transrectal ultrasound- and image fusion-guided biopsies. Because of a lack of appropriate literature regarding the accuracy of direct in-bore MRI-guided biopsy, a threshold analysis was performed. The incremental cost-effectiveness ratio for fusion-guided biopsy compared with systematic transrectal ultrasound-guided biopsy was €1386 ($1470) per quality-adjusted life year gained, which was below the willingness-to-pay threshold and thus assumed cost-effective. If MRI findings are normal in a patient with clinically significant prostate cancer, the sensitivity of direct in-bore MRI-guided biopsy has to be at least 88.8%. If that is the case, the incremental cost-effectiveness ratio is €80,000 per quality-adjusted life year gained and thus cost-effective. Fusion-guided biopsy seems to be cost-effective compared with systematic transrectal ultrasound-guided biopsy. Future research is needed to determine whether direct in-bore MRI-guided biopsy is the best pathway; in this study a threshold was calculated at which it would be cost-effective.

The Cost-Effectiveness of an Intensive Treatment Protocol for Severe Dyslexia in Children

ERIC Educational Resources Information Center

Hakkaart-van Roijen, Leona; Goettsch, Wim G.; Ekkebus, Michel; Gerretsen, Patty; Stolk, Elly A.

2011-01-01

Studies of interventions for dyslexia have focused entirely on outcomes related to literacy. In this study, we considered a broader picture assessing improved quality of life compared with costs. A model served as a tool to compare costs and effects of treatment according to a new protocol and care as usual. Quality of life was measured and valued…

Comparative effectiveness and cost-effectiveness of the implantable miniature telescope.

PubMed

Brown, Gary C; Brown, Melissa M; Lieske, Heidi B; Lieske, Philip A; Brown, Kathryn S; Lane, Stephen S

2011-09-01

To assess the preference-based comparative effectiveness (human value gain) and the cost-utility (cost-effectiveness) of a telescope prosthesis (implantable miniature telescope) for the treatment of end-stage, age-related macular degeneration (AMD). A value-based medicine, second-eye model, cost-utility analysis was performed to quantify the comparative effectiveness and cost-effectiveness of therapy with the telescope prosthesis. Published, evidence-based data from the IMT002 Study Group clinical trial. Ophthalmic utilities were obtained from a validated cohort of >1000 patients with ocular diseases. Comparative effectiveness data were converted from visual acuity to utility (value-based) format. The incremental costs (Medicare) of therapy versus no therapy were integrated with the value gain conferred by the telescope prosthesis to assess its average cost-utility. The incremental value gains and incremental costs of therapy referent to (1) a fellow eye cohort and (2) a fellow eye cohort of those who underwent intra-study cataract surgery were integrated in incremental cost-utility analyses. All value outcomes and costs were discounted at a 3% annual rate, as per the Panel on Cost-Effectiveness in Health and Medicine. Comparative effectiveness was quantified using the (1) quality-adjusted life-year (QALY) gain and (2) percent human value gain (improvement in quality of life). The QALY gain was integrated with incremental costs into the cost-utility ratio ($/QALY, or US dollars expended per QALY gained). The mean, discounted QALY gain associated with use of the telescope prosthesis over 12 years was 0.7577. When the QALY loss of 0.0004 attributable to the adverse events was factored into the model, the final QALY gain was 0.7573. This resulted in a 12.5% quality of life gain for the average patient during the 12 years of the model. The average cost-utility versus no therapy for use of the telescope prosthesis was $14389/QALY. The incremental cost-utility referent to control fellow eyes was $14063/QALY, whereas the incremental cost-utility referent to fellow eyes that underwent intra-study cataract surgery was $11805/QALY. Therapy with the telescope prosthesis considerably improves quality of life and at the same time is cost-effective by conventional standards. Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Cost-effectiveness of supported employment for veterans with spinal cord injuries.

PubMed

Sinnott, Patricia L; Joyce, Vilija; Su, Pon; Ottomanelli, Lisa; Goetz, Lance L; Wagner, Todd H

2014-07-01

To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs). Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI. SCI centers in the Veterans Health Administration. Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76). A vocational rehabilitation program of SE for veterans with SCI. Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities. Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care. An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Cost-effectiveness analysis of total ankle arthroplasty.

PubMed

SooHoo, Nelson F; Kominski, Gerald

2004-11-01

There is renewed interest in total ankle arthroplasty as an alternative to ankle fusion in the treatment of end-stage ankle arthritis. Despite a lack of long-term data on the clinical outcomes associated with these implants, the use of ankle arthroplasty is expanding. The purpose of this cost-effectiveness analysis was to evaluate whether the currently available literature justifies the emerging use of total ankle arthroplasty. This study also identifies thresholds for the durability and function of ankle prostheses that, if met, would support more widespread dissemination of this new technology. A decision model was created for the treatment of ankle arthritis. The literature was reviewed to identify possible outcomes and their probabilities following ankle fusion and ankle arthroplasty. Each outcome was weighted for quality of life with use of a utility factor, and effectiveness was expressed in units of quality-adjusted life years. Gross costs were estimated from Medicare charge and reimbursement data for the relevant codes. The effect of the uncertainty of estimates of costs and effectiveness was assessed with sensitivity analysis. The reference case of our model assumed a ten-year duration of survival of the prosthesis, resulting in an incremental cost-effectiveness ratio for ankle arthroplasty of $18,419 per quality-adjusted life year gained. This reflects a gain of 0.52 quality-adjusted life years at a cost of $9578 when ankle arthroplasty is chosen over fusion. This ratio compares favorably with the cost-effectiveness of other medical and surgical interventions. Sensitivity analysis determined that the cost per quality-adjusted life year gained with ankle arthroplasty rises above $50,000 if the prosthesis is assumed to fail before seven years. Treatment options with ratios above $50,000 per quality-adjusted life year are commonly considered to have limited cost-effectiveness. This threshold is also crossed when the theoretical functional advantages of ankle arthroplasty are eliminated in sensitivity analysis. The currently available literature has not yet shown that total ankle arthroplasty predictably results in levels of durability and function that make it cost-effective at this time. However, the reference case of this analysis does demonstrate that total ankle arthroplasty has the potential to be a cost-effective alternative to ankle fusion. This reference case assumes that the theoretical functional advantages of ankle arthroplasty over ankle fusion will be borne out in future clinical studies. Performance of total ankle replacement will be better justified if these thresholds are met in published long-term clinical trials.

In Search of Cost-Effective Schools.

ERIC Educational Resources Information Center

Raywid, Mary Anne; Shaheen, Thomas A.

1994-01-01

Examines major cost-effectiveness proposals, describing developments that highlight concerns over making schools cost effective. The article discusses ways to blend the concerns of educational quality, equity, and costs (district consolidations, shared service and facilities arrangements, new accountability strategies, new information systems,…

Cost-Effectiveness of Integrating Tobacco Cessation Into Post-Traumatic Stress Disorder Treatment.

PubMed

Barnett, Paul G; Jeffers, Abra; Smith, Mark W; Chow, Bruce K; McFall, Miles; Saxon, Andrew J

2016-03-01

We examined the cost-effectiveness of smoking cessation integrated with treatment for post-traumatic stress disorder (PTSD). Smoking veterans receiving care for PTSD (N = 943) were randomized to care integrated with smoking cessation versus referral to a smoking cessation clinic. Smoking cessation services, health care cost and utilization, quality of life, and biochemically-verified abstinence from cigarettes were assessed over 18-months of follow-up. Clinical outcomes were combined with literature on changes in smoking status and the effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness over a lifetime horizon. We discounted cost and outcomes at 3% per year and report costs in 2010 US dollars. The mean of smoking cessation services cost was $1286 in those randomized to integrated care and $551 in those receiving standard care (P < .001). There were no significant differences in the cost of mental health services or other care. After 12 months, prolonged biochemically verified abstinence was observed in 8.9% of those randomized to integrated care and 4.5% of those randomized to standard care (P = .004). The model projected that Integrated Care added $836 in lifetime cost and generated 0.0259 quality adjusted life years (QALYs), an incremental cost-effectiveness ratio of $32 257 per QALY. It was 86.0% likely to be cost-effective compared to a threshold of $100 000/QALY. Smoking cessation integrated with treatment for PTSD was cost-effective, within a broad confidence region, but less cost-effective than most other smoking cessation programs reported in the literature. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Cost-Effectiveness of Integrating Tobacco Cessation Into Post-Traumatic Stress Disorder Treatment

PubMed Central

Jeffers, Abra; Smith, Mark W.; Chow, Bruce K.; McFall, Miles; Saxon, Andrew J.

2016-01-01

Abstract Introduction: We examined the cost-effectiveness of smoking cessation integrated with treatment for post-traumatic stress disorder (PTSD). Methods: Smoking veterans receiving care for PTSD ( N = 943) were randomized to care integrated with smoking cessation versus referral to a smoking cessation clinic. Smoking cessation services, health care cost and utilization, quality of life, and biochemically-verified abstinence from cigarettes were assessed over 18-months of follow-up. Clinical outcomes were combined with literature on changes in smoking status and the effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness over a lifetime horizon. We discounted cost and outcomes at 3% per year and report costs in 2010 US dollars. Results: The mean of smoking cessation services cost was $1286 in those randomized to integrated care and $551 in those receiving standard care ( P < .001). There were no significant differences in the cost of mental health services or other care. After 12 months, prolonged biochemically verified abstinence was observed in 8.9% of those randomized to integrated care and 4.5% of those randomized to standard care ( P = .004). The model projected that Integrated Care added $836 in lifetime cost and generated 0.0259 quality adjusted life years (QALYs), an incremental cost-effectiveness ratio of $32 257 per QALY. It was 86.0% likely to be cost-effective compared to a threshold of $100 000/QALY. Conclusions: Smoking cessation integrated with treatment for PTSD was cost-effective, within a broad confidence region, but less cost-effective than most other smoking cessation programs reported in the literature. PMID:25943761

A Logistic Life Cycle Cost-Benefit Analysis of Power Quality Management in the Avionics Repair Facility

DTIC Science & Technology

1998-06-01

quality management can have on the intermediate level of maintenance. Power quality management is a preventative process that focuses on identifying and correcting problems that cause bad power. Using cost-benefit analysis we compare the effects of implementing a power quality management program at AIMD Lemoore and AIMD Fallon. The implementation of power quality management can result in wide scale logistical support changes in regards to the life cycle costs of maintaining the DoD’s current inventory

Cost-effectiveness of dabigatran for stroke prophylaxis in atrial fibrillation.

PubMed

Shah, Shimoli V; Gage, Brian F

2011-06-07

Recent studies have investigated alternatives to warfarin for stroke prophylaxis in patients with atrial fibrillation (AF), but whether these alternatives are cost-effective is unknown. On the basis of the results from Randomized Evaluation of Long Term Anticoagulation Therapy (RE-LY) and other trials, we developed a decision-analysis model to compare the cost and quality-adjusted survival of various antithrombotic therapies. We ran our Markov model in a hypothetical cohort of 70-year-old patients with AF using a cost-effectiveness threshold of $50 000/quality-adjusted life-year. We estimated the cost of dabigatran as US $9 a day. For a patient with an average risk of major hemorrhage (≈3%/y), the most cost-effective therapy depended on stroke risk. For patients with the lowest stroke rate (CHADS2 stroke score of 0), only aspirin was cost-effective. For patients with a moderate stroke rate (CHADS2 score of 1 or 2), warfarin was cost-effective unless the risk of hemorrhage was high or quality of international normalized ratio control was poor (time in the therapeutic range <57.1%). For patients with a high stroke risk (CHADS(2) stroke score ≥3), dabigatran 150 mg (twice daily) was cost-effective unless international normalized ratio control was excellent (time in the therapeutic range >72.6%). Neither dabigatran 110 mg nor dual therapy (aspirin and clopidogrel) was cost-effective. Dabigatran 150 mg (twice daily) was cost-effective in AF populations at high risk of hemorrhage or high risk of stroke unless international normalized ratio control with warfarin was excellent. Warfarin was cost-effective in moderate-risk AF populations unless international normalized ratio control was poor.

To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis.

PubMed

Richardson, Monica L; Elliott, Christopher S; Shaw, Jonathan G; Comiter, Craig V; Chen, Bertha; Sokol, Eric R

2013-10-01

We compare the cost-effectiveness of 3 strategies for the use of a mid urethral sling to prevent occult stress urinary incontinence in patients undergoing abdominal sacrocolpopexy. Using decision analysis modeling we compared cost-effectiveness during a 1-year postoperative period of 3 treatment approaches including 1) abdominal sacrocolpopexy alone with deferred option for mid urethral sling, 2) abdominal sacrocolpopexy with universal concomitant mid urethral sling and 3) preoperative urodynamic study for selective mid urethral sling. Using published data we modeled probabilities of stress urinary incontinence after abdominal sacrocolpopexy with or without mid urethral sling, the predictive value of urodynamic study to detect occult stress urinary incontinence and the likelihood of complications after mid urethral sling. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost-effectiveness ratio per quality adjusted life-years gained. In addition to base case analysis, 1-way sensitivity analyses were performed. In our model, universally performing mid urethral sling at abdominal sacrocolpopexy was the most cost-effective approach with an incremental cost per quality adjusted life-year gained of $2,867 compared to abdominal sacrocolpopexy alone. Preoperative urodynamic study was more costly and less effective than universally performing intraoperative mid urethral sling. The cost-effectiveness of abdominal sacrocolpopexy plus mid urethral sling was robust to sensitivity analysis with a cost-effectiveness ratio consistently below $20,000 per quality adjusted life-year. Universal concomitant mid urethral sling is the most cost-effective prophylaxis strategy for occult stress urinary incontinence in women undergoing abdominal sacrocolpopexy. The use of preoperative urodynamic study to guide mid urethral sling placement at abdominal sacrocolpopexy is not cost-effective. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study.

PubMed

Epstein, David; Bojke, Laura; Sculpher, Mark J

2009-07-14

To describe the long term costs, health benefits, and cost effectiveness of laparoscopic surgery compared with those of continued medical management for patients with gastro-oesophageal reflux disease (GORD). We estimated resource use and costs for the first year on the basis of data from the REFLUX trial. A Markov model was used to extrapolate cost and health benefit over a lifetime using data collected in the REFLUX trial and other sources. The model compared laparoscopic surgery and continued proton pump inhibitors in male patients aged 45 and stable on GORD medication. Laparoscopic surgery versus continued medical management. We estimated quality adjusted life years and GORD related costs to the health service over a lifetime. Sensitivity analyses considered other plausible scenarios, in particular size and duration of treatment effect and the GORD symptoms of patients in whom surgery is unsuccessful. Main results The base case model indicated that surgery is likely to be considered cost effective on average with an incremental cost effectiveness ratio of pound2648 (euro3110; US$4385) per quality adjusted life year and that the probability that surgery is cost effective is 0.94 at a threshold incremental cost effectiveness ratio of pound20 000. The results were sensitive to some assumptions within the extrapolation modelling. Surgery seems to be more cost effective on average than medical management in many of the scenarios examined in this study. Surgery might not be cost effective if the treatment effect does not persist over the long term, if patients who return to medical management have poor health related quality of life, or if proton pump inhibitors were cheaper. Further follow-up of patients from the REFLUX trial may be valuable. ISRCTN15517081.

Update on value-based medicine.

PubMed

Brown, Melissa M; Brown, Gary C

2013-05-01

To update concepts in Value-Based Medicine, especially in view of the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act assures that some variant of Value-Based Medicine cost-utility analysis will play a key role in the healthcare system. It identifies the highest quality care, thereby maximizing the most efficacious use of healthcare resources and empowering patients and physicians.Standardization is critical for the creation and acceptance of a Value-Based Medicine, cost-utility analysis, information system, since 27 million different input variants can go into a cost-utility analysis. Key among such standards is the use of patient preferences (utilities), as patients best understand the quality of life associated with their health states. The inclusion of societal costs, versus direct medical costs alone, demonstrates that medical interventions are more cost effective and, in many instances, provide a net financial return-on-investment to society referent to the direct medical costs expended. Value-Based Medicine provides a standardized methodology, integrating critical, patient, quality-of-life preferences, and societal costs, to allow the highest quality, most cost-effective care. Central to Value-Based Medicine is the concept that all patients deserve the interventions that provide the greatest patient value (improvement in quality of life and/or length of life).

The impact of economic evaluation on quality management in spine surgery

PubMed Central

2009-01-01

Health care expenditures are substantially increasing within the last two decades prompting the imperative need for economic evaluations in health care. Historically, economic evaluations in health care have been carried out by four approaches: (1) the human-capital approach (HCA), (2) cost-effectiveness analysis (CEA), (3) cost-utility analysis (CUA) and (4) cost-benefit analysis (CBA). While the HCA cannot be recommended because of methodological shortcomings, CEA and CUA have been used frequently in healthcare. In CEA, costs are measured in monetary terms and health effects are measured in a non-monetary unit, e.g. number of successfully treated patients. In an attempt to develop an effectiveness measure that incorporates effects on both quantity and quality of life, so-called Quality Adjusted Life Years (QUALYs) were introduced. Contingent valuation surveys are used in cost-benefit analyses (CBA) to elicit the consumer’s monetary valuations for program benefits by applying the willingness-to-pay approach. A distinguished feature of CBA is that costs and benefits are expressed in the same units of value, i.e. money. Only recently, economic evaluations have started to explore various spinal interventions particularly the very expensive fusion operations. While most of the studies used CEA or CUA approaches, CBAs are still rare. Most studies fail to show that sophisticated spinal interventions are more cost-effective than conventional treatments. In spite of the lack of therapeutic or cost-effectiveness for most spinal surgeries, there is rapidly growing spinal implant market demonstrating market imperfection and information asymmetry. A change can only be anticipated when physicians start to focus on the improvement of health care quality as documented by outcome research and economic evaluations of cost-effectiveness and net benefits. PMID:19337760

The economic effect of Planet Health on preventing bulimia nervosa.

PubMed

Wang, Li Yan; Nichols, Lauren P; Austin, S Bryn

2011-08-01

To assess the economic effect of the school-based obesity prevention program Planet Health on preventing disordered weight control behaviors and to determine the cost-effectiveness of the intervention in terms of its combined effect on prevention of obesity and disordered weight control behaviors. On the basis of the intervention's short-term effect on disordered weight control behaviors prevention, we projected the number of girls who were prevented from developing bulimia nervosa by age 17 years. We further estimated medical costs saved and quality-adjusted life years gained by the intervention over 10 years. As a final step, we compared the intervention costs with the combined intervention benefits from both obesity prevention (reported previously) and prevention of disordered weight control behaviors to determine the overall cost-effectiveness of the intervention. Middle schools. A sample of 254 intervention girls aged 10 to 14 years. The Planet Health program was implemented during the school years from 1995 to 1997 and was designed to promote healthful nutrition and physical activity among youth. Intervention costs, medical costs saved, quality-adjusted life years gained, and cost-effectiveness ratio. An estimated 1 case of bulimia nervosa would have been prevented. As a result, an estimated $33 999 in medical costs and 0.7 quality-adjusted life years would be saved. At an intervention cost of $46 803, the combined prevention of obesity and disordered weight control behaviors would yield a net savings of $14 238 and a gain of 4.8 quality-adjusted life years. Primary prevention programs, such as Planet Health, warrant careful consideration by policy makers and program planners. The findings of this study provide additional argument for integrated prevention of obesity and eating disorders.

The impact of economic evaluation on quality management in spine surgery.

PubMed

Boos, Norbert

2009-08-01

Health care expenditures are substantially increasing within the last two decades prompting the imperative need for economic evaluations in health care. Historically, economic evaluations in health care have been carried out by four approaches: (1) the human-capital approach (HCA), (2) cost-effectiveness analysis (CEA), (3) cost-utility analysis (CUA) and (4) cost-benefit analysis (CBA). While the HCA cannot be recommended because of methodological shortcomings, CEA and CUA have been used frequently in healthcare. In CEA, costs are measured in monetary terms and health effects are measured in a non-monetary unit, e.g. number of successfully treated patients. In an attempt to develop an effectiveness measure that incorporates effects on both quantity and quality of life, so-called Quality Adjusted Life Years (QUALYs) were introduced. Contingent valuation surveys are used in cost-benefit analyses (CBA) to elicit the consumer's monetary valuations for program benefits by applying the willingness-to-pay approach. A distinguished feature of CBA is that costs and benefits are expressed in the same units of value, i.e. money. Only recently, economic evaluations have started to explore various spinal interventions particularly the very expensive fusion operations. While most of the studies used CEA or CUA approaches, CBAs are still rare. Most studies fail to show that sophisticated spinal interventions are more cost-effective than conventional treatments. In spite of the lack of therapeutic or cost-effectiveness for most spinal surgeries, there is rapidly growing spinal implant market demonstrating market imperfection and information asymmetry. A change can only be anticipated when physicians start to focus on the improvement of health care quality as documented by outcome research and economic evaluations of cost-effectiveness and net benefits.

[Cost-effectiveness analysis of an alternative for the provision of primary health care for beneficiaries of Seguro Popular in Mexico].

PubMed

Figueroa-Lara, Alejandro; González-Block, Miguel A

2016-01-01

To estimate the cost-effectiveness ratio of public and private health care providers funded by Seguro Popular. A pilot contracting primary care health care scheme in the state of Hidalgo, Mexico, was evaluated through a population survey to assess quality of care and detection decreased of vision. Costs were assessed from the payer perspective using institutional sources.The alternatives analyzed were a private provider with capitated and performance-based payment modalities, and a public provider funded through budget subsidies. Sensitivity analysis was performed using Monte Carlo simulations. The private provider is dominant in the quality and cost-effective detection of decreased vision. Strategic purchasing of private providers of primary care has shown promising results as an alternative to improving quality of health services and reducing costs.

Economic Evaluation of Telemedicine for Patients in ICUs.

PubMed

Yoo, Byung-Kwang; Kim, Minchul; Sasaki, Tomoko; Melnikow, Joy; Marcin, James P

2016-02-01

Despite telemedicine's potential to improve patients' health outcomes and reduce costs in the ICU, hospitals have been slow to introduce telemedicine in the ICU due to high up-front costs and mixed evidence on effectiveness. This study's first aim was to conduct a cost-effectiveness analysis to estimate the incremental cost-effectiveness ratio of telemedicine in the ICU, compared with ICU without telemedicine, from the healthcare system perspective. The second aim was to examine potential cost saving of telemedicine in the ICU through probabilistic analyses and break-even analyses. Simulation analyses performed by standard decision models. Hypothetical ICU defined by the U.S. literature. Hypothetical adult patients in ICU defined by the U.S. literature. The intervention was the introduction of telemedicine in the ICU, which was assumed to affect per-patient per-hospital-stay ICU cost and hospital mortality. Telemedicine in the ICU operation costs included the telemedicine equipment-installation (start-up) costs with 5-year depreciation, maintenance costs, and clinician staffing costs. Telemedicine in the ICU effectiveness was measured by cumulative quality-adjusted life years for 5 years after ICU discharge. The base case cost-effectiveness analysis estimated telemedicine in the ICU to extend 0.011 quality-adjusted life years with an incremental cost of $516 per patient compared with ICU without telemedicine, resulting in an incremental cost-effectiveness ratio of $45,320 per additional quality-adjusted life year (= $516/0.011). The probabilistic cost-effectiveness analysis estimated an incremental cost-effectiveness ratio of $50,265 with a wide 95% CI from a negative value (suggesting cost savings) to $375,870. These probabilistic analyses projected that cost saving is achieved 37% of 1,000 iterations. Cost saving is also feasible if the per-patient per-hospital-stay operational cost and physician cost were less than $422 and less than $155, respectively, based on break-even analyses. Our analyses suggest that telemedicine in the ICU is cost-effective in most cases and cost saving in some cases. The thresholds of cost and effectiveness, estimated by break-even analyses, help hospitals determine the impact of telemedicine in the ICU and potential cost saving.

Introducing nonpoint source transferable quotas in nitrogen trading: The effects of transaction costs and uncertainty.

PubMed

Zhou, Xiuru; Ye, Weili; Zhang, Bing

2016-03-01

Transaction costs and uncertainty are considered to be significant obstacles in the emissions trading market, especially for including nonpoint source in water quality trading. This study develops a nonlinear programming model to simulate how uncertainty and transaction costs affect the performance of point/nonpoint source (PS/NPS) water quality trading in the Lake Tai watershed, China. The results demonstrate that PS/NPS water quality trading is a highly cost-effective instrument for emissions abatement in the Lake Tai watershed, which can save 89.33% on pollution abatement costs compared to trading only between nonpoint sources. However, uncertainty can significantly reduce the cost-effectiveness by reducing trading volume. In addition, transaction costs from bargaining and decision making raise total pollution abatement costs directly and cause the offset system to deviate from the optimal state. While proper investment in monitoring and measuring of nonpoint emissions can decrease uncertainty and save on the total abatement costs. Finally, we show that the dispersed ownership of China's farmland will bring high uncertainty and transaction costs into the PS/NPS offset system, even if the pollution abatement cost is lower than for point sources. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Effects of Quality of Care on Costs: A Conceptual Framework

PubMed Central

Nuckols, Teryl K; Escarce, José J; Asch, Steven M

2013-01-01

Context The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs. Methods We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources. Findings The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain. Conclusions The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status–related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality. PMID:23758513

Can Nonurgent Emergency Department Care Costs be Reduced? Empirical Evidence from a U.S. Nationally Representative Sample.

PubMed

Xin, Haichang; Kilgore, Meredith L; Sen, Bisakha Pia; Blackburn, Justin

2015-09-01

A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs. Copyright © 2015 Elsevier Inc. All rights reserved.

Cost-effectiveness analysis of adjunct VSL#3 therapy versus standard medical therapy in pediatric ulcerative colitis.

PubMed

Park, K T; Perez, Felipe; Tsai, Raymond; Honkanen, Anita; Bass, Dorsey; Garber, Alan

2011-11-01

Inflammatory bowel diseases (IBDs) are costly chronic gastrointestinal diseases, with pediatric IBD representing increased costs per patient compared to adult disease. Health care expenditures for ulcerative colitis (UC) are >$2 billion annually. It is not clear whether the addition of VSL#3 to standard medical therapy in UC induction and maintenance of remission is a cost-effective strategy. We performed a systematic review of the literature and created a Markov model simulating a cohort of 10-year-old patients with severe UC, studying them until 100 years of age or death. We compared 2 strategies: standard medical therapy versus medical therapy + VSL#3. For both strategies, we assumed that patients progressed through escalating therapies--mesalamine, azathioprine, and infliximab--before receiving a colectomy + ileal pouch anal anastamosis (IPAA) if the 3 medical therapy options were exhausted. The primary outcome measure was the incremental cost-effectiveness ratio (ICER), defined as the difference of costs between strategies for each quality-adjusted life-year (QALY) gained. One-way sensitivity analyses were performed on variables to determine the key variables affecting cost-effectiveness. Standard medical care accrued a lifetime cost of $203,317 per patient, compared to $212,582 per patient for medical therapy + VSL#3. Lifetime QALYs gained was comparable for standard medical therapy and medical therapy + VSL#3 at 24.93 versus 25.05, respectively. Using the definition of ICER <50,000/QALY as a cost-effective intervention, medical therapy + VSL#3 produced an ICER of $79,910 per QALY gained, making this strategy cost-ineffective. Sensitivity analyses showed that 4 key parameters could affect the cost-effectiveness of the 2 strategies: cost of colectomy + IPAA, maintenance cost after surgery, probability of developing pouchitis after surgery, and the quality of life after a colectomy + IPAA. High surgical and postsurgical costs, a high probability of developing pouchitis, and a low quality of life after a colectomy + IPAA could make adjunct VSL#3 use a cost-effective strategy. Given present data, adjunct VSL#3 use for pediatric UC induction and maintenance of remission is not cost-effective, although several key parameters could make this strategy cost-effective. The quality of life after an IPAA is the single most important variable predicting whether this procedure benefits patients over escalating standard medical therapy.

The effect on patient loyalty of service quality, patient visit experience and perceived switching costs: lessons from one Taiwan university hospital.

PubMed

Wang, Hsiu-Ling; Huang, Jun-Ying; Howng, Shen-Long

2011-02-01

The reimbursement system changed from fee-for-service to fixed prospective payments in Taiwan, the effect on the physician-patient's relationship is worth being studied. We examined the relationship between patient visit experience, cost perceptions and the two important aspects of quality of care, curing and interpersonal performance, and patients' loyalty to the hospital physicians. A total of 404 patients from an acute care hospital in Taiwan, Kaohsiung Medical University Hospital (KMUH), were investigated using a self-administered mailing survey. All measures including patient loyalty (PL), curing service quality (CSQ), interpersonal service quality (ISQ), visit experience (VE) and perceived switching costs (PSC), were adapted and modified from existing scales. Our results showed that the physician's CSQ and ISQ positively affected patients' loyalty to KMUH. The interaction between the main effects of service quality, patients' VE and three types of switching visit costs, yielded additional insights into the importance of service quality for patient retention. The CSQ of physicians becomes a more important determinant of loyalty than ISQ as patients' VE increases. The importance of CSQ and ISQ increases in relation to PL as the perceived procedural and relational costs of changing care providers increases. Neither CSQ nor ISQ has a reduced relationship with PL as the perceived financial costs of switching hospitals increase. Our study indicates that the impact of CSQ and ISQ on loyalty varies according to the perceived visit costs of changing hospitals and the patients' VE.

The value-based medicine comparative effectiveness and cost-effectiveness of penetrating keratoplasty for keratoconus.

PubMed

Roe, Richard H; Lass, Jonathan H; Brown, Gary C; Brown, Melissa M

2008-10-01

To perform a base case, comparative effectiveness, and cost-effectiveness (cost-utility) analysis of penetrating keratoplasty for patients with severe keratoconus. Visual acuity data were obtained from a large, retrospective multicenter study in which patients with keratoconus with less than 20/40 best corrected visual acuity and/or the inability to wear contact lenses underwent penetrating keratoplasty, with an average follow-up of 2.1 years. The results were combined with other retrospective studies investigating complication rates of penetrating keratoplasty. The data were then incorporated into a cost-utility model using patient preference-based, time trade-off utilities, computer-based decision analysis, and a net present value model to account for the time value of outcomes and money. The comparative effectiveness of the intervention is expressed in quality-of-life gain and QALYs (quality-adjusted life-years), and the cost-effectiveness results are expressed in the outcome of $/QALY (dollars spent per QALY). Penetrating keratoplasty in 1 eye for patients with severe keratoconus results in a comparative effectiveness (value gain) of 16.5% improvement in quality of life every day over the 44-year life expectancy of the average patient with severe keratoconus. Discounting the total value gain of 5.36 QALYs at a 3% annual discount rate yields 3.05 QALYs gained. The incremental cost for penetrating keratoplasty, including all complications, is $5934 ($5913 discounted at 3% per year). Thus, the incremental cost-utility (discounted at 3% annually) for this intervention is $5913/3.05 QALYs = $1942/QALY. If both eyes undergo corneal transplant, the total discounted value gain is 30% and the overall cost-utility is $2003. Surgery on the second eye confers a total discounted value gain of 2.5 QALYs, yielding a quality-of-life gain of 11.6% and a discounted cost-utility of $2238/QALY. Penetrating keratoplasty for patients with severe keratoconus seems to be a comparatively effective and cost-effective procedure when compared with other interventions across different medical specialties.

Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL.

PubMed

Freeman, James V; Hutton, David W; Barnes, Geoffrey D; Zhu, Ruo P; Owens, Douglas K; Garber, Alan M; Go, Alan S; Hlatky, Mark A; Heidenreich, Paul A; Wang, Paul J; Al-Ahmad, Amin; Turakhia, Mintu P

2016-06-01

Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data. We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation. Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice. © 2016 American Heart Association, Inc.

Smoke Alarm Giveaway and Installation Programs

PubMed Central

Liu, Ying; Mack, Karin A.; Diekman, Shane T.

2015-01-01

Background The burden of residential fire injury and death is substantial. Targeted smoke alarm giveaway and installation programs are popular interventions used to reduce residential fire mortality and morbidity. Purpose To evaluate the cost effectiveness and cost benefit of implementing a giveaway or installation program in a small hypothetic community with a high risk of fire death and injury through a decision-analysis model. Methods Model inputs included program costs; program effectiveness (life-years and quality-adjusted life-years saved); and monetized program benefits (medical cost, productivity, property loss and quality-of-life losses averted) and were identified through structured reviews of existing literature (done in 2011) and supplemented by expert opinion. Future costs and effectiveness were discounted at a rate of 3% per year. All costs were expressed in 2011 U.S. dollars. Results Cost-effectiveness analysis (CEA) resulted in anaverage cost-effectiveness ratio (ACER) of $51,404 per quality-adjusted life-years (QALYs) saved and $45,630 per QALY for the giveaway and installation programs, respectively. Cost–benefit analysis (CBA) showed that both programs were associated with a positive net benefit with a benefit–cost ratio of 2.1 and 2.3, respectively. Smoke alarm functional rate, baseline prevalence of functional alarms, and baseline home fire death rate were among the most influential factors for the CEA and CBA results. Conclusions Both giveaway and installation programs have an average cost-effectiveness ratio similar to or lower than the median cost-effectiveness ratio reported for other interventionsto reduce fatal injuries in homes. Although more effort is required, installation programs result in lower cost per outcome achieved compared with giveaways. PMID:22992356

Design of the Economic Evaluation for the Interventional Management of Stroke (III) Trial

PubMed Central

Mauldin, Patrick D.; Simpson, Kit N.; Palesch, Yuko Y.; Spilker, Judy S.; Hill, Michael D.; Khatri, Pooja; Broderick, Joseph P.

2011-01-01

SUMMARY Rationale Stroke is a common and costly condition where an effective early reatment may be expected to affect patients’ future quality of life, the cost of acute medical treatment, and the cost of rehabilitation and any supportive care needed for their remaining lifetime. To assist in informing discussions on early adoption of potential treatments, economic analyses should accompany investigations that seek to improve outcomes for stroke patients. Aims The primary aim is to assess whether IV/IA rt-PA therapy is cost-effective at 3 months compared to IV rt-PA, and provides cost-savings or is cost-neutral by 12 months. Design Cost-effectiveness of the two treatment arms will be measured at months 3, 6, 9, and 12. Cost-effectiveness will be calculated using 1) standard cost-effectiveness methodology (Incremental Cost-Effectiveness Ratios), and 2) an econometric model to assess multiple outcome measures while controlling for multiple subject and treatment-related factors that are known to affect both outcomes and costs. Study Outcomes Total cost for the initial hospitalization of treating stroke subjects randomized to either IV/IA or IV rt-PA treatment arms will be measured, as will differences in types of resource utilization over 12 months between the two arms of the trial. Quality-of-life data (EuroQol EQ-5D) will be collected over a 12-month period and quality adjusted life years (QALYs) will be used as a morbidity-adjusted measure of effectiveness. Subgroup analyses will include dichotomized NIH Stroke Scale (<20, ≥20), country, time between onset and randomization, and IA devices. PMID:18706008

The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda

PubMed Central

Karamagi, Esther; Kigonya, Angella; Lawino, Anna; Marquez, Lani; Lunsford, Sarah Smith; Twinomugisha, Albert

2018-01-01

Background Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M—providing a written manual; MH—providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC—manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care. Methods This controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions. Results The most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35% improvement), anesthesia administration (20% improvement), and post-operative instructions (37% improvement). The least intensive method (M; $1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality. Conclusion Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda. PMID:29672578

Cost-effectiveness of subthalmic nucleus deep brain stimulation for the treatment of advanced Parkinson disease in Hong Kong: a prospective study.

PubMed

Zhu, X L; Chan, Danny T M; Lau, Claire K Y; Poon, Wai S; Mok, Vincent C T; Chan, Anne Y Y; Wong, Lawrence K S; Yeung, Jonas H M; Leung, Michael C M; Tang, Venus Y H; Wong, Rosanna K M; Yeung, Carol

2014-12-01

Deep brain stimulation (DBS) is an effective but costly treatment for patients with advanced Parkinson disease (PD). This study examined the cost-effectiveness of DBS in relation to its improved effectiveness to help funding decision makers decide whether the treatment should be adopted. The incremental cost-effective ratio (ICER) per quality-adjusted life year has been benchmarked as being between US$50,000 and US$100,000 by US agencies, whereas it is less than €30,000 per quality-adjusted life year in Europe. To provide cost-effectiveness information of subthalamic nucleus DBS for patients with advanced PD. Direct medical expenses during the year before the DBS treatment were used to measure the baseline cost. Cost-effectiveness was measured by the ICER for the Unified Parkinson's Disease Rating Scale Part III and the ICER for the EuroQol Group's Health-Related Quality of Life measurement. Thirteen patients with advanced PD were recruited between January 2009 and January 2011. A 1-point improvement in the Unified Parkinson's Disease Rating Scale Part III score was associated with an ICER of US$926 in the first year and US$421 in the second year. A 1-point improvement on the EuroQol Group's Health-Related Quality of Life measurement was associated with an ICER of US$123,110 in the first year and US$62,846 in the second year. Cost-effectiveness of subthalamic nucleus DBS for treatment of advanced PD is greater during a 2-year period than 1 year only. These results can be used as a reference for the use of DBS for PD in a region with public health financing. Copyright © 2014 Elsevier Inc. All rights reserved.

Systematic review of cost effectiveness studies of telemedicine interventions

PubMed Central

Whitten, Pamela S; Mair, Frances S; Haycox, Alan; May, Carl R; Williams, Tracy L; Hellmich, Seth

2002-01-01

Objectives To systematically review cost benefit studies of telemedicine. Design Systematic review of English language, peer reviewed journal articles. Data sources Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. Studies selected 55 of 612 identified articles that presented actual cost benefit data. Main outcome measures Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. Results 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the “value for money” that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. Conclusion There is no good evidence that telemedicine is a cost effective means of delivering health care. What is already known on this topicThe use of telemedicine has garnered much attention in the past decadeHundreds of articles have been published claiming that telemedicine is cost effectiveHowever, missing from the literature is a synthesis or meta-analysis of these publicationsWhat this study addsA comprehensive literature search of cost related articles on telemedicine identified more than 600 articles, but only 9% contained any cost benefit dataOnly 4% of these articles met quality criteria justifying inclusion in a formalised quality review, and most of these were small scale, short term, pragmatic evaluations with few generalisable conclusionsThere is little published evidence to confirm whether or not telemedicine is a cost effective alternative to standard healthcare delivery PMID:12065269

A PRELIMINARY METHODOLOGY FOR EVALUATING THE COST-EFFECTIVENESS OF ALTERNATIVE INDOOR AIR QUALITY APPROACHES

EPA Science Inventory

The report defines a simplified methodology that can be used by indoor air quality (IAQ) diagnosticians, architects/engineers, building owners/operators, and the scientific community for preliminary comparison of the cost-effectiveness of alternative IAQ control measures for any ...

Congestion Mitigation and Air Quality (CMAQ) Improvement Program: Cost-Effectiveness Tables Development and Methodology

DOT National Transportation Integrated Search

2015-05-01

This document presents summary and detailed findings from a research effort to develop estimates of the cost-effectiveness of a range of project types funded under the Congestion Mitigation and Air Quality (CMAQ) Improvement Program. In this study, c...

Cost-utility analysis of a three-month exercise programme vs usual care following multidisciplinary rehabilitation for chronic low back pain.

PubMed

Henchoz, Yves; Pinget, Christophe; Wasserfallen, Jean-Blaise; Paillex, Roland; de Goumoëns, Pierre; Norberg, Michael; Kai-Lik So, Alexander

2010-10-01

To assess the cost-utility of an exercise programme vs usual care after functional multidisciplinary rehabilitation in patients with chronic low back pain. Cost-utility analysis alongside a randomized controlled trial. A total of 105 patients with chronic low back pain. Chronic low back pain patients completing a 3-week functional multidisciplinary rehabilitation were randomized to either a 3-month exercise programme (n = 56) or usual care (n = 49). The exercise programme consisted of 24 training sessions during 12 weeks. At the end of functional multidisciplinary rehabilitation and at 1-year follow-up quality of life was measured with the SF-36 questionnaire, converted into utilities and transformed into quality--adjusted life years. Direct and indirect monthly costs were measured using cost diaries. The incremental cost-effectiveness ratio was calculated as the incremental cost of the exercise programme divided by the difference in quality-adjusted life years between both groups. Quality of life improved significantly at 1-year follow-up in both groups. Similarly, both groups significantly reduced total monthly costs over time. No significant difference was observed between groups. The incremental cost-effectiveness ratio was 79,270 euros. Adding an exercise programme after functional multidisciplinary rehabilitation compared with usual care does not offer significant long-term benefits in quality of life and direct and indirect costs.

Cost effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing permanent colostomy for rectal cancer.

PubMed

Lee, Lawrence; Saleem, Abdulaziz; Landry, Tara; Latimer, Eric; Chaudhury, Prosanto; Feldman, Liane S

2014-01-01

Parastomal hernia (PSH) is common after stoma formation. Studies have reported that mesh prophylaxis reduces PSH, but there are no cost-effectiveness data. Our objective was to determine the cost effectiveness of mesh prophylaxis vs no prophylaxis to prevent PSH in patients undergoing abdominoperineal resection with permanent colostomy for rectal cancer. Using a cohort Markov model, we modeled the costs and effectiveness of mesh prophylaxis vs no prophylaxis at the index operation in a cohort of 60-year-old patients undergoing abdominoperineal resection for rectal cancer during a time horizon of 5 years. Costs were expressed in 2012 Canadian dollars (CAD$) and effectiveness in quality-adjusted life years. Deterministic and probabilistic sensitivity analyses were performed. In patients with stage I to III rectal cancer, prophylactic mesh was dominant (less costly and more effective) compared with no mesh. In patients with stage IV disease, mesh prophylaxis was associated with higher cost (CAD$495 more) and minimally increased effectiveness (0.05 additional quality-adjusted life years), resulting in an incremental cost-effectiveness ratio of CAD$10,818 per quality-adjusted life year. On sensitivity analyses, the decision was sensitive to the probability of mesh infection and the cost of the mesh, and method of diagnosing PSH. In patients undergoing abdominoperineal resection with permanent colostomy for rectal cancer, mesh prophylaxis might be the less costly and more effective strategy compared with no mesh to prevent PSH in patients with stage I to III disease, and might be cost effective in patients with stage IV disease. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The cost-effectiveness of TheraBite® as treatment for acute myogenic temporomandibular disorder.

PubMed

Heres Diddens, Andreas; Kraaijenga, Sophie; Coupé, Veerle; Hilgers, Frans; van der Molen, Lisette; Smeele, Ludi; Retèl, Valesca

2017-09-01

Temporomandibular disorder (TMD) is a very common and costly pain problem concerning the temporomandibular joint. A previous study has shown that for the treatment of acute myogenic TMD, TheraBite® (TB) offers a faster and greater effect than usual care consisting of physical therapy (PT). This study estimates the cost-effectiveness of TB compared to PT. Differences in costs and quality-adjusted life-years (QALYs) between TB and PT are analyzed using a decision model. The point estimate for the incremental cost-effectiveness ratio is -28,068 EUR (-30,191 USD) per QALY (dominant) for TB versus PT. At the willingness-to-pay ratio of 20,000 EUR (21,513 USD) per QALY, TB has a 97% probability of being cost-effective compared to PT. TB is expected to be cost-effective compared to PT for the treatment of acute myogenic TMD, offering faster recovery of quality of life for patients, at a lower cost to society.

Cost effectiveness of population based BRCA1 founder mutation testing in Sephardi Jewish women.

PubMed

Patel, Shreeya; Legood, Rosa; Evans, D Gareth; Turnbull, Clare; Antoniou, Antonis C; Menon, Usha; Jacobs, Ian; Manchanda, Ranjit

2018-04-01

Population-based BRCA1/BRCA2 founder-mutation testing has been demonstrated as cost effective compared with family history based testing in Ashkenazi Jewish women. However, only 1 of the 3 Ashkenazi Jewish BRCA1/BRCA2 founder mutations (185delAG[c.68_69delAG]), 5382insC[c.5266dupC]), and 6174delT[c.5946delT]) is found in the Sephardi Jewish population (185delAG[c.68_69delAG]), and the overall prevalence of BRCA mutations in the Sephardi Jewish population is accordingly lower (0.7% compared with 2.5% in the Ashkenazi Jewish population). Cost-effectiveness analyses of BRCA testing have not previously been performed at these lower BRCA prevalence levels seen in the Sephardi Jewish population. Here we present a cost-effectiveness analysis for UK and US populations comparing population testing with clinical criteria/family history-based testing in Sephardi Jewish women. A Markov model was built comparing the lifetime costs and effects of population-based BRCA1 testing, with testing using family history-based clinical criteria in Sephardi Jewish women aged ≥30 years. BRCA1 carriers identified were offered magnetic resonance imaging/mammograms and risk-reducing surgery. Costs are reported at 2015 prices. Outcomes include breast cancer, ovarian cancer, and excess deaths from heart disease. All costs and outcomes are discounted at 3.5%. The time horizon is lifetime, and perspective is payer. The incremental cost-effectiveness ratio per quality-adjusted life-year was calculated. Parameter uncertainty was evaluated through 1-way and probabilistic sensitivity analysis. Population testing resulted in gain in life expectancy of 12 months (quality-adjusted life-year = 1.00). The baseline discounted incremental cost-effectiveness ratio for UK population-based testing was £67.04/quality-adjusted life-year and for US population was $308.42/quality-adjusted life-year. Results were robust in the 1-way sensitivity analysis. The probabilistic sensitivity analysis showed 100% of simulations were cost effective at £20,000/quality-adjusted life-year UK and the $100,000/quality-adjusted life-year US willingness-to-pay thresholds. Scenario analysis showed that population testing remains cost effective in UK and US populations, even if premenopausal oophorectomy does not reduce breast cancer risk or if hormone replacement therapy compliance is nil. Population-based BRCA1 testing is highly cost effective compared with clinical criteria-driven approach in Sephardi Jewish women. This supports changing the paradigm to population-based BRCA testing in the Jewish population, regardless of Ashkenazi/Sephardi ancestry. Copyright © 2017 Elsevier Inc. All rights reserved.

Preferred drug lists: potential impact on healthcare economics.

PubMed

Ovsag, Kimberly; Hydery, Sabrina; Mousa, Shaker A

2008-01-01

To analyze the implementation of Medicaid preferred drug lists (PDLs) in a number of states and determine its impact on quality of care and cost relative to other segments of healthcare. We reviewed research and case studies found by searching library databases, primarily MEDLINE and EBSCOHost, and searching pertinent journals. Keywords initially included "drug lists," "prior authorization," "prior approval," and "Medicaid." We added terms such as "influence use of other healthcare services," "quality of care," and "overall economic impact." We mainly used primary sources. Based on our literature review, we determined that there are a number of issues regarding Medicaid PDLs that need to be addressed. Some issues include: (a) the potential for PDLs to influence the utilization of other healthcare services, (b) criteria used by Medicaid for determining acceptance of drugs onto a PDL, (c) the effect of PDL implementation on compliance to new regimens, (d) the potential effects of restricting medication availability on quality of care, (e) administrative costs associated with PDLs, and (f) satisfaction rates among patients and medical providers. This review highlighted expected short-term cost savings with limited degree of compromised quality of PDL implementation, but raised the concern about the potential long-term decline in quality of care and overall economic impact. The number of concerns raised indicates that further studies are warranted regarding both short-term cost benefits as well as potential long-term effects of Medicaid PDL implementation. Objective analysis of these effects is necessary to ensure cost-effectiveness and quality of care.

The costs and cost-effectiveness of an integrated sepsis treatment protocol.

PubMed

Talmor, Daniel; Greenberg, Dan; Howell, Michael D; Lisbon, Alan; Novack, Victor; Shapiro, Nathan

2008-04-01

Sepsis is associated with high mortality and treatment costs. International guidelines recommend the implementation of integrated sepsis protocols; however, the true cost and cost-effectiveness of these are unknown. To assess the cost-effectiveness of an integrated sepsis protocol, as compared with conventional care. Prospective cohort study of consecutive patients presenting with septic shock and enrolled in the institution's integrated sepsis protocol. Clinical and economic outcomes were compared with a historical control cohort. Beth Israel Deaconess Medical Center. Overall, 79 patients presenting to the emergency department with septic shock in the treatment cohort and 51 patients in the control group. An integrated sepsis treatment protocol incorporating empirical antibiotics, early goal-directed therapy, intensive insulin therapy, lung-protective ventilation, and consideration for drotrecogin alfa and steroid therapy. In-hospital treatment costs were collected using the hospital's detailed accounting system. The cost-effectiveness analysis was performed from the perspective of the healthcare system using a lifetime horizon. The primary end point for the cost-effectiveness analysis was the incremental cost per quality-adjusted life year gained. Mortality in the treatment group was 20.3% vs. 29.4% in the control group (p = .23). Implementing an integrated sepsis protocol resulted in a mean increase in cost of approximately $8,800 per patient, largely driven by increased intensive care unit length of stay. Life expectancy and quality-adjusted life years were higher in the treatment group; 0.78 and 0.54, respectively. The protocol was associated with an incremental cost of $11,274 per life-year saved and a cost of $16,309 per quality-adjusted life year gained. In patients with septic shock, an integrated sepsis protocol, although not cost-saving, appears to be cost-effective and compares very favorably to other commonly delivered acute care interventions.

Quantifying the Impact of Feedstock Quality on the Design of Bioenergy Supply Chain Networks

DOE PAGES

Castillo-Villar, Krystel; Minor-Popocatl, Hertwin; Webb, Erin

2016-03-01

Logging residues, which refer to the unused portions of trees cut during logging, are important sources of biomass for the emerging biofuel industry and are critical feedstocks for the first-type biofuel facilities (e.g., corn-ethanol facilities). Logging residues are under-utilized sources of biomass for energetic purposes. To support the scaling-up of the bioenergy industry, it is essential to design cost-effective biofuel supply chains that not only minimize costs, but also consider the biomass quality characteristics. The biomass quality is heavily dependent upon the moisture and the ash contents. Ignoring the biomass quality characteristics and its intrinsic costs may yield substantial economicmore » losses that will only be discovered after operations at a biorefinery have begun. Here this paper proposes a novel bioenergy supply chain network design model that minimizes operational costs and includes the biomass quality-related costs. The proposed model is unique in the sense that it supports decisions where quality is not unrealistically assumed to be perfect. The effectiveness of the proposed methodology is proven by assessing a case study in the state of Tennessee, USA. The results demonstrate that the ash and moisture contents of logging residues affect the performance of the supply chain (in monetary terms). Higher-than-target moisture and ash contents incur in additional quality-related costs. The quality-related costs in the optimal solution (with final ash content of 1% and final moisture of 50%) account for 27% of overall supply chain cost. In conclusion, based on the numeral experimentation, the total supply chain cost increased 7%, on average, for each additional percent in the final ash content.« less

Quantifying the Impact of Feedstock Quality on the Design of Bioenergy Supply Chain Networks

DOE Office of Scientific and Technical Information (OSTI.GOV)

Castillo-Villar, Krystel; Minor-Popocatl, Hertwin; Webb, Erin

Logging residues, which refer to the unused portions of trees cut during logging, are important sources of biomass for the emerging biofuel industry and are critical feedstocks for the first-type biofuel facilities (e.g., corn-ethanol facilities). Logging residues are under-utilized sources of biomass for energetic purposes. To support the scaling-up of the bioenergy industry, it is essential to design cost-effective biofuel supply chains that not only minimize costs, but also consider the biomass quality characteristics. The biomass quality is heavily dependent upon the moisture and the ash contents. Ignoring the biomass quality characteristics and its intrinsic costs may yield substantial economicmore » losses that will only be discovered after operations at a biorefinery have begun. Here this paper proposes a novel bioenergy supply chain network design model that minimizes operational costs and includes the biomass quality-related costs. The proposed model is unique in the sense that it supports decisions where quality is not unrealistically assumed to be perfect. The effectiveness of the proposed methodology is proven by assessing a case study in the state of Tennessee, USA. The results demonstrate that the ash and moisture contents of logging residues affect the performance of the supply chain (in monetary terms). Higher-than-target moisture and ash contents incur in additional quality-related costs. The quality-related costs in the optimal solution (with final ash content of 1% and final moisture of 50%) account for 27% of overall supply chain cost. In conclusion, based on the numeral experimentation, the total supply chain cost increased 7%, on average, for each additional percent in the final ash content.« less

Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality.

PubMed

Bowblis, John R; Roberts, Amy Restorick

2018-06-01

Health care providers face fixed reimbursement rates from government sources and need to carefully adjust staffing to achieve the highest quality within a given cost structure. With data from the Certification and Survey Provider Enhanced Reports (1999-2015), this study holistically examined how staffing levels affect two publicly reported measures of quality in the nursing home industry, the number of deficiency citations and the deficiency score. While higher staffing consistently yielded better quality, the largest quality improvements resulted from increasing administrative registered nurses and social service staffing. After adjusting for wages, the most cost-effective investment for improving overall deficiency outcomes was increasing social services. Deficiencies related to quality of care were improved most by increasing administrative nursing and social service staff. Quality of life deficiencies were improved most by increasing social service and activities staff. Approaches to improve quality through staffing adjustments should target specific types of staff to maximize return on investment.

Cost-effectiveness of apixaban vs warfarin for secondary stroke prevention in atrial fibrillation

PubMed Central

Easton, J. Donald; Johnston, S. Claiborne; Kim, Anthony S.

2012-01-01

Objective: To compare the cost-effectiveness of apixaban vs warfarin for secondary stroke prevention in patients with atrial fibrillation (AF). Methods: Using standard methods, we created a Markov decision model based on the estimated cost of apixaban and data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial and other trials of warfarin therapy for AF. We quantified the cost and quality-adjusted life expectancy resulting from apixaban 5 mg twice daily compared with those from warfarin therapy targeted to an international normalized ratio of 2–3. Our base case population was a cohort of 70-year-old patients with no contraindication to anticoagulation and a history of stroke or TIA from nonvalvular AF. Results: Warfarin therapy resulted in a quality-adjusted life expectancy of 3.91 years at a cost of $378,500. In comparison, treatment with apixaban led to a quality-adjusted life expectancy of 4.19 years at a cost of $381,700. Therefore, apixaban provided a gain of 0.28 quality-adjusted life-years (QALYs) at an additional cost of $3,200, resulting in an incremental cost-effectiveness ratio of $11,400 per QALY. Our findings were robust in univariate sensitivity analyses varying model inputs across plausible ranges. In Monte Carlo analysis, apixaban was cost-effective in 62% of simulations using a threshold of $50,000 per QALY and 81% of simulations using a threshold of $100,000 per QALY. Conclusions: Apixaban appears to be cost-effective relative to warfarin for secondary stroke prevention in patients with AF, assuming that it is introduced at a price similar to that of dabigatran. PMID:22993279

An Economic Evaluation of a Video- and Text-Based Computer-Tailored Intervention for Smoking Cessation: A Cost-Effectiveness and Cost-Utility Analysis of a Randomized Controlled Trial

PubMed Central

Stanczyk, Nicola E.; Smit, Eline S.; Schulz, Daniela N.; de Vries, Hein; Bolman, Catherine; Muris, Jean W. M.; Evers, Silvia M. A. A.

2014-01-01

Background Although evidence exists for the effectiveness of web-based smoking cessation interventions, information about the cost-effectiveness of these interventions is limited. Objective The study investigated the cost-effectiveness and cost-utility of two web-based computer-tailored (CT) smoking cessation interventions (video- vs. text-based CT) compared to a control condition that received general text-based advice. Methods In a randomized controlled trial, respondents were allocated to the video-based condition (N = 670), the text-based condition (N = 708) or the control condition (N = 721). Societal costs, smoking status, and quality-adjusted life years (QALYs; EQ-5D-3L) were assessed at baseline, six-and twelve-month follow-up. The incremental costs per abstinent respondent and per QALYs gained were calculated. To account for uncertainty, bootstrapping techniques and sensitivity analyses were carried out. Results No significant differences were found in the three conditions regarding demographics, baseline values of outcomes and societal costs over the three months prior to baseline. Analyses using prolonged abstinence as outcome measure indicated that from a willingness to pay of €1,500, the video-based intervention was likely to be the most cost-effective treatment, whereas from a willingness to pay of €50,400, the text-based intervention was likely to be the most cost-effective. With regard to cost-utilities, when quality of life was used as outcome measure, the control condition had the highest probability of being the most preferable treatment. Sensitivity analyses yielded comparable results. Conclusion The video-based CT smoking cessation intervention was the most cost-effective treatment for smoking abstinence after twelve months, varying the willingness to pay per abstinent respondent from €0 up to €80,000. With regard to cost-utility, the control condition seemed to be the most preferable treatment. Probably, more time will be required to assess changes in quality of life. Future studies with longer follow-up periods are needed to investigate whether cost-utility results regarding quality of life may change in the long run. Trial Registration Nederlands Trial Register NTR3102 PMID:25310007

An economic evaluation of a video- and text-based computer-tailored intervention for smoking cessation: a cost-effectiveness and cost-utility analysis of a randomized controlled trial.

PubMed

Stanczyk, Nicola E; Smit, Eline S; Schulz, Daniela N; de Vries, Hein; Bolman, Catherine; Muris, Jean W M; Evers, Silvia M A A

2014-01-01

Although evidence exists for the effectiveness of web-based smoking cessation interventions, information about the cost-effectiveness of these interventions is limited. The study investigated the cost-effectiveness and cost-utility of two web-based computer-tailored (CT) smoking cessation interventions (video- vs. text-based CT) compared to a control condition that received general text-based advice. In a randomized controlled trial, respondents were allocated to the video-based condition (N = 670), the text-based condition (N = 708) or the control condition (N = 721). Societal costs, smoking status, and quality-adjusted life years (QALYs; EQ-5D-3L) were assessed at baseline, six-and twelve-month follow-up. The incremental costs per abstinent respondent and per QALYs gained were calculated. To account for uncertainty, bootstrapping techniques and sensitivity analyses were carried out. No significant differences were found in the three conditions regarding demographics, baseline values of outcomes and societal costs over the three months prior to baseline. Analyses using prolonged abstinence as outcome measure indicated that from a willingness to pay of €1,500, the video-based intervention was likely to be the most cost-effective treatment, whereas from a willingness to pay of €50,400, the text-based intervention was likely to be the most cost-effective. With regard to cost-utilities, when quality of life was used as outcome measure, the control condition had the highest probability of being the most preferable treatment. Sensitivity analyses yielded comparable results. The video-based CT smoking cessation intervention was the most cost-effective treatment for smoking abstinence after twelve months, varying the willingness to pay per abstinent respondent from €0 up to €80,000. With regard to cost-utility, the control condition seemed to be the most preferable treatment. Probably, more time will be required to assess changes in quality of life. Future studies with longer follow-up periods are needed to investigate whether cost-utility results regarding quality of life may change in the long run. Nederlands Trial Register NTR3102.

Cost Effectiveness of Monoclonal Antibody Therapy for Rare Diseases: A Systematic Review.

PubMed

Park, Taehwan; Griggs, Scott K; Suh, Dong-Churl

2015-08-01

Monoclonal antibody (mAb)-based orphan drugs have led to advances in the treatment of diseases by selectively targeting molecule functions. However, their high treatment costs impose a substantial cost burden on patients and society. The study aimed to systematically review cost-effectiveness evidence of mAb orphan drugs. Ovid MEDLINE(®), EMBASE(®), and PsycINFO(®) were searched in June 2014 and articles were selected if they conducted economic evaluations of the mAb orphan drugs that had received marketing approval in the USA. The quality of the selected studies was assessed using the Quality of Health Economic Studies (QHES) instrument. We reviewed 16 articles that included 24 economic evaluations of nine mAb orphan drugs. Six of these nine drugs were included in cost-utility analysis studies, whereas three drugs were included in cost-effectiveness analysis studies. Previous cost-utility analysis studies revealed that four mAb orphan drugs (cetuximab, ipilimumab, rituximab, and trastuzumab) were found to be cost effective; one drug (bevacizumab) was not cost effective; and one drug (infliximab) was not consistent across the studies. Prior cost-effectiveness analysis studies which included three mAb orphan drugs (adalimumab, alemtuzumab, and basiliximab) showed that the incremental cost per effectiveness gained for these drugs ranged from $US4669 to $Can52,536 Canadian dollars. The quality of the included studies was good or fair with the exception of one study. Some mAb orphan drugs were reported as cost effective under the current decision-making processes. Use of these expensive drugs, however, can raise an equity issue which concerns fairness in access to treatment. The issue of equal access to drugs needs to be considered alongside other societal values in making the final health policy decisions.

Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial.

PubMed

Briffa, Tom G; Eckermann, Simon D; Griffiths, Alison D; Harris, Phillip J; Heath, M Rose; Freedman, Saul B; Donaldson, Lana T; Briffa, N Kathryn; Keech, Anthony C

2005-11-07

To estimate the incremental effects on cost and quality of life of cardiac rehabilitation after an acute coronary syndrome. Open randomised controlled trial with 1 year's follow-up. Analysis was on an intention-to-treat basis. Two tertiary hospitals in Sydney. 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor. 113 patients aged 41-75 years who were self-caring and literate in English. Patients with uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis or physical impairment were excluded. Costs (hospitalisations, medication use, outpatient visits, investigations, and personal expenses); and measures of quality of life. Incremental cost per quality-adjusted life year (QALY) saved at 1 year (this estimate combines within-study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality). Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival, 3 years of treatment effect on survival and variations in utility. The estimated incremental cost per QALY saved for rehabilitation relative to standard care was 42,535 US dollars when modelling included the reported treatment effect on survival. This increased to 70,580 US dollars per QALY saved if treatment effect on survival was not included. The results were sensitive to variations in utility and ranged from 19,685 US dollars per QALY saved to rehabilitation not being cost-effective. The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome. The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee.

Cost effectiveness of adopted quality requirements in hospital laboratories.

PubMed

Hamza, Alneil; Ahmed-Abakur, Eltayib; Abugroun, Elsir; Bakhit, Siham; Holi, Mohamed

2013-01-01

The present study was designed in quasi-experiment to assess adoption of the essential clauses of particular clinical laboratory quality management requirements based on international organization for standardization (ISO 15189) in hospital laboratories and to evaluate the cost effectiveness of compliance to ISO 15189. The quality management intervention based on ISO 15189 was conceded through three phases; pre - intervention phase, Intervention phase and Post-intervention phase. In pre-intervention phase the compliance to ISO 15189 was 49% for study group vs. 47% for control group with P value 0.48, while the post intervention results displayed 54% vs. 79% for study group and control group respectively in compliance to ISO 15189 and statistically significant difference (P value 0.00) with effect size (Cohen's d) of (0.00) in pre-intervention phase and (0.99) in post - intervention phase. The annual average cost per-test for the study group and control group was 1.80 ± 0.25 vs. 1.97 ± 0.39, respectively with P value 0.39 whereas the post-intervention results showed that the annual average total costs per-test for study group and control group was 1.57 ± 0.23 vs 2.08 ± 0.38, P value 0.019 respectively, with cost-effectiveness ratio of (0.88) in pre -intervention phase and (0.52) in post-intervention phase. The planned adoption of quality management requirements (QMS) in clinical laboratories had great effect to increase the compliance percent with quality management system requirement, raise the average total cost effectiveness, and improve the analytical process capability of the testing procedure.

The costs and benefits of enhanced depression care to employers.

PubMed

Wang, Philip S; Patrick, Amanda; Avorn, Jerry; Azocar, Francisca; Ludman, Evette; McCulloch, Joyce; Simon, Gregory; Kessler, Ronald

2006-12-01

Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment. To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives. Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature. Hypothetical cohort of 40-year-old workers. Intervention Enhanced depression care consisting of a depression screen and care management for those depressed vs usual care. Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer's perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon. From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19 976 per quality-adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer's perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In 1-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions. If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers.

Cost-utility analysis of deep brain stimulation surgery plus best medical therapy versus best medical therapy in patients with Parkinson's: Economic evaluation alongside the PD SURG trial.

PubMed

McIntosh, Emma; Gray, Alastair; Daniels, Jane; Gill, Steven; Ives, Natalie; Jenkinson, Crispin; Mitchell, Rosalind; Pall, Hardev; Patel, Smitaa; Quinn, Niall; Rick, Caroline; Wheatley, Keith; Williams, Adrian

2016-08-01

Williams and colleagues reported that DBS surgery for patients with advanced PD improves motor function and quality of life compared to best medical therapy alone at 1 year, but with surgery-related side effects in a minority. This article reports on the economic evaluation alongside this trial. Detailed resource use and quality of life over 12 months after randomization was obtained from the trial reported by Williams and colleagues. Outcomes were measured using the EQ-5D and quality-adjusted life years calculated. Year 1 costs for surgery were significantly higher than in best medical therapy, at £19,069 compared to £9,813, a difference of £9,256 (95% confidence interval [CI]: £7,625, £10,887). There was a small, significant gain in utility at 1 year but a statistically insignificant gain of 0.02 quality-adjusted life years (95% CI: -0.015, 0.05) in the surgical arm. The incremental cost per quality-adjusted life year of surgery at 1 year was £468,528. Extrapolation reveals that after 5 years, this ratio is likely to reduce to £45,180, but subsequently rise to £70,537 at 10 years owing to the increased probability of battery replacements (and re-replacements) beyond 5 years. In this patient group, DBS is not cost-effective at 1 year. Extrapolation, however, reveals an increasing likelihood of cost-effectiveness up to 5 years and reducing cost-effectiveness between 5 and 10 years. These models are sensitive to assumptions about future costs and quality-adjusted life years gained. © 2016 International Parkinson and Movement Disorder Society. © 2016 International Parkinson and Movement Disorder Society.

Cost-effectiveness of a transitional home-based palliative care program for patients with end-stage heart failure.

PubMed

Wong, Frances Kam Yuet; So, Ching; Ng, Alina Yee Man; Lam, Po-Tin; Ng, Jeffrey Sheung Ching; Ng, Nancy Hiu Yim; Chau, June; Sham, Michael Mau Kwong

2018-02-01

Studies have shown positive clinical outcomes of specialist palliative care for end-stage heart failure patients, but cost-effectiveness evaluation is lacking. To examine the cost-effectiveness of a transitional home-based palliative care program for patients with end-stage heart failure patients as compared to the customary palliative care service. A cost-effectiveness analysis was conducted alongside a randomized controlled trial (Trial number: NCT02086305). The costs included pre-program training, intervention, and hospital use. Quality of life was measured using SF-6D. The study took place in three hospitals in Hong Kong. The inclusion criteria were meeting clinical indicators for end-stage heart failure patients including clinician-judged last year of life, discharged to home within the service area, and palliative care referral accepted. A total of 84 subjects (study = 43, control = 41) were recruited. When the study group was compared to the control group, the net incremental quality-adjusted life years gain was 0.0012 (28 days)/0.0077 (84 days) and the net incremental costs per case was -HK$7935 (28 days)/-HK$26,084 (84 days). The probability of being cost-effective was 85% (28 days)/100% (84 days) based on the cost-effectiveness thresholds recommended both by National Institute for Health and Clinical Excellence (£20,000/quality-adjusted life years) and World Health Organization (Hong Kong gross domestic product/capita in 2015, HK$328117). Results suggest that a transitional home-based palliative care program is more cost-effective than customary palliative care service. Limitations of the study include small sample size, study confined to one city, clinic consultation costs, and societal costs including patient costs and unpaid care-giving costs were not included.

Smoke alarm giveaway and installation programs: an economic evaluation.

PubMed

Liu, Ying; Mack, Karin A; Diekman, Shane T

2012-10-01

The burden of residential fire injury and death is substantial. Targeted smoke alarm giveaway and installation programs are popular interventions used to reduce residential fire mortality and morbidity. To evaluate the cost effectiveness and cost benefit of implementing a giveaway or installation program in a small hypothetic community with a high risk of fire death and injury through a decision-analysis model. Model inputs included program costs; program effectiveness (life-years and quality-adjusted life-years saved); and monetized program benefits (medical cost, productivity, property loss and quality-of-life losses averted) and were identified through structured reviews of existing literature (done in 2011) and supplemented by expert opinion. Future costs and effectiveness were discounted at a rate of 3% per year. All costs were expressed in 2011 U.S. dollars. Cost-effectiveness analysis (CEA) resulted in an average cost-effectiveness ratio (ACER) of $51,404 per quality-adjusted life-years (QALYs) saved and $45,630 per QALY for the giveaway and installation programs, respectively. Cost-benefit analysis (CBA) showed that both programs were associated with a positive net benefit with a benefit-cost ratio of 2.1 and 2.3, respectively. Smoke alarm functional rate, baseline prevalence of functional alarms, and baseline home fire death rate were among the most influential factors for the CEA and CBA results. Both giveaway and installation programs have an average cost-effectiveness ratio similar to or lower than the median cost-effectiveness ratio reported for other interventions to reduce fatal injuries in homes. Although more effort is required, installation programs result in lower cost per outcome achieved compared with giveaways. Published by Elsevier Inc.

The Cost-Effectiveness of Antibiotic Prophylaxis for Patients at Risk of Infective Endocarditis.

PubMed

Franklin, Matthew; Wailoo, Allan; Dayer, Mark J; Jones, Simon; Prendergast, Bernard; Baddour, Larry M; Lockhart, Peter B; Thornhill, Martin H

2016-11-15

In March 2008, the National Institute for Health and Care Excellence recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE) undergoing dental procedures in the United Kingdom, citing a lack of evidence of efficacy and cost-effectiveness. We have performed a new economic evaluation of AP on the basis of contemporary estimates of efficacy, adverse events, and resource implications. A decision analytic cost-effectiveness model was used. Health service costs and benefits (measured as quality-adjusted life-years) were estimated. Rates of IE before and after the National Institute for Health and Care Excellence guidance were available to estimate prophylactic efficacy. AP adverse event rates were derived from recent UK data, and resource implications were based on English Hospital Episode Statistics. AP was less costly and more effective than no AP for all patients at risk of IE. The results are sensitive to AP efficacy, but efficacy would have to be substantially lower for AP not to be cost-effective. AP was even more cost-effective in patients at high risk of IE. Only a marginal reduction in annual IE rates (1.44 cases in high-risk and 33 cases in all at-risk patients) would be required for AP to be considered cost-effective at £20 000 ($26 600) per quality-adjusted life-year. Annual cost savings of £5.5 to £8.2 million ($7.3-$10.9 million) and health gains >2600 quality-adjusted life-years could be achieved from reinstating AP in England. AP is cost-effective for preventing IE, particularly in those at high risk. These findings support the cost-effectiveness of guidelines recommending AP use in high-risk individuals. © 2016 The Authors.

Two-Year and Lifetime Cost-Effectiveness of Intensity Modulated Radiation Therapy Versus 3-Dimensional Conformal Radiation Therapy for Head-and-Neck Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kohler, Racquel E.; Sheets, Nathan C.; Wheeler, Stephanie B.

2013-11-15

Purpose: To assess the cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) in the treatment of head-and neck-cancer (HNC). Methods and Materials: We used a Markov model to simulate radiation therapy-induced xerostomia and dysphagia in a hypothetical cohort of 65-year-old HNC patients. Model input parameters were derived from PARSPORT (CRUK/03/005) patient-level trial data and quality-of-life and Medicare cost data from published literature. We calculated average incremental cost-effectiveness ratios (ICERs) from the US health care perspective as cost per quality-adjusted life-year (QALY) gained and compared our ICERs with current cost-effectiveness standards whereby treatment comparators less thanmore » $50,000 per QALY gained are considered cost-effective. Results: In the first 2 years after initial treatment, IMRT is not cost-effective compared with 3D-CRT, given an average ICER of $101,100 per QALY gained. However, over 15 years (remaining lifetime on the basis of average life expectancy of a 65-year-old), IMRT is more cost-effective at $34,523 per QALY gained. Conclusion: Although HNC patients receiving IMRT will likely experience reduced xerostomia and dysphagia symptoms, the small quality-of-life benefit associated with IMRT is not cost-effective in the short term but may be cost-effective over a patient's lifetime, assuming benefits persist over time and patients are healthy and likely to live for a sustained period. Additional data quantifying the long-term benefits of IMRT, however, are needed.« less

Cost-Effectiveness of Cranberry Capsules to Prevent Urinary Tract Infection in Long-Term Care Facilities: Economic Evaluation with a Randomized Controlled Trial

PubMed Central

van den Hout, Wilbert B; Caljouw, Monique A A; Putter, Hein; Cools, Herman J M; Gussekloo, Jacobijn

2014-01-01

Objectives To investigate whether the preventive use of cranberry capsules in long-term care facility (LTCF) residents is cost-effective depending on urinary tract infection (UTI) risk. Design Economic evaluation with a randomized controlled trial. Setting Long-term care facilities. Participants LTCF residents (N = 928, 703 female, median age 84), stratified according to UTI risk. Measurements UTI incidence (clinically or strictly defined), survival, quality of life, quality-adjusted life years (QALYs), and costs. Results In the weeks after a clinical UTI, participants showed a significant but moderate deterioration in quality of life, survival, care dependency, and costs. In high-UTI-risk participants, cranberry costs were estimated at €439 per year (1.00 euro = 1.37 U.S. dollar), which is €3,800 per prevented clinically defined UTI (95% confidence interval = €1,300–infinity). Using the strict UTI definition, the use of cranberry increased costs without preventing UTIs. Taking cranberry capsules had a 22% probability of being cost-effective compared with placebo (at a willingness to pay of €40,000 per QALY). In low-UTI-risk participants, use of cranberry capsules was only 3% likely to be cost-effective. Conclusion In high-UTI-risk residents, taking cranberry capsules may be effective in preventing UTIs but is not likely to be cost-effective in the investigated dosage, frequency, and setting. In low-UTI-risk LTCF residents, taking cranberry capsules twice daily is neither effective nor cost-effective. PMID:25180379

Cost analysis and exploratory cost-effectiveness of youth-friendly sexual and reproductive health services in the Republic of Moldova

PubMed Central

2014-01-01

Background Youth-friendly sexual and reproductive health services (YFHS) have high priority in many countries. Yet, little is known about the cost and cost-effectiveness of good quality YFHS in resource limited settings. This paper analyses retrospectively costs and potential cost-effectiveness of four well performing youth-friendly health centres (YFHC) in Moldova. This study assesses: (1) what were the costs of YFHSs at centre level, (2) how much would scaling-up to a national good quality YFHS programme cost, and (3) was the programme potentially cost-effective? Methods Four well performing YFHCs were selected for the study. YFHS costs were analysed per centre, funding source, service and person reached. The costing results were extrapolated to estimate cost of a good quality national YFHS programme in Moldova. A threshold analysis was carried out to estimate the required impact level for the YFHSs to break-even (become cost saving). Results Average annual cost of a well performing YFHC was USD 26,000 in 2011. 58% was financed by the National Health Insurance Company and the rest by external donors (42%). Personnel salaries were the largest expense category (47%). The annual implementation costs of a good quality YFHSs in all 38 YFHCs of Moldova were estimated to be USD 1.0 million. The results of the threshold analysis indicate that the annual break-even impact points in a YFHC for: 1) STI services would be >364 averted STIs, 2) early pregnancy and contraceptive services >178 averted unwanted pregnancies, and 3) HIV services only >0.65 averted new HIV infections. Conclusions The costing results highlight the following: 1) significant additional resources would be required for implementation of a good quality national YFHS programme, 2) the four well performing YFHCs rely heavily on external funding (42%), 3) which raises questions about financial sustainability of the programme. At the same time results of the threshold analysis are encouraging. The result suggest that, together the three SRH components (STI, early pregnancy and contraception, and HIV) are potentially cost saving. High cost savings resulting from averted lifetime treatment cost of HIV infected persons are likely to off-set the costs of STIs and unwanted pregnancies. PMID:25047074

Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review.

PubMed

Hugo, Cherie; Isenring, Elisabeth; Miller, Michelle; Marshall, Skye

2018-05-01

observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care. residential aged care homes. systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies. eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low. this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

Biological therapies in Crohn's disease: are they cost-effective? A critical appraisal of model-based analyses.

PubMed

Marchetti, Monia; Liberato, Nicola Lucio

2014-12-01

In refractory Crohn's disease, anti-TNF and anti-α 4 integrin agents are used for ameliorating disease activity but impose high costs to health-care systems. The authors systematically reviewed cost-effectiveness analyses based on decision models: most of the studies were judged to have a good quality, but a large portion assessed health and costs in a short time horizon, usually disregarding fistulizing disease and not considering safety. Infliximab induction followed by on-demand retreatment consistently proved to have a good cost per quality-adjusted life year, while maintenance treatment never satisfied commonly accepted cost-utility thresholds. Challenges in cost-effectiveness analysis include the lack of a standard model structure, a large variability in the costs of surgery and poor data on indirect costs. As clinical practice is moving to mucosal healing as a robust response marker, personalized schedules of anti-TNF therapies might prove cost-effective even in the perspective of the health-care system in the near future.

Cost-effectiveness of aortic valve replacement in the elderly: an introductory study.

PubMed

Wu, YingXing; Jin, Ruyun; Gao, Guangqiang; Grunkemeier, Gary L; Starr, Albert

2007-03-01

With increased life expectancy and improved technology, valve replacement is being offered to increasing numbers of elderly patients with satisfactory clinical results. By using standard econometric techniques, we estimated the relative cost-effectiveness of aortic valve replacement by drawing on a large prospective database at our institution. By using aortic valve replacement as an example, this introductory report paves the way to more definitive studies of these issues in the future. From 1961 to 2003, 4617 adult patients underwent aortic valve replacement at our service. These patients were provided with a prospective lifetime follow-up. As of 2005, these patients had accumulated 31,671 patient-years of follow-up (maximum 41 years) and had returned 22,396 yearly questionnaires. A statistical model was used to estimate the future life years of patients who are currently alive. In the absence of direct estimates of utility, quality-adjusted life years were estimated from New York Heart Association class. The cost-effectiveness ratio was calculated by the patient's age at surgery. The overall cost-effectiveness ratio was approximately 13,528 dollars per quality-adjusted life year gained. The cost-effectiveness ratio increased according to age at surgery, up to 19,826 dollars per quality-adjusted life year for octogenarians and 27,182 dollars per quality-adjusted life year for nonagenarians. Given the limited scope of this introductory study, aortic valve replacement is cost-effective for all age groups and is very cost-effective for all but the most elderly according to standard econometric rules of thumb.

Cost-effectiveness of treatment of diabetic macular edema.

PubMed

Pershing, Suzann; Enns, Eva A; Matesic, Brian; Owens, Douglas K; Goldhaber-Fiebert, Jeremy D

2014-01-07

Macular edema is the most common cause of vision loss among patients with diabetes. To determine the cost-effectiveness of different treatments of diabetic macular edema (DME). Markov model. Published literature and expert opinion. Patients with clinically significant DME. Lifetime. Societal. Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both. Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy. VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost. Long-term outcome data for treated and untreated diseases are limited. The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions. Agency for Healthcare Research and Quality.

Solving the Value Equation: Assessing Surgeon Performance Using Risk-Adjusted Quality-Cost Diagrams and Surgical Outcomes.

PubMed

Knechtle, William S; Perez, Sebastian D; Raval, Mehul V; Sullivan, Patrick S; Duwayri, Yazan M; Fernandez, Felix; Sharma, Joe; Sweeney, John F

Quality-cost diagrams have been used previously to assess interventions and their cost-effectiveness. This study explores the use of risk-adjusted quality-cost diagrams to compare the value provided by surgeons by presenting cost and outcomes simultaneously. Colectomy cases from a single institution captured in the National Surgical Quality Improvement Program database were linked to hospital cost-accounting data to determine costs per encounter. Risk adjustment models were developed and observed average cost and complication rates per surgeon were compared to expected cost and complication rates using the diagrams. Surgeons were surveyed to determine if the diagrams could provide information that would result in practice adjustment. Of 55 surgeons surveyed on the utility of the diagrams, 92% of respondents believed the diagrams were useful. The diagrams seemed intuitive to interpret, and making risk-adjusted comparisons accounted for patient differences in the evaluation.

Maximizing cost-effectiveness by adjusting treatment strategy according to glaucoma severity

PubMed Central

Guedes, Ricardo Augusto Paletta; Guedes, Vanessa Maria Paletta; Gomes, Carlos Eduardo de Mello; Chaoubah, Alfredo

2016-01-01

Abstract Background: The aim of this study is to determine the most cost-effective strategy for the treatment of primary open-angle glaucoma (POAG) in Brazil, from the payer's perspective (Brazilian Public Health System) in the setting of the Glaucoma Referral Centers. Methods: Study design was a cost-effectiveness analysis of different treatment strategies for POAG. We developed 3 Markov models (one for each glaucoma stage: early, moderate and advanced), using a hypothetical cohort of POAG patients, from the perspective of the Brazilian Public Health System (SUS) and a horizon of the average life expectancy of the Brazilian population. Different strategies were tested according to disease severity. For early glaucoma, we compared observation, laser and medications. For moderate glaucoma, medications, laser and surgery. For advanced glaucoma, medications and surgery. Main outcome measures were ICER (incremental cost-effectiveness ratio), medical direct costs and QALY (quality-adjusted life year). Results: In early glaucoma, both laser and medical treatment were cost-effective (ICERs of initial laser and initial medical treatment over observation only, were R$ 2,811.39/QALY and R$ 3,450.47/QALY). Compared to observation strategy, the two alternatives have provided significant gains in quality of life. In moderate glaucoma population, medical treatment presented the highest costs among treatment strategies. Both laser and surgery were highly cost-effective in this group. For advanced glaucoma, both tested strategies were cost-effective. Starting age had a great impact on results in all studied groups. Initiating glaucoma therapy using laser or surgery were more cost-effective, the younger the patient. Conclusion: All tested treatment strategies for glaucoma provided real gains in quality of life and were cost-effective. However, according to the disease severity, not all strategies provided the same cost-effectiveness profile. Based on our findings, there should be a preferred strategy for each glaucoma stage, according to a cost-effectiveness ratio ranking. PMID:28033286

A comparison of alternative strategies for cost-effective water quality management in lakes.

PubMed

Kramer, Daniel Boyd; Polasky, Stephen; Starfield, Anthony; Palik, Brian; Westphal, Lynne; Snyder, Stephanie; Jakes, Pamela; Hudson, Rachel; Gustafson, Eric

2006-09-01

Roughly 45% of the assessed lakes in the United States are impaired for one or more reasons. Eutrophication due to excess phosphorus loading is common in many impaired lakes. Various strategies are available to lake residents for addressing declining lake water quality, including septic system upgrades and establishing riparian buffers. This study examines 25 lakes to determine whether septic upgrades or riparian buffers are a more cost-effective strategy to meet a phosphorus reduction target. We find that riparian buffers are the more cost-effective strategy in every case but one. Large transaction costs associated with the negotiation and monitoring of riparian buffers, however, may be prohibiting lake residents from implementing the most cost-effective strategy.

A Comparison of Alternative Strategies for Cost-Effective Water Quality Management in Lakes

NASA Astrophysics Data System (ADS)

Kramer, Daniel Boyd; Polasky, Stephen; Starfield, Anthony; Palik, Brian; Westphal, Lynne; Snyder, Stephanie; Jakes, Pamela; Hudson, Rachel; Gustafson, Eric

2006-09-01

Roughly 45% of the assessed lakes in the United States are impaired for one or more reasons. Eutrophication due to excess phosphorus loading is common in many impaired lakes. Various strategies are available to lake residents for addressing declining lake water quality, including septic system upgrades and establishing riparian buffers. This study examines 25 lakes to determine whether septic upgrades or riparian buffers are a more cost-effective strategy to meet a phosphorus reduction target. We find that riparian buffers are the more cost-effective strategy in every case but one. Large transaction costs associated with the negotiation and monitoring of riparian buffers, however, may be prohibiting lake residents from implementing the most cost-effective strategy.

MRI-Guided Focused Ultrasound Surgery for Uterine Fibroid Treatment: A Cost-Effectiveness Analysis

PubMed Central

Kong, Chung Y.; Omer, Zehra B.; Pandharipande, Pari V.; Swan, J. Shannon; Srouji, Serene; Gazelle, G. Scott; Fennessy, Fiona M.

2015-01-01

Objective To evaluate the cost-effectiveness of a treatment strategy for symptomatic uterine fibroids that employs Magnetic Resonance guided Focused Ultrasound (MRgFUS) as a first-line therapy relative to uterine artery embolization (UAE) or abdominal hysterectomy (HYST). Materials and Methods We developed a decision-analytic model to compare the cost-effectiveness of three treatment strategies: MRgFUS, UAE and HYST. Short and long-term utilities specific to each treatment were incorporated, allowing us to account for differences in quality of life across the strategies considered. Lifetime costs and quality-adjusted life-years (QALYs) were calculated for each strategy. An incremental cost-effectiveness analysis was performed, using a societal willingness-to-pay (WTP) threshold of $50,000 per QALY to designate a strategy as cost-effective. Sensitivity analysis was performed on all key model parameters. Results In the base-case analysis, in which treatment for symptomatic fibroids started at age 40, UAE was the most effective and expensive strategy (22.81 QALYs, $22,164), followed by MRgFUS (22.80 QALYs, $19,796) and HYST (22.60 QALYs, $13,291). MRgFUS was cost-effective relative to HYST, with an associated incremental cost-effectiveness ratio (ICER) of $33,110/QALY. MRgFUS was also cost-effective relative to UAE – the ICER of UAE relative to MRgFUS ($270,057) far exceeded the WTP threshold of $50,000/QALY. In sensitivity analysis, results were robust to changes in most parameters, but were sensitive to changes in probabilities of recurrence and symptom relief following certain procedures, and quality of life associated with symptomatic fibroids. Conclusions MRgFUS is cost-effective relative to both UAE and hysterectomy for the treatment of women with symptomatic fibroids. PMID:25055272

Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.

PubMed

Schackman, Bruce R; Leff, Jared A; Polsky, Daniel; Moore, Brent A; Fiellin, David A

2012-06-01

Primary care physicians with appropriate training may prescribe buprenorphine-naloxone (bup/nx) to treat opioid dependence in US office-based settings, where many patients prefer to be treated. Bup/nx is off patent but not available as a generic. We evaluated the cost-effectiveness of long-term office-based bup/nx treatment for clinically stable opioid-dependent patients compared to no treatment. A decision analytic model simulated a hypothetical cohort of clinically stable opioid-dependent individuals who have already completed 6 months of office-based bup/nx treatment. Data were from a published cohort study that collected treatment retention, opioid use, and costs for this population, and published quality-of-life weights. Uncertainties in estimated monthly costs and quality-of-life weights were evaluated in probabilistic sensitivity analyses, and the economic value of additional research to reduce these uncertainties was also evaluated. Bup/nx, provider, and patient costs in 2010 US dollars, quality-adjusted life years (QALYs), and incremental cost-effectiveness (CE) ratios ($/QALY); costs and QALYs are discounted at 3% annually. In the base case, office-based bup/nx for clinically stable patients has a CE ratio of $35,100/QALY compared to no treatment after 24 months, with 64% probability of being < $100,000/QALY in probabilistic sensitivity analysis. With a 50% bup/nx price reduction the CE ratio is $23,000/QALY with 69% probability of being < $100,000/QALY. Alternative quality-of-life weights result in CE ratios of $138,000/QALY and $90,600/QALY. The value of research to reduce quality-of-life uncertainties for 24-month results is $6,400 per person eligible for treatment at the current bup/nx price and $5,100 per person with a 50% bup/nx price reduction. Office-based bup/nx for clinically stable patients may be a cost-effective alternative to no treatment at a threshold of $100,000/QALY depending on assumptions about quality-of-life weights. Additional research about quality-of-life benefits and broader health system and societal cost savings of bup/nx therapy is needed.

Cost-utility analysis of great saphenous vein ablation with radiofrequency, foam and surgery in the emerging health-care setting of Thailand.

PubMed

Siribumrungwong, Boonying; Noorit, Pinit; Wilasrusmee, Chumpon; Leelahavarong, Pattara; Thakkinstian, Ammarin; Teerawattananon, Yot

2016-09-01

To conduct economic evaluations of radiofrequency ablation, ultrasound-guided foam sclerotherapy and surgery for great saphenous vein ablation. A cost-utility and cohort analysis from societal perspective was performed to estimate incremental cost-effectiveness ratio. Transitional probabilities were from meta-analysis. Direct medical, direct non-medical, indirect costs, and utility were from standard Thai costings and cohort. Probabilistic sensitivity analysis was performed to assess parameter uncertainties. Seventy-seven patients (31 radiofrequency ablation, 19 ultrasound-guided foam sclerotherapy, and 27 surgeries) were enrolled from October 2011 to February 2013. Compared with surgery, radiofrequency ablation costed 12,935 and 20,872 Baht higher, whereas ultrasound-guided foam sclerotherapy costed 6159 lower and 1558 Bath higher for outpatient and inpatient, respectively. At one year, radiofrequency ablation had slightly lower quality-adjusted life-year, whereas ultrasound-guided foam sclerotherapy yielded additional 0.025 quality-adjusted life-year gained. Because of costing lower and greater quality-adjusted life-year than other compared alternatives, outpatient ultrasound-guided foam sclerotherapy was an option being dominant. Probabilistic sensitivity analysis resulted that at the Thai ceiling threshold of 160,000 Baht/quality-adjusted life-year gained, ultrasound-guided foam sclerotherapy had chances of 0.71 to be cost-effective. Ultrasound-guided foam sclerotherapy seems to be cost-effective for treating great saphenous vein reflux compared to surgery in Thailand at one-year results. © The Author(s) 2015.

A Systematic Review of the Economic Evidence for Home Support Interventions in Dementia.

PubMed

Clarkson, Paul; Davies, Linda; Jasper, Rowan; Loynes, Niklas; Challis, David

2017-09-01

Recent evidence signals the need for effective forms of home support to people with dementia and their carers. The cost-effectiveness evidence of different approaches to support is scant. To appraise economic evidence on the cost-effectiveness of home support interventions for dementia to inform future evaluation. A systematic literature review of full and partial economic evaluations was performed using the British National Health Service Economic Evaluation Database supplemented by additional references. Study characteristics and findings, including incremental cost-effectiveness ratios, when available, were summarized narratively. Study quality was appraised using the National Health Service Economic Evaluation Database critical appraisal criteria and independent ratings, agreed by two reviewers. Studies were located on a permutation matrix describing their mix of incremental costs/effects to aid decision making. Of the 151 articles retrieved, 14 studies met the inclusion criteria: 8 concerning support to people with dementia and 6 to carers. Five studies were incremental cost-utility analyses, seven were cost-effectiveness analyses, and two were cost consequences analyses. Five studies expressed incremental cost-effectiveness ratios as cost per quality-adjusted life-year (£6,696-£207,942 per quality-adjusted life-year). In four studies, interventions were dominant over usual care. Two interventions were more costly but more beneficial and were favorable against current acceptability thresholds. Occupational therapy, home-based exercise, and a carers' coping intervention emerged as cost-effective approaches for which there was better evidence. These interventions used environmental modifications, behavior management, physical activity, and emotional support as active components. More robust evidence is needed to judge the value of these and other interventions across the dementia care pathway. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Cost-effectiveness of smoking cessation treatment initiated during psychiatric hospitalization: analysis from a randomized, controlled trial

PubMed Central

Barnett, Paul G.; Wong, Wynnie; Jeffers, Abra; Hall, Sharon M.; Prochaska, Judith J.

2016-01-01

Objective We examined the cost-effectiveness of smoking cessation treatment for psychiatric inpatients. Method Smokers, regardless of intention to quit, were recruited during psychiatric hospitalization and randomized to receive stage-based smoking cessation services or usual aftercare. Smoking cessation services, quality of life, and biochemically-verified abstinence from cigarettes were assessed during 18-months of follow-up. Trial findings were combined with literature on changes in smoking status and the age and gender adjusted effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness during a lifetime horizon. Results Among 223 smokers randomized between 2006 and 2008, the mean cost of smoking cessation services was $189 in the experimental treatment group and $37 in the usual care condition (p < 0.001). At the end of follow-up, 18.75% of the experimental group was abstinent from cigarettes, compared to 6.80% abstinence in the usual care group (p <0.05). The model projected that the intervention added $43 in lifetime cost and generated 0.101 additional Quality Adjusted Life Years (QALYs), an incremental cost-effectiveness ratio of $428 per QALY. Probabilistic sensitivity analysis found the experimental intervention was cost-effective against the acceptance criteria of $50,000/QALY in 99.0% of the replicates. Conclusions A cessation intervention for smokers identified in psychiatric hospitalization did not result in higher mental health care costs in the short-run and was highly cost-effective over the long-term. The stage-based intervention was a feasible and cost-effective way of addressing the high smoking prevalence in persons with serious mental illness. PMID:26528651

Cost-effectiveness analysis of applying the Cholesterol and Recurrent Events (CARE) study protocol in Hong Kong.

PubMed

Chau, J; Cheung, B M; McGhee, S M; Lauder, I J; Lau, C P; Kumana, C R

2001-12-01

To determine the cost-effectiveness of secondary prevention with pravastatin in Hong Kong patients with coronary heart disease and average cholesterol levels. Cost-effectiveness analysis based on published results of the CARE study. Men and women post-myocardial infarction with average cholesterol levels. Cost-effectiveness analysis: cost per life saved, cost per fatal or non-fatal coronary event prevented, cost per procedure prevented, and cost per fatal or non-fatal stroke prevented. Cost-utility analysis: gross cost and net cost per quality-adjusted life year gained calculated using two alternative models. Cost per life saved or death prevented was HK$4,442,350 (non-discounted); cost per fatal or non-fatal cardiac event prevented HK$1,146,413; cost per procedure prevented HK$732,759; and cost per fatal or non-fatal stroke prevented HK$2,961,566. Net cost per quality adjusted life year gained was HK$73,218 and HK$65,280 non-discounted, respectively using the two alternative models. The results of this study can assist in prioritising the use of health care resources in Hong Kong but should be considered alongside the benefits and costs of alternative interventions for coronary heart disease.

The comparative effectiveness and cost-effectiveness of ranibizumab for neovascular macular degeneration revisited.

PubMed

Brown, Gary C; Brown, Melissa M; Lieske, Heidi B; Turpcu, Adam; Rajput, Yamina

2017-01-01

To compare a near decade of follow-up, newer control cohort data, use of both the societal and third party insurer cost perspectives, and integration of unilateral/bilateral therapy on the comparative effectiveness and cost-effectiveness of intravitreal ranibizumab therapy for neovascular, age-related macular degeneration (AMD). Value-Based Medicine ® , 12-year, combined-eye model, cost-utility analysis employing MARINA and HORIZON clinical trial data. Preference-based comparative effectiveness outcomes were quantified in (1) QALY (quality-adjusted life-year) gain, and (2) percent improvement in quality-of-life, while cost-effectiveness outcomes were quantified in (3) the cost-utility ratio (CUR) and financial return-on-investment (ROI) to society. Using MARINA and HORIZON trial data and a meta-analysis control cohort after 24 months, ranibizumab therapy conferred a combined-eye patient value (quality-of-life) gain of 16.3%, versus 10.4% found in 2006. The two-year direct ophthalmic medical cost for ranibizumab therapy was $46,450, a 33.8% real dollar decrease from 2006. The societal cost perspective CUR was -$242,920/QALY, indicating a $282,517 financial return-on-investment (ROI), or 12.3%/year to society for direct ophthalmic medical costs expended. The 3rd party insurer CUR ranged from $21,199/QALY utilizing all direct, medical costs, to $69,591/QALY using direct ophthalmic medical costs. Ranibizumab therapy for neovascular AMD in 2015, considering treatment of both eyes, conferred greater patient value gain (comparative effectiveness) and improved cost-effectiveness than in 2006, as well as a large monetary return-on-investment to the Gross Domestic Product and nation's wealth. The model herein integrates important novel features for neovascular age-related macular degeneration, vitreoretinal cost effectiveness analyses, including: (1) treatment of both eyes, (2) a long-term, untreated control cohort, and (3) the use of societal costs.

A Pilot Cost-Effectiveness Analysis of Treatments in Newly Diagnosed High-Grade Gliomas: The Example of 5-Aminolevulinic Acid Compared With White-Light Surgery

PubMed Central

Alves, Marta; Castel-Branco, Marta; Stummer, Walter

2015-01-01

BACKGROUND: High-grade gliomas are aggressive, incurable tumors characterized by extensive diffuse invasion of the normal brain parenchyma. Novel therapies at best prolong survival; their costs are formidable and benefit is marginal. Economic restrictions thus require knowledge of the cost-effectiveness of treatments. Here, we show the cost-effectiveness of enhanced resections in malignant glioma surgery using a well-characterized tool for intraoperative tumor visualization, 5-aminolevulinic acid (5-ALA). OBJECTIVE: To evaluate the cost-effectiveness of 5-ALA fluorescence-guided neurosurgery compared with white-light surgery in adult patients with newly diagnosed high-grade glioma, adopting the perspective of the Portuguese National Health Service. METHODS: We used a Markov model (cohort simulation). Transition probabilities were estimated with the use of data from 1 randomized clinical trial and 1 noninterventional prospective study. Utility values and resource use were obtained from published literature and expert opinion. Unit costs were taken from official Portuguese reimbursement lists (2012 values). The health outcomes considered were quality-adjusted life-years, life-years, and progression-free life-years. Extensive 1-way and probabilistic sensitivity analyses were performed. RESULTS: The incremental cost-effectiveness ratios are below €10 000 in all evaluated outcomes, being around €9100 per quality-adjusted life-year gained, €6700 per life-year gained, and €8800 per progression-free life-year gained. The probability of 5-ALA fluorescence-guided surgery cost-effectiveness at a threshold of €20000 is 96.0% for quality-adjusted life-year, 99.6% for life-year, and 98.8% for progression-free life-year. CONCLUSION: 5-ALA fluorescence-guided surgery appears to be cost-effective in newly diagnosed high-grade gliomas compared with white-light surgery. This example demonstrates cost-effectiveness analyses for malignant glioma surgery to be feasible on the basis of existing data. ABBREVIATIONS: 5-ALA, 5-aminolevulinic acid ICER, incremental cost-effectiveness ratio LY, life-year PFLY, progression-free life-year QALY, quality-adjusted life-year PMID:25714513

Patient mobility and health care quality when regions and patients differ in income.

PubMed

Brekke, Kurt R; Levaggi, Rosella; Siciliani, Luigi; Straume, Odd Rune

2016-12-01

We study the effects of cross-border patient mobility on health care quality and welfare when income varies across and within regions. We use a Salop model with a high-, middle-, and low-income region. In each region, a policy maker chooses health care quality to maximise the utility of its residents when health care costs are financed by general income taxation. In equilibrium, regions with higher income offer better quality, which creates an incentive for patient mobility from lower- to higher-income regions. Assuming a prospective payment scheme based on DRG-pricing, we find that lower non-monetary (administrative) mobility costs have (i) no effect on quality or welfare in the high-income region; (ii) a negative effect on quality but a positive effect on welfare for the middle-income region; and (iii) ambiguous effects on quality and welfare for the low-income region. Lower monetary mobility costs (copayments) might reduce welfare in both the middle- and low-income region. Thus, health policies that stimulate cross-border patient mobility can be counterproductive when regions differ in income. Copyright © 2016 Elsevier B.V. All rights reserved.

Can we maximize both value and quality in gynecologic cancer care? A work in progress.

PubMed

Havrilesky, Laura J; Fountain, Cynthia

2014-01-01

Value is defined as desirable health outcomes achieved per monetary unit spent. Comparative effectiveness research and cost-effectiveness research are methods that have been developed to quantify effectiveness and value to inform management decisions. In this article we review the comparative and cost-effectiveness literature in the field of ovarian cancer treatment. Studies have shown that improved ovarian cancer survival is associated with complete primary surgical cytoreduction, with treatment at high volume facilities by subspecialist providers (gynecologic oncologists) and with National Comprehensive Cancer Network (NCCN) guideline-adherent care in both surgical staging and chemotherapy regimens. Intraperitoneal/intravenous chemotherapy (compared with intravenous alone) has been associated with improved survival and cost-effectiveness. Bevacizumab for primary and maintenance therapy has been found to not be cost-effective (even in selective subsets) despite a small progression-free survival (PFS) advantage. For platinum-sensitive recurrent ovarian cancer, secondary cytoreduction and platinum-based combinations are associated with improved overall survival (OS); several platinum-based combinations have also been found cost-effective. For platinum-resistant recurrence, single agent therapy and supportive care are cost-effective compared with combination therapies. Although little prospective clinical research has been done around end-of-life care, one study reported that for platinum-resistant ovarian cancer, palliative intervention would potentially reduce costs and increase quality adjusted life years compared with usual care (based on improvement in quality of life [QOL]). Overall, cost comparisons of individual chemotherapy regimens are highly dependent on market prices of novel therapeutic agents.

Contribution of education to cost-effective care of microcytic, hypochromic anemia.

PubMed

Mulligan, J L; Arnold, L; Sanders, R; Brumwell, M; Rupani, M; Stelle, R; Romang, L; Sinnett, M; Ryan, P; Sirridge, M S

1984-06-01

Through a handbook, a seminar, and multiple opportunities for reinforcement in clinical settings, faculty in family medicine conducted an educational program that presented cost-effective practice standards for the care of anemia patients to resident physicians. A comparison of the quality and cost of anemia care by the residents before and during the program ascertained its value. The quality of patient care by residents rose significantly during the program. In addition, the residents' utilization of tests, therapy, and clinic visits and attendant costs reached more appropriate levels. These results should encourage faculty to respond to the current national need for the development of educational materials on cost-effective care of patients with common health problems.

The costs and benefits of water fluoridation in NZ.

PubMed

Moore, David; Poynton, Matthew; Broadbent, Jonathan M; Thomson, W Murray

2017-11-28

Implementing community water fluoridation involves costs, but these need to be considered against the likely benefits. We aimed to assess the cost-benefit and cost-effectiveness of water fluoridation in New Zealand (NZ) in terms of expenditure and quality-adjusted life years. Based on published studies, we determined the risk reduction effects of fluoridation, we quantified its health benefits using standardised dental indexes, and we calculated financial savings from averted treatment. We analysed NZ water supplies to estimate the financial costs of fluoridation. We devised a method to represent dental caries experience in quality-adjusted life years. Over 20 years, the net discounted saving from adding fluoride to reticulated water supplies supplying populations over 500 would be NZ$1401 million, a nine times pay-off. Between 8800 and 13,700 quality-adjusted life years would be gained. While fluoridating reticulated water supplies for large communities is cost-effective, it is unlikely to be so with populations smaller than 500. Community water fluoridation remains highly cost-effective for all but very small communities. The health benefits-while (on average) small per person-add up to a substantial reduction in the national disease burden across all ethnic and socioeconomic groups.

Treatment strategies for pelvic organ prolapse: a cost-effectiveness analysis.

PubMed

Hullfish, Kathie L; Trowbridge, Elisa R; Stukenborg, George J

2011-05-01

To compare the relative cost effectiveness of treatment decision alternatives for post-hysterectomy pelvic organ prolapse (POP). A Markov decision analysis model was used to assess and compare the relative cost effectiveness of expectant management, use of a pessary, and surgery for obtaining months of quality-adjusted life over 1 year. Sensitivity analysis was conducted to determine whether the results depended on specific estimates of patient utilities for pessary use, probabilities for complications and other events, and estimated costs. Only two treatment alternatives were found to be efficient choices: initial pessary use and vaginal reconstructive surgery (VRS). Pessary use (including patients that eventually transitioned to surgery) achieved 10.4 quality-adjusted months, at a cost of $10,000 per patient, while VRS obtained 11.4 quality-adjusted months, at $15,000 per patient. Sensitivity analysis demonstrated that these baseline results depended on several key estimates in the model. This analysis indicates that pessary use and VRS are the most cost-effective treatment alternatives for treating post-hysterectomy vaginal prolapse. Additional research is needed to standardize POP outcomes and complications, so that healthcare providers can best utilize cost information in balancing the risks and benefits of their treatment decisions.

Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema.

PubMed

Ramsey, Scott D; Berry, Kristin; Etzioni, Ruth; Kaplan, Robert M; Sullivan, Sean D; Wood, Douglas E

2003-05-22

The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema, included a prospective economic analysis. After pulmonary rehabilitation, 1218 patients at 17 medical centers were randomly assigned to lung-volume-reduction surgery or continued medical treatment. Costs for the use of medical care, medications, transportation, and time spent receiving treatment were derived from Medicare claims and data from the trial. Cost effectiveness was calculated over the duration of the trial and was estimated for 10 years of follow-up with the use of modeling based on observed trends in survival, cost, and quality of life. Interim analyses identified a group of patients with excess mortality and little chance of improved functional status after surgery. When these patients were excluded, the cost-effectiveness ratio for lung-volume-reduction surgery as compared with medical therapy was 190,000 dollars per quality-adjusted life-year gained at 3 years and 53,000 dollars per quality-adjusted life-year gained at 10 years. Subgroup analyses identified patients with predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was 98,000 dollars per quality-adjusted life-year gained at 3 years and 21,000 dollars at 10 years. Bootstrap analysis revealed substantial uncertainty for the subgroup and 10-year estimates. Given its cost and benefits over three years of follow-up, lung-volume-reduction surgery is costly relative to medical therapy. Although the predictions are subject to substantial uncertainty, the procedure may be cost effective if benefits can be maintained over time. Copyright 2003 Massachusetts Medical Society

Development of the IBSAL-SimMOpt Method for the Optimization of Quality in a Corn Stover Supply Chain

DOE PAGES

Chavez, Hernan; Castillo-Villar, Krystel; Webb, Erin

2017-08-01

Variability on the physical characteristics of feedstock has a relevant effect on the reactor’s reliability and operating cost. Most of the models developed to optimize biomass supply chains have failed to quantify the effect of biomass quality and preprocessing operations required to meet biomass specifications on overall cost and performance. The Integrated Biomass Supply Analysis and Logistics (IBSAL) model estimates the harvesting, collection, transportation, and storage cost while considering the stochastic behavior of the field-to-biorefinery supply chain. This paper proposes an IBSAL-SimMOpt (Simulation-based Multi-Objective Optimization) method for optimizing the biomass quality and costs associated with the efforts needed to meetmore » conversion technology specifications. The method is developed in two phases. For the first phase, a SimMOpt tool that interacts with the extended IBSAL is developed. For the second phase, the baseline IBSAL model is extended so that the cost for meeting and/or penalization for failing in meeting specifications are considered. The IBSAL-SimMOpt method is designed to optimize quality characteristics of biomass, cost related to activities intended to improve the quality of feedstock, and the penalization cost. A case study based on 1916 farms in Ontario, Canada is considered for testing the proposed method. Analysis of the results demonstrates that this method is able to find a high-quality set of non-dominated solutions.« less

Development of the IBSAL-SimMOpt Method for the Optimization of Quality in a Corn Stover Supply Chain

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chavez, Hernan; Castillo-Villar, Krystel; Webb, Erin

Variability on the physical characteristics of feedstock has a relevant effect on the reactor’s reliability and operating cost. Most of the models developed to optimize biomass supply chains have failed to quantify the effect of biomass quality and preprocessing operations required to meet biomass specifications on overall cost and performance. The Integrated Biomass Supply Analysis and Logistics (IBSAL) model estimates the harvesting, collection, transportation, and storage cost while considering the stochastic behavior of the field-to-biorefinery supply chain. This paper proposes an IBSAL-SimMOpt (Simulation-based Multi-Objective Optimization) method for optimizing the biomass quality and costs associated with the efforts needed to meetmore » conversion technology specifications. The method is developed in two phases. For the first phase, a SimMOpt tool that interacts with the extended IBSAL is developed. For the second phase, the baseline IBSAL model is extended so that the cost for meeting and/or penalization for failing in meeting specifications are considered. The IBSAL-SimMOpt method is designed to optimize quality characteristics of biomass, cost related to activities intended to improve the quality of feedstock, and the penalization cost. A case study based on 1916 farms in Ontario, Canada is considered for testing the proposed method. Analysis of the results demonstrates that this method is able to find a high-quality set of non-dominated solutions.« less

Diagnostic value and cost-effectiveness of good quality digital images accompanying electronic referrals for suspected skin malignancies.

PubMed

Ng, Michael F Y; Stevenson, J Howard

2011-04-01

The aim of this study was to investigate the outcome and cost-effectiveness of good and poor quality photographs accompanying the electronic referrals for suspected skin malignancies. A retrospective study of 100 patients, divided into 2 groups, 50 with good quality photographs and 50 with poor quality photographs. Patients with no digital images, or who failed to attend, or patients with incomplete notes were excluded from the study. The treatment pathway, waiting times, and estimated cost between the 2 groups were compared. Good photographs were more likely to be treated at the 1-Stop Clinic (P = 0.05). Good images had a better positive predictive value than poor quality images (62.55% vs. 42.86%). Good quality images are more accurate than poor quality images in triaging of patients, and thus more effective in facilitating the treatment of malignant lesions timely. Good quality photographs allow a delayed appropriate treatment of benign lesions. This increases the safety for patients in a queue in a rationed health care system, and improves patient flow.

Cost-effectiveness of Electroconvulsive Therapy vs Pharmacotherapy/Psychotherapy for Treatment-Resistant Depression in the United States.

PubMed

Ross, Eric L; Zivin, Kara; Maixner, Daniel F

2018-05-09

Electroconvulsive therapy (ECT) is a highly effective treatment for depression but is infrequently used owing to stigma, uncertainty about indications, adverse effects, and perceived high cost. To assess the cost-effectiveness of ECT compared with pharmacotherapy/psychotherapy for treatment-resistant major depressive disorder in the United States. A decision analytic model integrating data on clinical efficacy, costs, and quality-of-life effects of ECT compared with pharmacotherapy/psychotherapy was used to simulate depression treatment during a 4-year horizon from a US health care sector perspective. Model input data were drawn from multiple meta-analyses, randomized trials, and observational studies of patients with depression. Where possible, data sources were restricted to US-based studies of nonpsychotic major depression. Data were analyzed between June 2017 and January 2018. Six alternative strategies for incorporating ECT into depression treatment (after failure of 0-5 lines of pharmacotherapy/psychotherapy) compared with no ECT. Remission, response, and nonresponse of depression; quality-adjusted life-years; costs in 2013 US dollars; and incremental cost-effectiveness ratios. Strategies with incremental cost-effectiveness ratios of $100 000 per quality-adjusted life-year or less were designated cost-effective. Based on the Sequenced Treatment Alternatives to Relieve Depression trial, we simulated a population with a mean (SD) age of 40.7 (13.2) years, and 62.2% women. Over 4 years, ECT was projected to reduce time with uncontrolled depression from 50% of life-years to 33% to 37% of life-years, with greater improvements when ECT is offered earlier. Mean health care costs were increased by $7300 to $12 000, with greater incremental costs when ECT was offered earlier. In the base case, third-line ECT was cost-effective, with an ICER of $54 000 per quality-adjusted life-year. Third-line ECT remained cost-effective in a range of univariate, scenario, and probabilistic sensitivity analyses. Incorporating all input data uncertainty, we estimate a 74% to 78% likelihood that at least 1 of the ECT strategies is cost-effective and a 56% to 58% likelihood that third-line ECT is the optimal strategy. For US patients with treatment-resistant depression, ECT may be an effective and cost-effective treatment option. Although many factors influence the decision to proceed with ECT, these data suggest that, from a health-economic standpoint, ECT should be considered after failure of 2 or more lines of pharmacotherapy/psychotherapy.

Disease management positively affects patient quality of life.

PubMed

Walker, David R; Landis, Darryl L; Stern, Patricia M; Vance, Richard P

2003-04-01

Health care costs are spiraling upward. The population of the United States is aging, and many baby boomers will develop multiple chronic health conditions. Disease management is one method for reducing costs associated with chronic health conditions. Although these programs have been proven effective in improving patient health, detailed information about their effect on patient quality of life has been scarce. This article provides preliminary evidence that disease management programs for coronary artery disease, chronic obstructive pulmonary disease, diabetes, and heart failure lead to improved quality of life, which correlates with a healthier, more satisfied, and less costly patient.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children.

PubMed

Wu, James X; Sacks, Greg D; Dawes, Aaron J; DeUgarte, Daniel; Lee, Steven L

2017-07-01

Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis. Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness. Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations. Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis. Cost-Effectiveness Study: Level II. Published by Elsevier Inc.

Quality-adjusted cost of care: a meaningful way to measure growth in innovation cost versus the value of health gains.

PubMed

Lakdawalla, Darius; Shafrin, Jason; Lucarelli, Claudio; Nicholson, Sean; Khan, Zeba M; Philipson, Tomas J

2015-04-01

Technology drives both health care spending and health improvement. Yet policy makers rarely see measures of cost growth that account for both effects. To fill this gap, we present the quality-adjusted cost of care, which illustrates cost growth net of growth in the value of health improvements, measured as survival gains multiplied by the value of survival. We applied the quality-adjusted cost of care to two cases. For colorectal cancer, drug cost per patient increased by $34,493 between 1998 and 2005 as a result of new drug launches, but value from offsetting health improvements netted a modest $1,377 increase in quality-adjusted cost of care. For multiple myeloma, new therapies increased treatment cost by $72,937 between 2004 and 2009, but offsetting health benefits lowered overall quality-adjusted cost of care by $67,863. However, patients with multiple myeloma on established first-line therapies saw costs rise without corresponding benefits. All three examples document rapid cost growth, but they provide starkly different answers to the question of whether society got what it paid for. Project HOPE—The People-to-People Health Foundation, Inc.

Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Health Technology Assessment

PubMed Central

2016-01-01

Background In Ontario, current treatment for eligible patients who have an acute ischemic stroke is intravenous thrombolysis (IVT). However, there are some limitations and contraindications to IVT, and outcomes may not be favourable for patients with stroke caused by a proximal intracranial occlusion. An alternative is mechanical thrombectomy with newer devices, and a number of recent studies have suggested that this treatment is more effective for improving functional independence and clinical outcomes. The objective of this health technology assessment was to evaluate the clinical effectiveness and cost-effectiveness of new-generation mechanical thrombectomy devices (with or without IVT) compared to IVT alone (if eligible) in patients with acute ischemic stroke. Methods We conducted a systematic review of the literature, limited to randomized controlled trials that examined the effectiveness of mechanical thrombectomy using stent retrievers and thromboaspiration devices for patients with acute ischemic stroke. We assessed the quality of the evidence using the GRADE approach. We developed a Markov decision-analytic model to assess the cost-effectiveness of mechanical thrombectomy (with or without IVT) versus IVT alone (if eligible), calculated incremental cost-effectiveness ratios using a 5-year time horizon, and conducted sensitivity analyses to examine the robustness of the estimates. Results There was a substantial, statistically significant difference in rate of functional independence (GRADE: high quality) between those who received mechanical thrombectomy (with or without IVT) and IVT alone (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.88–3.04). We did not observe a difference in mortality (GRADE: moderate quality) (OR 0.80, 95% CI 0.60–1.07) or symptomatic intracerebral hemorrhage (GRADE: moderate quality) (OR 1.11, 95% CI 0.66–1.87). In the base-case cost-utility analysis, which had a 5 year time horizon, the costs and effectiveness for mechanical thrombectomy were $126,939 and 1.484 quality-adjusted life-years (QALYs) (2.969 life-years). The costs and effectiveness for IVT alone were $124,419 and 1.273 QALYs (2.861 life-years), respectively. Mechanical thrombectomy was associated with an incremental cost-effectiveness ratio of $11,990 per QALY gained. Probabilistic sensitivity analysis showed that the probability of mechanical thrombectomy being cost-effective was 57.5%, 89.7%, and 99.6%, at thresholds of $20,000, $50,000, and $100,000 per QALY gained, respectively. We estimated that adopting mechanical thrombectomy would lead to a cost increase of approximately $1 to 2 million. Conclusions High quality evidence showed that mechanical thrombectomy significantly improved functional independence and appeared to be cost-effective compared to IVT alone for patients with acute ischemic stroke. PMID:27026799

A cost-utility analysis of transcatheter versus surgical aortic valve replacement for the treatment of aortic stenosis in the population with intermediate surgical risk.

PubMed

Tam, Derrick Y; Hughes, Avery; Fremes, Stephen E; Youn, Saerom; Hancock-Howard, Rebecca L; Coyte, Peter C; Wijeysundera, Harindra C

2018-05-01

Although transcatheter aortic valve implantation has been shown to be noninferior to surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk, the cost-effectiveness of this strategy in this population is unknown. Our objective was to conduct a cost-utility analysis comparing transcatheter aortic valve implantation with surgical aortic valve replacement in the population with intermediate risk severe aortic stenosis. A fully probabilistic Markov model with 30-day cycles was constructed from the Canadian third-party payer's perspective to estimate the difference in cost and effectiveness (measured as quality-adjusted life years) of transcatheter aortic valve implantation versus surgical aortic valve replacement for intermediate-risk patients over a lifetime time horizon, discounted at 1.5% per annum. Clinical trial data from The Placement of Aortic Transcatheter Valve 2 informed the efficacy inputs. Costs (adjusted to 2016 Canadian dollars) were obtained from the Canadian Institute of Health Information and the Ontario Schedule of Benefits. Incremental cost-effectiveness ratios were calculated. In the base-case analysis, total lifetime costs for transcatheter aortic valve implantation were $10,548 higher than surgical aortic valve replacement but added 0.23 quality-adjusted life years, for an incremental cost-effectiveness ratio of $46,083/quality-adjusted life-years gained. Deterministic 1-way analyses showed that the incremental cost-effectiveness ratio was sensitive to rates of complications and cost of the transcatheter aortic valve implantation prosthesis. There was moderate-to-high parameter uncertainty; transcatheter aortic valve implantation was the preferred option in only 52.7% and 55.4% of the simulations at a $50,000 and $100,000 per quality-adjusted life years willingness-to-pay thresholds, respectively. On the basis of current evidence, transcatheter aortic valve implantation may be cost-effective for the treatment of severe aortic stenosis in patients with intermediate surgical risk. There remains moderate-to-high uncertainty surrounding the base-case incremental cost-effectiveness ratio. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Preferred drug lists: Potential impact on healthcare economics

PubMed Central

Ovsag, Kimberly; Hydery, Sabrina; Mousa, Shaker A

2008-01-01

Objectives To analyze the implementation of Medicaid preferred drug lists (PDLs) in a number of states and determine its impact on quality of care and cost relative to other segments of healthcare. Methods We reviewed research and case studies found by searching library databases, primarily MEDLINE and EBSCOHost, and searching pertinent journals. Keywords initially included “drug lists,” “prior authorization,” “prior approval,” and “Medicaid.” We added terms such as “influence use of other healthcare services,” “quality of care,” and “overall economic impact.” We mainly used primary sources. Results Based on our literature review, we determined that there are a number of issues regarding Medicaid PDLs that need to be addressed. Some issues include: (a) the potential for PDLs to influence the utilization of other healthcare services, (b) criteria used by Medicaid for determining acceptance of drugs onto a PDL, (c)the effect of PDL implementation on compliance to new regimens, (d) the potential effects of restricting medication availability on quality of care, (e) administrative costs associated with PDLs, and (f) satisfaction rates among patients and medical providers. This review highlighted expected short-term cost savings with limited degree of compromised quality of PDL implementation, but raised the concern about the potential long-term decline in quality of care and overall economic impact. Conclusions The number of concerns raised indicates that further studies are warranted regarding both short-term cost benefits as well as potential long-term effects of Medicaid PDL implementation. Objective analysis of these effects is necessary to ensure cost-effectiveness and quality of care. PMID:18561515

Cost-effectiveness of sacubitril/valsartan in chronic heart-failure patients with reduced ejection fraction.

PubMed

Ademi, Zanfina; Pfeil, Alena M; Hancock, Elizabeth; Trueman, David; Haroun, Rola Haroun; Deschaseaux, Celine; Schwenkglenks, Matthias

2017-11-29

We aimed to assess the cost effectiveness of sacubitril/valsartan compared to angiotensin-converting enzyme inhibitors (ACEIs) for the treatment of individuals with chronic heart failure and reduced-ejection fraction (HFrEF) from the perspective of the Swiss health care system. The cost-effectiveness analysis was implemented as a lifelong regression-based cohort model. We compared sacubitril/valsartan with enalapril in chronic heart failure patients with HFrEF and New York-Heart Association Functional Classification II-IV symptoms. Regression models based on the randomised clinical phase III PARADIGM-HF trials were used to predict events (all-cause mortality, hospitalisations, adverse events and quality of life) for each treatment strategy modelled over the lifetime horizon, with adjustments for patient characteristics. Unit costs were obtained from Swiss public sources for the year 2014, and costs and effects were discounted by 3%. The main outcome of interest was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life years (QALYs) gained. Deterministic sensitivity analysis (DSA) and scenario and probabilistic sensitivity analysis (PSA) were performed. In the base-case analysis, the sacubitril/valsartan strategy showed a decrease in the number of hospitalisations (6.0% per year absolute reduction) and lifetime hospital costs by 8.0% (discounted) when compared with enalapril. Sacubitril/valsartan was predicted to improve overall and quality-adjusted survival by 0.50 years and 0.42 QALYs, respectively. Additional net-total costs were CHF 10 926. This led to an ICER of CHF 25 684. In PSA, the probability of sacubitril/valsartan being cost-effective at thresholds of CHF 50 000 was 99.0%. The treatment of HFrEF patients with sacubitril/valsartan versus enalapril is cost effective, if a willingness-to-pay threshold of CHF 50 000 per QALY gained ratio is assumed.

MEDIAN-BASED INCREMENTAL COST-EFFECTIVENESS RATIOS WITH CENSORED DATA

PubMed Central

Bang, Heejung; Zhao, Hongwei

2016-01-01

Cost-effectiveness is an essential part of treatment evaluation, in addition to effectiveness. In the cost-effectiveness analysis, a measure called the incremental cost-effectiveness ratio (ICER) is widely utilized, and the mean cost and the mean (quality-adjusted) life years have served as norms to summarize cost and effectiveness for a study population. Recently, the median-based ICER was proposed for complementary or sensitivity analysis purposes. In this paper, we extend this method when some data are censored. PMID:26010599

Cost Effectiveness of Adopted Quality Requirements in Hospital Laboratories

PubMed Central

HAMZA, Alneil; AHMED-ABAKUR, Eltayib; ABUGROUN, Elsir; BAKHIT, Siham; HOLI, Mohamed

2013-01-01

Background The present study was designed in quasi-experiment to assess adoption of the essential clauses of particular clinical laboratory quality management requirements based on international organization for standardization (ISO 15189) in hospital laboratories and to evaluate the cost effectiveness of compliance to ISO 15189. Methods: The quality management intervention based on ISO 15189 was conceded through three phases; pre – intervention phase, Intervention phase and Post-intervention phase. Results: In pre-intervention phase the compliance to ISO 15189 was 49% for study group vs. 47% for control group with P value 0.48, while the post intervention results displayed 54% vs. 79% for study group and control group respectively in compliance to ISO 15189 and statistically significant difference (P value 0.00) with effect size (Cohen’s d) of (0.00) in pre-intervention phase and (0.99) in post – intervention phase. The annual average cost per-test for the study group and control group was 1.80 ± 0.25 vs. 1.97 ± 0.39, respectively with P value 0.39 whereas the post-intervention results showed that the annual average total costs per-test for study group and control group was 1.57 ± 0.23 vs 2.08 ± 0.38, P value 0.019 respectively, with cost-effectiveness ratio of (0.88) in pre -intervention phase and (0.52) in post-intervention phase. Conclusion: The planned adoption of quality management requirements (QMS) in clinical laboratories had great effect to increase the compliance percent with quality management system requirement, raise the average total cost effectiveness, and improve the analytical process capability of the testing procedure. PMID:23967422

Systematic Review and Quality Appraisal of Cost-Effectiveness Analyses of Pharmacologic Maintenance Treatment for Chronic Obstructive Pulmonary Disease: Methodological Considerations and Recommendations.

PubMed

van der Schans, Simon; Goossens, Lucas M A; Boland, Melinde R S; Kocks, Janwillem W H; Postma, Maarten J; van Boven, Job F M; Rutten-van Mölken, Maureen P M H

2017-01-01

Worldwide, chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic lung disease with considerable clinical and socioeconomic impact. Pharmacologic maintenance drugs (such as bronchodilators and inhaled corticosteroids) play an important role in the treatment of COPD. The cost effectiveness of these treatments has been frequently assessed, but studies to date have largely neglected the impact of treatment sequence and the exact stage of disease in which the drugs are used in real life. We aimed to systematically review recently published articles that reported the cost effectiveness of COPD maintenance treatments, with a focus on key findings, quality and methodological issues. We performed a systematic literature search in Embase, PubMed, the UK NHS Economic Evaluation Database (NHS-EED) and EURONHEED (European Network of Health Economics Evaluation Databases) and included all relevant articles published between 2011 and 2015 in either Dutch, English or German. Main study characteristics, methods and outcomes were extracted and critically assessed. The Quality of Health Economic Studies (QHES) instrument was used as basis for quality assessment, but additional items were also addressed. The search identified 18 recent pharmacoeconomic analyses of COPD maintenance treatments. Papers reported the cost effectiveness of long-acting muscarinic antagonist (LAMA) monotherapy (n = 6), phosphodiesterase (PDE)-4 inhibitors (n = 4), long-acting beta agonist/inhaled corticosteroid (LABA/ICS) combinations (n = 4), LABA monotherapy (n = 2) and LABA/LAMA combinations (n = 2). All but two studies were funded by the manufacturer, and all studies indicated favourable cost effectiveness; however, the number of quality-adjusted life-years (QALYs) gained was small. Less than half of the studies reported a COPD-specific outcome in addition to a generic outcome (mostly QALYs). Exacerbation and mortality rates were found to be the main drivers of cost effectiveness. According to the QHES, the quality of the studies was generally sufficient, but additional assessment revealed that most studies poorly represented the cost effectiveness of real-life medication use. The majority of studies showed that pharmacologic COPD maintenance treatment is cost effective, but most studies poorly reflected real-life drug use. Consistent and COPD-specific methodology is recommended.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke: experience from Australian stroke center.

PubMed

Tan Tanny, Sharman P; Busija, Lucy; Liew, Danny; Teo, Sarah; Davis, Stephen M; Yan, Bernard

2013-08-01

Previous economic studies outside Australia have demonstrated that patients treated with tissue-type plasminogen activator (tPA) within 4.5 hours of stroke onset have lower healthcare costs than those not. We aim to perform cost-effectiveness analysis of intravenous tPA in an Australian setting. Data on clinical outcomes and costs were derived for 378 patients who received intravenous tPA within 4.5 hours of stroke onset at Royal Melbourne Hospital (Australia) between January 2003 and December 2011. To simulate clinical outcomes and costs for a hypothetical control group assumed not to have received tPA, we applied efficacy data from a meta-analysis of randomized trials to outcomes observed in the tPA group. During a 1-year time-horizon, net costs, years of life lived, and quality-adjusted life-years were compared and incremental cost-effectiveness ratios derived for tPA versus no tPA. In the study population, mean (SD) age was 68.2 (13.5) years and 206 (54.5%) were men. Median National Institutes of Health Stroke Scale score (interquartile range) at presentation was 12.5 (8-18). Compared with no tPA, we estimated that tPA would result in 0.02 life-years and 0.04 quality-adjusted life-years saved per person>1 year. The net cost of tPA was AUD $55.61 per patient. The incremental cost-effectiveness ratios were AUD $2377 per life-year saved and AUD $1478 per quality-adjusted life-years saved. Because the costs of tPA are incurred only once, the incremental cost-effectiveness ratios would decrease with increasing time-horizon. Uncertainty analyses indicated the results to be robust. Intravenous tPA within 4.5 hours represents a cost-effective intervention for acute ischemic stroke.

Cost-Effectiveness and Cost-Utility of Internet-Based Computer Tailoring for Smoking Cessation

PubMed Central

Evers, Silvia MAA; de Vries, Hein; Hoving, Ciska

2013-01-01

Background Although effective smoking cessation interventions exist, information is limited about their cost-effectiveness and cost-utility. Objective To assess the cost-effectiveness and cost-utility of an Internet-based multiple computer-tailored smoking cessation program and tailored counseling by practice nurses working in Dutch general practices compared with an Internet-based multiple computer-tailored program only and care as usual. Methods The economic evaluation was embedded in a randomized controlled trial, for which 91 practice nurses recruited 414 eligible smokers. Smokers were randomized to receive multiple tailoring and counseling (n=163), multiple tailoring only (n=132), or usual care (n=119). Self-reported cost and quality of life were assessed during a 12-month follow-up period. Prolonged abstinence and 24-hour and 7-day point prevalence abstinence were assessed at 12-month follow-up. The trial-based economic evaluation was conducted from a societal perspective. Uncertainty was accounted for by bootstrapping (1000 times) and sensitivity analyses. Results No significant differences were found between the intervention arms with regard to baseline characteristics or effects on abstinence, quality of life, and addiction level. However, participants in the multiple tailoring and counseling group reported significantly more annual health care–related costs than participants in the usual care group. Cost-effectiveness analysis, using prolonged abstinence as the outcome measure, showed that the mere multiple computer-tailored program had the highest probability of being cost-effective. Compared with usual care, in this group €5100 had to be paid for each additional abstinent participant. With regard to cost-utility analyses, using quality of life as the outcome measure, usual care was probably most efficient. Conclusions To our knowledge, this was the first study to determine the cost-effectiveness and cost-utility of an Internet-based smoking cessation program with and without counseling by a practice nurse. Although the Internet-based multiple computer-tailored program seemed to be the most cost-effective treatment, the cost-utility was probably highest for care as usual. However, to ease the interpretation of cost-effectiveness results, future research should aim at identifying an acceptable cutoff point for the willingness to pay per abstinent participant. PMID:23491820

The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

PubMed

Burgess, James F; Shwartz, Michael; Stolzmann, Kelly; Sullivan, Jennifer L

2018-05-18

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data. One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool. We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days. With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs. The relationship between cost and quality depends on facility size and current level of performance. © Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

Improving Quality and Reducing Cost: Designs for Effective Learning.

ERIC Educational Resources Information Center

Twigg, Carol A.

2003-01-01

Discusses 30 institutions participating in a program exploring how large-enrollment introductory courses can be redesigned using technology to extend access to a new population of students without trading quality for cost savings. (EV)

Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy.

PubMed

Schroeck, Florian Rudolf; Jacobs, Bruce L; Bhayani, Sam B; Nguyen, Paul L; Penson, David; Hu, Jim

2017-11-01

Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode. To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer. We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively. RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy. Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective. We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense. Published by Elsevier B.V.

Cost effectiveness of fecal DNA screening for colorectal cancer: a systematic review and quality appraisal of the literature.

PubMed

Skally, Mairead; Hanly, Paul; Sharp, Linda

2013-06-01

Fecal DNA (fDNA) testing is a noninvasive potential alternative to current colorectal cancer screening tests. We conducted a systematic review and quality assessment of studies of cost-effectiveness of fDNA as a colorectal cancer screening tool (compared with no screening and other screening modalities), and identified key variables that impinged on cost-effectiveness. We searched MEDLINE, Embase, and the Centre for Reviews and Dissemination for cost-effectiveness studies of fDNA-based screening, published in English by September 2011. Studies that undertook an economic evaluation of fDNA, using either a cost-effectiveness or cost-utility analysis, compared with other relevant screening modalities and/or no screening were included. Additional inclusion criteria related to the presentation of data pertaining to model variables including time horizon, costs, fDNA performance characteristics, screening uptake, and comparators. A total of 369 articles were initially identified for review. After removing duplicates and applying inclusion and exclusion criteria, seven articles were included in the final review. Data was abstracted on key descriptor variables including screening scenarios, time horizon, costs, test performance characteristics, screening uptake, comparators, and incremental cost-effectiveness ratios. Quality assessment was undertaken using a standard checklist for economic evaluations. Studies cited by cost-effectiveness articles as the source of data on fDNA test performance characteristics were also reviewed. Seven cost-effectiveness studies were included, from the USA (4), Canada (1), Israel (1), and Taiwan (1). Markov models (5), a partially observable Markov decision process model (1) and MISCAN and SimCRC (1) microsimulation models were used. All studies took a third-party payer perspective and one included, in addition, a societal perspective. Comparator screening tests, screening intervals, and specific fDNA tests varied between studies. fDNA sensitivity and specificity parameters were derived from 12 research studies and one meta-analysis. Outcomes assessed were life-years gained and quality-adjusted life-years gained. fDNA was cost-effective when compared with no screening in six studies. Compared with other screening modalities, fDNA was not considered cost-effective in any of the base-case analyses: in five studies it was dominated by all alternatives considered. Sensitivity analyses identified cost, compliance, and test parameters as key influential parameters. In general, poor presentation of "study design" and "data collection" details lowered the quality of included articles. Although the literature searches were designed for high sensitivity, the possibility cannot be excluded that some eligible studies may have been missed. Reports (such as Health Technology Assessments produced by government agencies) and other forms of grey literature were excluded because they are difficult to identify systematically and/or may not report methods and results in sufficient detail for assessment. On the basis of the available (albeit limited) evidence, while fDNA is cost-effective when compared with no screening, it is currently dominated by most of the other available screening options. Cost and test performance appear to be the main influences on cost-effectiveness.

Cost-Effectiveness of Providing Full Drug Coverage to Increase Medication Adherence in Post–Myocardial Infarction Medicare Beneficiaries

PubMed Central

Choudhry, Niteesh K.; Patrick, Amanda R.; Antman, Elliott M.; Avorn, Jerry; Shrank, William H.

2009-01-01

Background Effective therapies for the secondary prevention of coronary heart disease–related events are significantly underused, and attempts to improve adherence have often yielded disappointing results. Elimination of patient out-of-pocket costs may be an effective strategy to enhance medication use. We sought to estimate the incremental cost-effectiveness of providing full coverage for aspirin, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins (combination pharmacotherapy) to individuals enrolled in the Medicare drug benefit program after acute myocardial infarction. Methods and Results We created a Markov cost-effectiveness model to estimate the incremental cost-effectiveness of providing Medicare beneficiaries with full coverage for combination pharmacotherapy compared with current coverage under the Medicare Part D program. Our analysis was conducted from the societal perspective and considered a lifetime time horizon. In a sensitivity analysis, we repeated our analysis from the perspective of Medicare. In the model, post–myocardial infarction Medicare beneficiaries who received usual prescription drug coverage under the Part D program lived an average of 8.21 quality-adjusted life-years after their initial event, incurring coronary heart disease–related medical costs of $114 000. Those who received prescription drug coverage without deductibles or copayments lived an average of 8.56 quality-adjusted life-years and incurred $111 600 in coronary heart disease–related costs. Compared with current prescription drug coverage, full coverage for post–myocardial infarction secondary prevention therapies would result in greater functional life expectancy (0.35 quality-adjusted life-year) and less resource use ($2500). From the perspective of Medicare, full drug coverage was highly cost-effective ($7182/quality-adjusted life-year) but not cost saving. Conclusions Our analysis suggests that providing full coverage for combination therapy to post–myocardial infarction Medicare beneficiaries would save both lives and money from the societal perspective. PMID:18285564

Cost-effectiveness of prostate cancer screening: a simulation study based on ERSPC data.

PubMed

Heijnsdijk, E A M; de Carvalho, T M; Auvinen, A; Zappa, M; Nelen, V; Kwiatkowski, M; Villers, A; Páez, A; Moss, S M; Tammela, T L J; Recker, F; Denis, L; Carlsson, S V; Wever, E M; Bangma, C H; Schröder, F H; Roobol, M J; Hugosson, J; de Koning, H J

2015-01-01

The results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial showed a statistically significant 29% prostate cancer mortality reduction for the men screened in the intervention arm and a 23% negative impact on the life-years gained because of quality of life. However, alternative prostate-specific antigen (PSA) screening strategies for the population may exist, optimizing the effects on mortality reduction, quality of life, overdiagnosis, and costs. Based on data of the ERSPC trial, we predicted the numbers of prostate cancers diagnosed, prostate cancer deaths averted, life-years and quality-adjusted life-years (QALY) gained, and cost-effectiveness of 68 screening strategies starting at age 55 years, with a PSA threshold of 3, using microsimulation modeling. The screening strategies varied by age to stop screening and screening interval (one to 14 years or once in a lifetime screens), and therefore number of tests. Screening at short intervals of three years or less was more cost-effective than using longer intervals. Screening at ages 55 to 59 years with two-year intervals had an incremental cost-effectiveness ratio of $73000 per QALY gained and was considered optimal. With this strategy, lifetime prostate cancer mortality reduction was predicted as 13%, and 33% of the screen-detected cancers were overdiagnosed. When better quality of life for the post-treatment period could be achieved, an older age of 65 to 72 years for ending screening was obtained. Prostate cancer screening can be cost-effective when it is limited to two or three screens between ages 55 to 59 years. Screening above age 63 years is less cost-effective because of loss of QALYs because of overdiagnosis. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Vaccination against herpes zoster and postherpetic neuralgia in France: a cost-effectiveness analysis.

PubMed

Bresse, Xavier; Annemans, Lieven; Préaud, Emmanuelle; Bloch, Karine; Duru, Gérard; Gauthier, Aline

2013-06-01

This study assesses the cost-effectiveness of vaccination against herpes zoster (HZ) and postherpetic neuralgia in France, using a published Markov model. The cost-effectiveness of vaccinating individuals aged from 65 years or between 70 and 79 years was evaluated over their lifetime, from a third-party payer perspective. French-specific data were combined with results from clinical studies and international quality-of-life-based (EuroQol five-dimension questionnaire) utilities from the literature. HZ vaccination was highly cost effective in both populations. Incremental cost-effective ratios were estimated between €9513 and 12,304 per quality-adjusted life year gained, corresponding to €2240-2651 per HZ case avoided and €3539-4395 per postherpetic neuralgia case avoided. In addition to epidemiological and clinical evidence, economic evidence also supports the implementation of HZ vaccination in France.

Value-based medicine, comparative effectiveness, and cost-effectiveness analysis of topical cyclosporine for the treatment of dry eye syndrome.

PubMed

Brown, Melissa M; Brown, Gary C; Brown, Heidi C; Peet, Jonathan; Roth, Zachary

2009-02-01

To assess the comparative effectiveness and cost-effectiveness (cost-utility) of a 0.05% emulsion of topical cyclosporine (Restasis; Allergan Inc, Irvine, California) for the treatment of moderate to severe dry eye syndrome that is unresponsive to conventional therapy. Data from 2 multicenter, randomized, clinical trials and Food and Drug Administration files for topical cyclosporine, 0.05%, emulsion were used in Center for Value-Based Medicine analyses. Analyses included value-based medicine as a comparative effectiveness analysis and average cost-utility analysis using societal and third-party insurer cost perspectives. Outcome measures of comparative effectiveness were quality-adjusted life-year (QALY) gain and percentage of improvement in quality of life, and for cost-effectiveness were cost-utility ratio (CUR) using dollars per QALY. Topical cyclosporine, 0.05%, confers a value gain (comparative effectiveness) of 0.0319 QALY per year compared with topical lubricant therapy, a 4.3% improvement in quality of life for the average patient with moderate to severe dry eye syndrome that is unresponsive to conventional lubricant therapy. The societal perspective incremental CUR for cyclosporine over vehicle therapy is $34,953 per QALY and the societal perspective average CUR is $11,199 per QALY. The third-party-insurer incremental CUR is $37,179 per QALY, while the third-party-insurer perspective average CUR is $34,343 per QALY. Topical cyclosporine emulsion, 0.05%, confers considerable patient value and is a cost-effective therapy for moderate to severe dry eye syndrome that is unresponsive to conventional therapy.

Comparing cost-effectiveness of X-Stop with minimally invasive decompression in lumbar spinal stenosis: a randomized controlled trial.

PubMed

Lønne, Greger; Johnsen, Lars Gunnar; Aas, Eline; Lydersen, Stian; Andresen, Hege; Rønning, Roar; Nygaard, Øystein P

2015-04-15

Randomized clinical trial with 2-year follow-up. To compare the cost-effectiveness of X-stop to minimally invasive decompression in patients with symptomatic lumbar spinal stenosis. Lumbar spinal stenosis is the most common indication for operative treatment in elderly. Although surgery is more costly than nonoperative treatment, health outcomes for more than 2 years were shown to be significantly better. Surgical treatment with minimally invasive decompression is widely used. X-stop is introduced as another minimally invasive technique showing good results compared with nonoperative treatment. We enrolled 96 patients aged 50 to 85 years, with symptoms of neurogenic intermittent claudication within 250-m walking distance and 1- or 2-level lumbar spinal stenosis, randomized to either minimally invasive decompression or X-stop. Quality-adjusted life-years were based on EuroQol EQ-5D. The hospital unit costs were estimated by means of the top-down approach. Each cost unit was converted into a monetary value by dividing the overall cost by the amount of cost units produced. The analysis of costs and health outcomes is presented by the incremental cost-effectiveness ratio. The study was terminated after a midway interim analysis because of significantly higher reoperation rate in the X-stop group (33%). The incremental cost for X-stop compared with minimally invasive decompression was &OV0556;2832 (95% confidence interval: 1886-3778), whereas the incremental health gain was 0.11 quality-adjusted life-year (95% confidence interval: -0.01 to 0.23). Based on the incremental cost and effect, the incremental cost-effectiveness ratio was &OV0556;25,700. The majority of the bootstrap samples displayed in the northeast corner of the cost-effectiveness plane, giving a 50% likelihood that X-stop is cost-effective at the extra cost of &OV0556;25,700 (incremental cost-effectiveness ratio) for a quality-adjusted life-year. The significantly higher cost of X-stop is mainly due to implant cost and the significantly higher reoperation rate. 2.

Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance.

PubMed

Heller, Michael; Zanocco, Kyle; Zydowicz, Sara; Elaraj, Dina; Nayar, Ritu; Sturgeon, Cord

2012-09-01

The 2007 National Cancer Institute (NCI) conference on Thyroid Fine-Needle Aspiration (FNA) introduced the category atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS). Repeat FNA in 3 to 6 months was recommended for low-risk patients. Compliance with these recommendations has been suboptimal. We hypothesized that repeat FNA would be more effective than diagnostic lobectomy, with decreased costs and improved rates of cancer detection. Cost-effectiveness analysis was performed in which we compared diagnostic lobectomy with repeat FNA. A Markov model was developed. Outcomes and probabilities were identified from literature review. Third-party payer costs were estimated in 2010 US dollars. Outcomes were weighted by use of the quality-of-life utility factors, yielding quality-adjusted life years (QALYs). Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost, and utility estimates. The diagnostic lobectomy strategy cost $8,057 and produced 23.99 QALYs. Repeat FNA cost $2,462 and produced 24.05 QALYs. Repeat FNA was dominant until the cost of FNA increased to $6,091. Dominance of the repeat FNA strategy was not sensitive to the cost of operation or the complication rate. The NCI recommendations for repeat FNA regarding follow-up of AUS/FLUS results are cost-effective. Improving compliance with these guidelines should lead to less overall costs, greater quality of life, and fewer unnecessary operations. Copyright © 2012 Mosby, Inc. All rights reserved.

Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA

PubMed Central

Herzer, Kurt R; Niessen, Louis; Constenla, Dagna O; Ward, William J; Pronovost, Peter J

2014-01-01

Objective To assess the cost-effectiveness of a multifaceted quality improvement programme focused on reducing central line-associated bloodstream infections in intensive care units. Design Cost-effectiveness analysis using a decision tree model to compare programme to non-programme intensive care units. Setting USA. Population Adult patients in the intensive care unit. Costs Economic costs of the programme and of central line-associated bloodstream infections were estimated from the perspective of the hospital and presented in 2013 US dollars. Main outcome measures Central line-associated bloodstream infections prevented, deaths averted due to central line-associated bloodstream infections prevented, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was performed. Results Compared with current practice, the programme is strongly dominant and reduces bloodstream infections and deaths at no additional cost. The probabilistic sensitivity analysis showed that there was an almost 80% probability that the programme reduces bloodstream infections and the infections’ economic costs to hospitals. The opportunity cost of a bloodstream infection to a hospital was the most important model parameter in these analyses. Conclusions This multifaceted quality improvement programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programme's benefits should enhance implementation. The programme's implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections. PMID:25256190

Utility values associated with advanced or metastatic non-small cell lung cancer: data needs for economic modeling.

PubMed

Brown, Jacqueline; Cook, Keziah; Adamski, Kelly; Lau, Jocelyn; Bargo, Danielle; Breen, Sarah; Chawla, Anita

2017-04-01

Cost-effectiveness analyses often inform healthcare reimbursement decisions. The preferred measure of effectiveness is the quality adjusted life year (QALY) gained, where the quality of life adjustment is measured in terms of utility. Areas covered: We assessed the availability and variation of utility values for health states associated with advanced or metastatic non-small cell lung cancer (NSCLC) to identify values appropriate for cost-effectiveness models assessing alternative treatments. Our systematic search of six electronic databases (January 2000 to August 2015) found the current literature to be sparse in terms of utility values associated with NSCLC, identifying 27 studies. Utility values were most frequently reported over time and by treatment type, and less frequently by disease response, stage of disease, adverse events or disease comorbidities. Expert commentary: In response to rising healthcare costs, payers increasingly consider the cost-effectiveness of novel treatments in reimbursement decisions, especially in oncology. As the number of therapies available to treat NSCLC increases, cost-effectiveness analyses will play a key role in reimbursement decisions in this area. Quantifying the relationship between health and quality of life for NSCLC patients via utility values is an important component of assessing the cost effectiveness of novel treatments.

A Cost-Utility Analysis of 5 Strategies for the Management of Acute Otitis Media in Children.

PubMed

Shaikh, Nader; Dando, Emily E; Dunleavy, Mark L; Curran, Dorothy L; Martin, Judith M; Hoberman, Alejandro; Smith, Kenneth J

2017-10-01

To assess whether antimicrobial therapy in young children with acute otitis media reduces time to resolution of symptoms, overall symptom burden, and persistence of otoscopic evidence of infection. We used a cost-utility model to evaluate whether immediate antimicrobial treatment seems to be worthwhile, and if so, which antimicrobial agent is most cost effective. We compared the cost per quality-adjusted life-day of 5 treatment regimens in children younger than 2 years of age with acute otitis media: immediate amoxicillin/clavulanate, immediate amoxicillin, immediate cefdinir, watchful waiting, and delayed prescription (DP) for antibiotic. The 5 treatment regimens, listed in order from least effective to most effective were DP, watchful waiting, immediate cefdinir, immediate amoxicillin, and immediate amoxicillin/clavulanate. Listed in order from least costly to most costly, the regimens were DP, immediate amoxicillin, watchful waiting, immediate amoxicillin/clavulanate, and immediate cefdinir. The incremental cost-utility ratio of immediate amoxicillin compared with DP was $101.07 per quality-adjusted life-day gained. The incremental cost-utility ratio of immediate amoxicillin/clavulanate compared with amoxicillin was $2331.28 per quality-adjusted life-day gained. In children younger than 2 years of age with acute otitis media and no recent antibiotic exposure, immediate amoxicillin seems to be the most cost-effective initial treatment. Copyright © 2017 Elsevier Inc. All rights reserved.

Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre.

PubMed

Dinh, Michael M; Bein, Kendall J; Hendrie, Delia; Gabbe, Belinda; Byrne, Christopher M; Ivers, Rebecca

2016-09-01

Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.

Cost-effectiveness of different strategies for selecting and treating individuals at increased risk of osteoporosis or osteopenia: a systematic review.

PubMed

Müller, Dirk; Pulm, Jannis; Gandjour, Afschin

2012-01-01

To compare cost-effectiveness modeling analyses of strategies to prevent osteoporotic and osteopenic fractures either based on fixed thresholds using bone mineral density or based on variable thresholds including bone mineral density and clinical risk factors. A systematic review was performed by using the MEDLINE database and reference lists from previous reviews. On the basis of predefined inclusion/exclusion criteria, we identified relevant studies published since January 2006. Articles included for the review were assessed for their methodological quality and results. The literature search resulted in 24 analyses, 14 of them using a fixed-threshold approach and 10 using a variable-threshold approach. On average, 70% of the criteria for methodological quality were fulfilled, but almost half of the analyses did not include medication adherence in the base case. The results of variable-threshold strategies were more homogeneous and showed more favorable incremental cost-effectiveness ratios compared with those based on a fixed threshold with bone mineral density. For analyses with fixed thresholds, incremental cost-effectiveness ratios varied from €80,000 per quality-adjusted life-year in women aged 55 years to cost saving in women aged 80 years. For analyses with variable thresholds, the range was €47,000 to cost savings. Risk assessment using variable thresholds appears to be more cost-effective than selecting high-risk individuals by fixed thresholds. Although the overall quality of the studies was fairly good, future economic analyses should further improve their methods, particularly in terms of including more fracture types, incorporating medication adherence, and including or discussing unrelated costs during added life-years. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Cost-Effectiveness of Radiofrequency Catheter Ablation Compared with Antiarrhythmic Drug Therapy for Paroxysmal Atrial Fibrillation

PubMed Central

Reynolds, Matthew R.; Zimetbaum, Peter; Josephson, Mark E.; Ellis, Ethan; Danilov, Tatyana; Cohen, David J.

2009-01-01

Background Radiofrequency catheter ablation (RFA) has emerged as an important treatment strategy for AF. The potential cost-effectiveness of RFA for AF, relative to antiarrhythmic drug (AAD) therapy, has not been fully explored from a U.S. perspective. Methods and Results We constructed a Markov disease simulation model for a hypothetical cohort of drug- refractory paroxysmal AF patients managed either with RFA ± AAD or AAD alone. Costs and quality-adjusted life years (QALYs) were projected over 5 years. Model inputs were drawn from published clinical trial and registry data, from new registry and trial data analysis, and from data prospectively collected from AF patients managed with RFA at our institution. We assumed no benefit form ablation on stroke, heart failure or death, but did estimate changes in quality-adjusted life expectancy using data from several AF cohorts. In the base case scenario, cumulative costs with the RFA and AAD strategies were $26,584 and $19,898, respectively. Over 5 years, quality adjusted life expectancy was 3.51 QALYs with RFA, versus 3.38 for the AAD group. The incremental cost-effectiveness ratio for RFA vs. AAD was thus $51,431/QALY. Model results were most sensitive to time horizon, the relative utility weights of successful ablation vs. unsuccessful drug therapy, and to the cost of an ablation procedure. Conclusions RFA ± AAD for symptomatic, drug-refractory paroxysmal AF appears to be reasonably cost-effective compared with AAD therapy alone from the perspective of the US health care system, based on improved quality of life and avoidance of future health care costs. PMID:19808491

Cost Effectiveness of Telecare Management for Pain and Depression in Patients with Cancer: Results from a Randomized Trial

PubMed Central

Choi Yoo, Sung J.; Nyman, John A.; Cheville, Andrea L.; Kroenke, Kurt

2014-01-01

Objective Pain and depression are prevalent and treatable symptoms among patients with cancer yet they are often undetected and undertreated. The Indiana Cancer Pain and Depression (INCPAD) trial demonstrated that telecare management can improve pain and depression outcomes. This article investigates the incremental cost effectiveness of the INCPAD intervention. Methods The INCPAD trial was conducted in 16 community-based urban and rural oncology practices in Indiana. Of the 405 participants, 202 were randomized to the intervention group and 203 to the usual-care group. Intervention costs were determined and effectiveness outcomes were depression-free days and quality adjusted life years. Results The intervention group was associated with a yearly increase of 60.3 depression-free days (SE=15.4; p<0.01) and an increase of between 0.033 and 0.066 quality-adjusted life years compared to the usual care group. Total cost of the intervention per patient was $1189, which included physician, nurse care manager, and automated monitoring set-up and maintenance costs. Incremental cost per depression-free day was $19.72, which yields a range of $18,018 to $ 36,035 per quality-adjusted life year when converted to that metric. When measured directly, the incremental cost per quality-adjusted life year ranged from $10,826 based on the modified EQ-5D to $73,286.92 based on the SF-12. Conclusion Centralized telecare management, coupled with automated symptom monitoring, appears to be a cost effective intervention for managing pain and depression in cancer patients. PMID:25130518

Perceived work ability, quality of life, and fatigue in patients with rheumatoid arthritis after a 6-month course of TNF inhibitors: prospective intervention study and partial economic evaluation.

PubMed

Hoving, J L; Bartelds, G M; Sluiter, J K; Sadiraj, K; Groot, I; Lems, W F; Dijkmans, B A C; Wijbrandts, C A; Tak, P P; Nurmohamed, M T; Voskuyl, A E; Frings-Dresen, M H W

2009-01-01

The objective of this exploratory study was to evaluate the effects and costs of a 6-month course of tumour necrosis factor (TNF) inhibitors on work ability, quality of life, and fatigue in patients with rheumatoid arthritis (RA). In this prospective single-arm intervention study 59 consecutive patients of working age with established RA were recruited from an outpatient clinic in Amsterdam, the Netherlands. All patients received fortnightly subcutaneous injections of 40 mg adalimumab. The three outcomes at baseline and 6 months were: perceived work ability [Work Ability Index (WAI)], quality of life [Rheumatoid Arthritis Quality of Life instrument (RAQoL)], and fatigue [Checklist Individual Strength (CIS), Need for Recovery (NFR) scale]. Cost data of the preceding 6 months were collected using a self-administered patient questionnaire at baseline and follow-up. At 6 months, all outcomes showed a statistically significant improvement in mean scores from baseline, ranging from 10.0% (WAI), to 11.7% (RAQoL), to 15% (NFR) (subgroup paid work, n = 26). The total mean costs showed a twofold increase in mean costs per week per patient [difference EUR 169, 95% confidence interval (CI) EUR 113-226]. In this short-term exploratory evaluation, a 6-month course of TNF inhibitors improved work ability and quality of life, and reduced fatigue in patients with established RA. These effects are associated with an increase in total healthcare costs, attributable to the costs of TNF inhibitors. Randomized controlled trials with a longer follow-up are needed to show a long-term effect on work disability and the potential cost-effectiveness of TNF inhibitors.

The cost-effectiveness of temozolomide in the adjuvant treatment of newly diagnosed glioblastoma in the United States

PubMed Central

Messali, Andrew; Hay, Joel W.; Villacorta, Reginald

2013-01-01

Background The objective of this work was to determine the cost-effectiveness of temozolomide compared with that of radiotherapy alone in the adjuvant treatment of newly diagnosed glioblastoma. Temozolomide is the only chemotherapeutic agent to have demonstrated a significant survival benefit in a randomized clinical trial. Our analysis builds on earlier work by incorporating caregiver time costs and generic temozolomide availability. It is also the first analysis applicable to the US context. Methods A systematic literature review was conducted to collect relevant data. Transition probabilities were calculated from randomized controlled trial data comparing temozolomide plus radiotherapy with radiotherapy alone. Direct costs were calculated from charges reported by the Mayo Clinic. Utilities were obtained from a previous cost-utility analysis. Using these data, a Markov model with a 1-month cycle length and 5-year time horizon was constructed. Results The addition of brand Temodar and generic temozolomide to the standard radiotherapy regimen was associated with base-case incremental cost-effectiveness ratios of $102 364 and $8875, respectively, per quality-adjusted life-year. The model was most sensitive to the progression-free survival associated with the use of only radiotherapy. Conclusions Both the brand and generic base-case estimates are cost-effective under a willingness-to-pay threshold of $150 000 per quality-adjusted life-year. All 1-way sensitivity analyses produced incremental cost-effectiveness ratios below this threshold. We conclude that both the brand Temodar and generic temozolomide are cost-effective treatments for newly diagnosed glioblastoma within the US context. However, assuming that the generic product produces equivalent quality of life and survival benefits, it would be significantly more cost-effective than the brand option. PMID:23935155

Cost-effectiveness of heat and moisture exchangers compared to usual care for pulmonary rehabilitation after total laryngectomy in Poland.

PubMed

Retèl, Valesca P; van den Boer, Cindy; Steuten, Lotte M G; Okła, Sławomir; Hilgers, Frans J; van den Brekel, Michiel W

2015-09-01

The beneficial physical and psychosocial effects of heat and moisture exchangers (HMEs) for pulmonary rehabilitation of laryngectomy patients are well evidenced. However, cost-effectiveness in terms of costs per additional quality-adjusted life years (QALYs) has not yet been investigated. Therefore, a model-based cost-effectiveness analysis of using HMEs versus usual care (UC) (including stoma covers, suction system and/or external humidifier) for patients after laryngectomy was performed. Primary outcomes were costs, QALYs and incremental cost-effectiveness ratio (ICER). Secondary outcomes were pulmonary infections, and sleeping problems. The analysis was performed from a health care perspective of Poland, using a time horizon of 10 years and cycle length of 1 year. Transition probabilities were derived from various sources, amongst others a Polish randomized clinical trial. Quality of life data was derived from an Italian study on similar patients. Data on frequencies and mortality-related tracheobronchitis and/or pneumonia were derived from a Europe-wide survey amongst head and neck cancer experts. Substantial differences in quality-adjusted survival between the use of HMEs (3.63 QALYs) versus UC (2.95 QALYs) were observed. Total health care costs/patient were 39,553 PLN (9465 Euro) for the HME strategy and 4889 PLN (1168 Euro) for the UC strategy. HME use resulted in fewer pulmonary infections, and less sleeping problems. We could conclude that given the Polish threshold of 99,000 PLN/QALY, using HMEs is cost-effective compared to UC, resulting in 51,326 PLN/QALY (12,264 Euro/QALY) gained for patients after total laryngectomy. For the hospital period alone (2 weeks), HMEs were cost-saving: less costly and more effective.

The Cost-Effectiveness of Anterior Cruciate Ligament Reconstruction in Competitive Athletes.

PubMed

Stewart, Bruce A; Momaya, Amit M; Silverstein, Marc D; Lintner, David

2017-01-01

Competitive athletes value the ability to return to competitive play after the treatment of anterior cruciate ligament (ACL) injuries. ACL reconstruction has high success rates for return to play, but some studies indicate that patients may do well with nonoperative physical therapy treatment. To evaluate the cost-effectiveness of the treatment of acute ACL tears with either initial surgical reconstruction or physical therapy in competitive athletes. Economic and decision analysis; Level of evidence, 2. The incremental cost, incremental effectiveness, and incremental cost-effectiveness ratio (ICER) of ACL reconstruction compared with physical therapy were calculated from a cost-effectiveness analysis of ACL reconstruction compared with physical therapy for the initial management of acute ACL injuries in competitive athletes. The ACL reconstruction strategy and the physical therapy strategy were represented as Markov models. Costs and quality-adjusted life-years (QALYs) were evaluated over a 6-year time horizon and were analyzed from a societal perspective. Quality of life and probabilities of clinical outcomes were obtained from the peer-reviewed literature, and costs were compiled from a large academic hospital in the United States. One-way, 2-way, and probabilistic sensitivity analyses were used to assess the effect of uncertainty in variables on the ICER of ACL reconstruction. The ICER of ACL reconstruction compared with physical therapy was $22,702 per QALY gained. The ICER was most sensitive to the quality of life of returning to play or not returning to play, costs, and duration of follow-up but relatively insensitive to the rates and costs of complications, probabilities of return to play for both operative and nonoperative treatments, and discount rate. ACL reconstruction is a cost-effective strategy for competitive athletes with an ACL injury.

Cost-effectiveness of a motivational intervention for alcohol-involved youth in a hospital emergency department.

PubMed

Neighbors, Charles J; Barnett, Nancy P; Rohsenow, Damaris J; Colby, Suzanne M; Monti, Peter M

2010-05-01

Brief interventions in the emergency department targeting risk-taking youth show promise to reduce alcohol-related injury. This study models the cost-effectiveness of a motivational interviewing-based intervention relative to brief advice to stop alcohol-related risk behaviors (standard care). Average cost-effectiveness ratios were compared between conditions. In addition, a cost-utility analysis examined the incremental cost of motivational interviewing per quality-adjusted life year gained. Microcosting methods were used to estimate marginal costs of motivational interviewing and standard care as well as two methods of patient screening: standard emergency-department staff questioning and proactive outreach by counseling staff. Average cost-effectiveness ratios were computed for drinking and driving, injuries, vehicular citations, and negative social consequences. Using estimates of the marginal effect of motivational interviewing in reducing drinking and driving, estimates of traffic fatality risk from drinking-and-driving youth, and national life tables, the societal costs per quality-adjusted life year saved by motivational interviewing relative to standard care were also estimated. Alcohol-attributable traffic fatality risks were estimated using national databases. Intervention costs per participant were $81 for standard care, $170 for motivational interviewing with standard screening, and $173 for motivational interviewing with proactive screening. The cost-effectiveness ratios for motivational interviewing were more favorable than standard care across all study outcomes and better for men than women. The societal cost per quality-adjusted life year of motivational interviewing was $8,795. Sensitivity analyses indicated that results were robust in terms of variability in parameter estimates. This brief intervention represents a good societal investment compared with other commonly adopted medical interventions.

Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people.

PubMed

Sisk, J E; Moskowitz, A J; Whang, W; Lin, J D; Fedson, D S; McBean, A M; Plouffe, J F; Cetron, M S; Butler, J C

Clinical, epidemiologic, and policy considerations support updating the cost-effectiveness of pneumococcal vaccination for elderly people and targeting the evaluation only to prevention of pneumococcal bacteremia. To assess the implications for medical costs and health effects of vaccination against pneumococcal bacteremia in elderly people. Cost-effectiveness analysis of pneumococcal vaccination compared with no vaccination, from a societal perspective. The elderly population aged 65 years and older in the United States in 3 geographic areas: metropolitan Atlanta, Ga; Franklin County, Ohio; and Monroe County, New York. Incremental medical costs and health effects, expressed in quality-adjusted life-years per person vaccinated. Vaccination was cost saving, ie, it both reduced medical expenses and improved health, for all age groups and geographic areas analyzed in the base case. For people aged 65 years and older, vaccination saved $8.27 and gained 1.21 quality-adjusted days of life per person vaccinated. Vaccination of the 23 million elderly people unvaccinated in 1993 would have gained about 78000 years of healthy life and saved $194 million. In univariate sensitivity analysis, the results remained cost saving except for doubling vaccination costs, including future medical costs of survivors, and lowering vaccination effectiveness. With assumptions most unfavorable to vaccination, cost per quality-adjusted life-year ranged from $35 822 for ages 65 to 74 years to $598 487 for ages 85 years and older. In probabilistic sensitivity analysis, probability intervals were more narrow, with less than 5% probability that the ratio for ages 85 years and older would exceed $100000. Pneumococcal vaccination saves costs in the prevention of bacteremia alone and is greatly underused among the elderly population, on both health and economic grounds. These results support recent recommendations of the Advisory Committee on Immunization Practices and public and private efforts under way to improve vaccination rates.

A cost-effectiveness analysis of two different repositioning strategies for the prevention of pressure ulcers.

PubMed

Marsden, Grace; Jones, Katie; Neilson, Julie; Avital, Liz; Collier, Mark; Stansby, Gerard

2015-12-01

To assess the cost effectiveness of two repositioning strategies and inform the 2014 National Institute for Health and Care Excellence clinical guideline recommendations on pressure ulcer prevention. Pressure ulcers are distressing events, caused when skin and underlying tissues are placed under pressure sufficient to impair blood supply. They can have a substantial impact on quality of life and have significant resource implications. Repositioning is a key prevention strategy, but can be resource intensive, leading to variation in practice. This economic analysis was conducted to identify the most cost-effective repositioning strategy for the prevention of pressure ulcers. The economic analysis took the form of a cost-utility model. The clinical inputs to the model were taken from a systematic review of clinical data. The population in the model was older people in a nursing home. The economic model was developed with members of the guideline development group and included costs borne by the UK National Health Service. Outcomes were expressed as costs and quality adjusted life years. Despite being marginally more clinically effective, alternating 2 and 4 hourly repositioning is not a cost-effective use of UK National Health Service resources (compared with 4 hourly repositioning) for this high risk group of patients at a cost-effectiveness threshold of £20,000 per quality adjusted life years. These results were used to inform the clinical guideline recommendations for those who are at high risk of developing pressure ulcers. © 2015 John Wiley & Sons Ltd.

Cost-effectiveness of supported employment adapted for people with affective disorders.

PubMed

Saha, Sanjib; Bejerholm, Ulrika; Gerdtham, Ulf-G; Jarl, Johan

2018-04-01

The individual enabling and support (IES) model was effective in gaining competitive employment for people with affective disorders compared with traditional vocational rehabilitation (TVR) services in a randomized controlled trial in a Swedish setting. The object of this study is to perform a cost-effectiveness analysis of IES comparing to TVR. We considered the costs of intervention and productivity gain due to increased competitive employment. We estimated quality of life using EuroQol 5 Dimension (EQ-5D) and Manchester Short Assessment of Quality of Life (MANSA) scale. EQ-5D was translated into quality-adjusted life-years (QALY), using the UK, Danish, and Swedish tariffs. We performed the analysis from a societal perspective with a one-year timeframe. The cost of IES was €7247 lower per person per year (2014 prices) compared to TVR. There were no significant differences in QALY improvement within or between groups. However, quality of life measured by the MANSA scale significantly improved over the study period in IES. Besides the small sample size, details on the intervention costs for both IES and TVR group were unavailable and had to be obtained from external sources. Implementation of IES for people with affective disorders is most likely cost-saving and is potentially even dominating TVR, although a larger trial is required to establish this.

The business case for quality improvement: oral anticoagulation for atrial fibrillation.

PubMed

Rose, Adam J; Berlowitz, Dan R; Ash, Arlene S; Ozonoff, Al; Hylek, Elaine M; Goldhaber-Fiebert, Jeremy D

2011-07-01

The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation. Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR. A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative.

Systematic Review of the Costs and Benefits of Prescribed Cannabis-Based Medicines for the Management of Chronic Illness: Lessons from Multiple Sclerosis.

PubMed

Herzog, Samuel; Shanahan, Marian; Grimison, Peter; Tran, Anh; Wong, Nicole; Lintzeris, Nicholas; Simes, John; Stockler, Martin; Morton, Rachael L

2018-01-01

Cannabis-based medicines (CBMs) may offer relief from symptoms of disease; however, their additional cost needs to be considered alongside their effectiveness. We sought to review the economic costs and benefits of prescribed CBMs in any chronic illness, and the frameworks used for their economic evaluation. A systematic review of eight medical and economic databases, from inception to mid-December 2016, was undertaken. MeSH headings and text words relating to economic costs and benefits, and CBMs were combined. Study quality was assessed using relevant checklists and results were synthesised in narrative form. Of 2514 identified records, ten studies met the eligibility criteria, all for the management of multiple sclerosis (MS). Six contained economic evaluations, four studies reported utility-based quality of life, and one was a willingness-to-pay study. Four of five industry-sponsored cost-utility analyses for MS spasticity reported nabiximols as being cost-effective from a European health system perspective. Incremental cost-effectiveness ratios per quality-adjusted life-year (QALY) gained for these five studies were £49,257 (UK); £10,891 (Wales); €11,214 (Germany); €4968 (Italy); and dominant (Spain). Nabiximols for the management of MS spasticity was not associated with statistically significant improvements in EQ-5D scores compared with standard care. Study quality was moderate overall, with limited inclusion of both relevant societal costs and discussions of potential bias. Prescribed CBMs are a potentially cost-effective add-on treatment for MS spasticity; however, this evidence is uncertain. Further investment in randomised trials with in-built economic evaluations is warranted for a wider range of clinical indications. PROSPERO Registration Number: CRD42014006370.

A value-based medicine analysis of ranibizumab for the treatment of subfoveal neovascular macular degeneration.

PubMed

Brown, Melissa M; Brown, Gary C; Brown, Heidi C; Peet, Jonathan

2008-06-01

To assess the conferred value and average cost-utility (cost-effectiveness) for intravitreal ranibizumab used to treat occult/minimally classic subfoveal choroidal neovascularization associated with age-related macular degeneration (AMD). Value-based medicine cost-utility analysis. MARINA (Minimally Classic/Occult Trial of the Anti-Vascular Endothelial Growth Factor Antibody Ranibizumab in the Treatment of Neovascular AMD) Study patients utilizing published primary data. Reference case, third-party insurer perspective, cost-utility analysis using 2006 United States dollars. Conferred value in the forms of (1) quality-adjusted life-years (QALYs) and (2) percent improvement in health-related quality of life. Cost-utility is expressed in terms of dollars expended per QALY gained. All outcomes are discounted at a 3% annual rate, as recommended by the Panel on Cost-effectiveness in Health and Medicine. Data are presented for the second-eye model, first-eye model, and combined model. Twenty-two intravitreal injections of 0.5 mg of ranibizumab administered over a 2-year period confer 1.039 QALYs, or a 15.8% improvement in quality of life for the 12-year period of the second-eye model reference case of occult/minimally classic age-related subfoveal choroidal neovascularization. The reference case treatment cost is $52652, and the cost-utility for the second-eye model is $50691/QALY. The quality-of-life gain from the first-eye model is 6.4% and the cost-utility is $123887, whereas the most clinically simulating combined model yields a quality-of-life gain of 10.4% and cost-utility of $74169. By conventional standards and the most commonly used second-eye and combined models, intravitreal ranibizumab administered for occult/minimally classic subfoveal choroidal neovascularization is a cost-effective therapy. Ranibizumab treatment confers considerably greater value than other neovascular macular degeneration pharmaceutical therapies that have been studied in randomized clinical trials.

Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial.

PubMed

Waaler Bjørnelv, G M; Frihagen, F; Madsen, J E; Nordsletten, L; Aas, E

2012-06-01

We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective. Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly. A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients' quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios. Over the 2-year period, patients treated with hemiarthroplasty gained 0.15-0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings. Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.

Newborns with suspected occult spinal dysraphism: a cost-effectiveness analysis of diagnostic strategies.

PubMed

Medina, L S; Crone, K; Kuntz, K M

2001-12-01

To assess the clinical and economic consequences of different diagnostic strategies in newborns with suspected occult spinal dysraphism. A decision-analytic model was constructed to project the cost and health outcomes of magnetic resonance imaging (MRI), ultrasound (US), plain radiographs, and no imaging in newborns with suspected occult spinal dysraphism. Morbidity and mortality rates of early versus late diagnosis of dysraphism and the sensitivity and specificity of MRI, US, and plain radiographs were obtained from the literature. Cost estimates were obtained from a hospital cost accounting database and from the Medicaid fee schedule. We found that the choice of imaging strategy depends on the underlying risk of occult spinal dysraphism. In low-risk children with intergluteal dimple or newborns of diabetic mothers (pretest probability: 0.3%-0.34%), US was the most effective strategy with an incremental cost-effectiveness ratio of $55 100 per quality-adjusted life year gained. For children with lumbosacral dimples, who have a higher pretest probability of 3.8%, US was less costly and more effective than the other 3 strategies considered. In intermediate-risk newborns with low anorectal malformation (pretest probability: 27%), US was more effective and less costly than radiographs and no imaging. However, MRI was more effective than US at an incremental cost-effectiveness of $1000 per quality-adjusted life year gained. In the high-risk group that included high anorectal malformation, cloacal malformation, and exstrophy (pretest probability: 44%-46%), MRI was actually cost-saving when compared with the other diagnostic strategies. For the intermediate-risk group, we found our analysis to be sensitive to the costs and diagnostic performances (sensitivity and specificity) of MRI and US. Lower MRI cost or greater MRI diagnostic performance improved the cost-effectiveness of the MRI strategy, whereas lower US cost or greater US diagnostic performance worsened the cost-effectiveness of the MRI strategy. Therefore, individual or institutional expertise with a specific diagnostic modality (MRI versus US) may influence the optimal diagnostic strategy. In newborns with suspected occult dysraphism, appropriate selection of patients and diagnostic strategy may increase quality-adjusted life expectancy and decrease cost of medical work-up.

Evaluation and Characterization of Health Economics and Outcomes Research in SAARC Nations.

PubMed

Mehta, Manthan; Nerurkar, Rajan

2018-05-01

To identify, evaluate, and characterize the variety, quality, and intent of the health economics and outcomes research studies being conducted in SAARC (South Asian Association for Regional Cooperation) nations. Studies published in English language between 1990 and 2015 were retrieved from Medline databases using relevant search strategies. Studies were independently reviewed as per Cochrane methodology and information on the type of research and outcomes were extracted. Quality of reporting was assessed. Of the 2638 studies screened from eight SAARC nations, a total of 179 were included for review (India = 140; Bangladesh = 12; Sri Lanka = 8; Pakistan = 7; Afghanistan = 5; Nepal = 4; Bhutan = 2; Maldives = 1). The broad study categories were cost-effectiveness analyses (CEAs = 76 studies), cost analyses (35 studies), and burden of illness (BOI=26 studies). The outcomes evaluated were direct costs, indirect costs, and incremental cost-effectiveness ratio (ICER), quality-adjusted life-years (QALYs), and disability-adjusted life-years (DALYs). Cost of medicines, consultation and hospital charges, and monitoring costs were assessed as direct medical costs along with non-direct medical costs such as travel and food for patients and caregivers. The components of indirect costs were loss of income of patients and caregivers and loss of productivity. Quality of life (QoL) was assessed in 48 studies. The most commonly used instrument for assessing QoL was the WHO-Quality of Life BREF (WHOQOL-BREF) questionnaire (76%). The Quality of Health Economic Studies (QHES) score was used for quality assessment of full economic studies (44 studies). The mean QHES score was 43.76. This review identifies various patterns of health economic studies in eight SAARC nations. The quality of economic evaluation studies for health care in India, Bangladesh, Sri Lanka, Pakistan, Afghanistan, Nepal, Bhutan, and Maldives needs improvement. There is a need to generate the capacity of researchers to undertake quality economic evaluations as well as an orientation of the policy makers so that there is a demand for such studies as well as a scope for its use in policy making.

Effects of a preceptorship programme on turnover rate, cost, quality and professional development.

PubMed

Lee, Tso-Ying; Tzeng, Wen-Chii; Lin, Chia-Huei; Yeh, Mei-Ling

2009-04-01

The purpose of the present study was to design a preceptorship programme and to evaluate its effects on turnover rate, turnover cost, quality of care and professional development. A high turnover rate of nurses is a common global problem. How to improve nurses' willingness to stay in their jobs and reduce the high turnover rate has become a focus. Well-designed preceptorship programmes could possibly decrease turnover rates and improve professional development. A quasi-experimental research design was used. First, a preceptorship programme was designed to establish the role and responsibilities of preceptors in instructing new nurses. Second, a quasi-experimental design was used to evaluate the preceptorship programme. Data on new nurses' turnover rate, turnover cost, quality of nursing care, satisfaction of preceptor's teaching and preceptor's perception were measured. After conducting the preceptorship programme, the turnover rate was 46.5% less than the previous year. The turnover cost was decreased by US$186,102. Additionally, medication error rates made by new nurses dropped from 50-0% and incident rates of adverse events and falls decreased. All new nurses were satisfied with preceptor guidance. The preceptorship programme effectively lowered the turnover rate of new nurses, reduced turnover costs and enhanced the quality of nursing care, especially by reducing medication error incidents. Positive feedback about the programme was received from new nurses. Study findings may offer healthcare administrators another option for retaining new nurses, controlling costs, improving quality and fostering professional development. In addition, incentives and effective support from the organisation must be considered when preceptors perform preceptorship responsibilities.

Methodological quality of economic evaluations of new pharmaceuticals in The Netherlands.

PubMed

Hoomans, Ties; Severens, Johan L; van der Roer, Nicole; Delwel, Gepke O

2012-03-01

In the Netherlands, decisions about the reimbursement of new pharmaceuticals are based on cost effectiveness, as well as therapeutic value and budget impact. Since 1 January 2005, drug manufacturers are formally required to substantiate the cost effectiveness of drugs that have therapeutic added value in comparison with existing ones through pharmacoeconomic evaluations. Dutch guidelines for pharmacoeconomic research provide methods guidance, ensuring consistency in both the evidence and the decision-making process about drug reimbursement. This study reviewed the methodological quality of all 21 formally required pharmacoeconomic evaluations of new pharmaceuticals between 1 January 2005 and 1 October 2008, and verified whether these evaluations complied with pharmacoeconomic guidelines. Data on the quality of the pharmacoeconomic evaluations were extracted from the pharmacoeconomic reports published by the Dutch Health Care Insurance Board (CVZ). The Board's newsletters provided information on the advice to, and reimbursement decisions made by, the Dutch Minister of Health. All data extraction was carried out by two independent reviewers, and descriptive analyses were conducted. The methodological quality was sound in only 8 of the 21 pharmacoeconomic evaluations. In most cases, the perspective of analysis, the comparator drugs, and the reporting of both total and incremental costs and effects were correct. However, drug indication, form (i.e. cost utility/cost effectiveness) and time horizon of the evaluations were frequently flawed. Moreover, the costs and effects of the pharmaceuticals were not always analysed correctly, and modelling studies were often non-transparent. Twelve drugs were reimbursed, and nine were not. The compliance with pharmacoeconomic guidelines in economic evaluations of new pharmaceuticals can be improved. This would improve the methodological quality of the pharmacoeconomic evaluations and ensure consistency in the evidence and the decision-making process for drug reimbursement in the Netherlands.

Cost-effectiveness of neurostimulation in Parkinson's disease with early motor complications.

PubMed

Dams, Judith; Balzer-Geldsetzer, Monika; Siebert, Uwe; Deuschl, Günther; Schuepbach, W M Michael; Krack, Paul; Timmermann, Lars; Schnitzler, Alfons; Reese, Jens-Peter; Dodel, Richard

2016-08-01

Recent research efforts have focused on the effects of deep brain stimulation of the subthalamic nucleus (STN DBS) for selected patients with mild-to-moderate PD experiencing motor complications. We assessed the cost utility of subthalamic DBS compared with the best medical treatment for German patients below the age of 61 with early motor complications of PD. We applied a previously published Markov model that integrated health utilities based on EuroQoL and direct costs over patients' lifetime adjusted to the German health care payer perspective (year of costing: 2013). Effectiveness was evaluated using the Parkinson's Disease Questionnaire 39 summary index. We performed sensitivity analyses to assess uncertainty. In the base-case analysis, the incremental cost-utility ratio for STN DBS compared to best medical treatment was 22,700 Euros per quality-adjusted life year gained. The time to, and costs for, battery exchange had a major effect on the incremental cost-utility ratios, but never exceeded a threshold of 50,000 Euros per quality-adjusted life year. Our decision analysis supports the fact that STN DBS at earlier stages of the disease is cost-effective in patients below the age of 61 when compared with the best medical treatment in the German health care system. This finding was supported by detailed sensitivity analyses reporting robust results. Whereas the EARLYSTIM study has shown STN DBS to be superior to medical therapy with respect to quality of life for patients with early motor complications, this further analysis has shown its cost-effectiveness. © 2016 International Parkinson and Movement Disorder Society. © 2016 International Parkinson and Movement Disorder Society.

InnovaSEC in Action: Cost-effectiveness of Barostim in the Treatment of Refractory Hypertension in Spain.

PubMed

Soto, Marcelo; Sampietro-Colom, Laura; Sagarra, Joan; Brugada-Terradellas, Josep

2016-06-01

In Spain, 0.3% of patients with hypertension are refractory to conventional treatment. The complications resulting from deficient control of this condition can lead to poor quality of life for the patient and considerable health care costs. Barostim is an implantable device designed to lower blood pressure in these patients. The aim of this study was to analyze the cost-effectiveness of Barostim compared with drug therapy in hypertensive patients refractory to conventional treatment (at least 3 antihypertensive drugs, including 1 diuretic agent). We used a Markov model adapted to the epidemiology of the Spanish population to simulate the natural history of a cohort of patients with refractory hypertension over their lifetime. Data on the effectiveness of the treatments studied were obtained from the literature, and data on costs were taken from hospital administrative databases and official sources. Deterministic and probabilistic sensitivity analyses were conducted. Barostim increased the number of quality-adjusted life years by 0.78 and reduced the number of hypertension-associated clinical events. The incremental cost-effectiveness ratio in a cohort of men reached 68 726 euros per year of quality-adjusted life. One of the main elements that makes this technology costly is the need for battery replacement. The results were robust. Barostim is not a cost-effective strategy for the treatment of refractory hypertension in Spain. The cost-effectiveness ratio could be improved by future reductions in the cost of the battery. Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Trends in Managed Care Cost Containment: An Analysis of the Managed Care Backlash.

PubMed

Dugan, Jerome

2015-12-01

Consumer dissatisfaction with the quality and limitations of managed health care led to rapid disenrollment from managed care plans and demands for regulation between 1998 and 2003. Managed care organizations, particularly health maintenance organizations (HMOs), now face quality and coverage mandates that restrict them from using their most aggressive strategies for managing costs. This paper examines the effect of this backlash on managed care's ability to contain costs among short-term, non-federal hospitals between 1998 and 2008. The results show that the impact of increased HMO penetration on inpatient costs reversed over the study period, but HMOs were still effective at containing outpatient costs. These findings have important policy implications for understanding the continuing role that HMOs should play in cost containment policy and for understanding how effective the latest wave of cost containment institutions may perform in heavily regulated markets. Copyright © 2014 John Wiley & Sons, Ltd.

Economic analysis of temperature-controlled laminar airflow (TLA) for the treatment of patients with severe persistent allergic asthma.

PubMed

Brazier, Peter; Schauer, Uwe; Hamelmann, Eckard; Holmes, Steve; Pritchard, Clive; Warner, John O

2016-01-01

Chronic asthma is a significant burden for individual sufferers, adversely impacting their quality of working and social life, as well as being a major cost to the National Health Service (NHS). Temperature-controlled laminar airflow (TLA) therapy provides asthma patients at BTS/SIGN step 4/5 an add-on treatment option that is non-invasive and has been shown in clinical studies to improve quality of life for patients with poorly controlled allergic asthma. The objective of this study was to quantify the cost-effectiveness of TLA (Airsonett AB) technology as an add-on to standard asthma management drug therapy in the UK. The main performance measure of interest is the incremental cost per quality-adjusted life year (QALY) for patients using TLA in addition to usual care versus usual care alone. The incremental cost of TLA use is based on an observational clinical study monitoring the incidence of exacerbations with treatment valued using NHS cost data. The clinical effectiveness, used to derive the incremental QALY data, is based on a randomised double-blind placebo-controlled clinical trial comprising participants with an equivalent asthma condition. For a clinical cohort of asthma patients as a whole, the incremental cost-effectiveness ratio (ICER) is £8998 per QALY gained, that is, within the £20 000/QALY cost-effectiveness benchmark used by the National Institute for Health and Care Excellence (NICE). Sensitivity analysis indicates that ICER values range from £18 883/QALY for the least severe patients through to TLA being dominant, that is, cost saving as well as improving quality of life, for individuals with the most severe and poorly controlled asthma. Based on our results, Airsonett TLA is a cost-effective addition to treatment options for stage 4/5 patients. For high-risk individuals with more severe and less well controlled asthma, the use of TLA therapy to reduce incidence of hospitalisation would be a cost saving to the NHS.

The cost-effectiveness of life-saving interventions in Japan. Do chemical regulations cost too much?

PubMed

Kishimoto, Atsuo; Oka, Tosihiro; Nakanishi, Junko

2003-10-01

This paper compares the cost-effectiveness of life-saving interventions in Japan, based on information collected from the health, safety and environmental literature. More than 50 life-saving interventions are analyzed. Cost-effectiveness is defined as the cost per life-year saved or as the cost per quality-adjusted life-year saved. Finding a large cost-effectiveness disparity between chemical controls and health care intervention, we raise the question of whether chemical regulations cost society too much. We point out the limitations of this study and propose a way to improve the incorporation of morbidity effects in cost-effectiveness analysis.

Economic evaluations of tobacco control mass media campaigns: a systematic review

PubMed Central

Atusingwize, Edwinah; Lewis, Sarah; Langley, Tessa

2015-01-01

Background International evidence shows that mass media campaigns are effective tobacco control interventions. However, they require substantial investment; a key question is whether their costs are justified by their benefits. The aim of this study was to systematically and comprehensively review economic evaluations of tobacco control mass media campaigns. Methods An electronic search of databases and grey literature was conducted to identify all published economic evaluations of tobacco control mass media campaigns. The authors reviewed studies independently and assessed the quality of studies using the Drummond 10-point checklist. A narrative synthesis was used to summarise the key features and quality of the identified studies. Results 10 studies met the inclusion criteria and were included in the review. All the studies included a cost effectiveness analysis, a cost utility analysis or both. The methods were highly heterogeneous, particularly in terms of the types of costs included. On the whole, studies were well conducted, but the interventions were often poorly described in terms of campaign content and intensity, and cost information was frequently inadequate. All studies concluded that tobacco control mass media campaigns are a cost effective public health intervention. Conclusions The evidence on the cost effectiveness of tobacco control mass media campaigns is limited, but of acceptable quality and consistently suggests that they offer good value for money. PMID:24985730

Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment.

PubMed

Frick, Kevin D; Clark, Melissa A; Steinwachs, Donald M; Langenberg, Patricia; Stovall, Dale; Munro, Malcolm G; Dickersin, Kay

2009-01-01

In this study, we sought to 1) describe elements of the financial and quality-of-life burden of dysfunctional uterine bleeding (DUB) from the perspective of women who agreed to obtain surgical treatment; 2) explore associations between DUB symptom characteristics and the financial and quality-of-life burden; 3) estimate the annual dollar value of the financial burden; and 4) estimate the most that could be spent on surgery to eliminate DUB symptoms for which medical treatment has been unsuccessful that would result in a $50,000/quality-adjusted life-year incremental cost-effectiveness ratio. We collected baseline data on DUB symptoms and aspects of the financial and quality-of-life burden for 237 women agreeing to surgery for DUB in a randomized trial comparing hysterectomy with endometrial ablation. Measures included out-of-pocket pharmaceutical expenditures, excess expenditures on pads or tampons, the value of time missed from paid work and home management activities, and health utility. We used chi2 and t tests to assess the statistical significance of associations between DUB characteristics and the financial and quality-of-life burden. The annual financial burden was estimated. Pelvic pain and cramps were associated with activity limitations and tiredness was associated with a lower health utility. Excess pharmaceutical and pad and tampon costs were $333 per patient per year (95% confidence interval [CI], $263-$403). Excess paid work and home management loss costs were $2,291 per patient per year (95% CI, $1847-$2752). Effective surgical treatment costing $40,000 would be cost-effective compared with unsuccessful medical treatment. The financial and quality-of-life effects of DUB represent a substantial burden.

The impact of health information exchange on healthcare quality and cost-effectiveness: A systematic literature review.

PubMed

Sadoughi, Farahnaz; Nasiri, Somayeh; Ahmadi, Hossein

2018-07-01

Health Information Exchange (HIE) is known as a technology that electronically shares all clinical and administrative data throughout healthcare settings. Despite this technology has a great potential in the healthcare industry, there is a limited and sparse evidence of articles which illustrated the impact of HIE on quality of care and cost-effectiveness. This work presents a systematic review that evaluates the impact of HIE on quality and cost-effectiveness, and the rates of HIE adoption and participation in healthcare organizations. We systematically searched all English papers that were indexed in four major databases (Science Direct, PubMed, IEEE and Web of Science) between 2005 and 2016. Consequently, 32 identified papers appeared in 21 international journals and conferences. Eligible studies independently were critically appraised, collected within data extraction form and then thematically analyzed by two reviewers and if necessary, the third author. The selected papers have been classified based on 11 main categories including publication year, journal and conference names, country and study design, types of data exchanged, healthcare levels, disease or disorder, participants in organizations and individuals, settings characteristics and HIE types, the impact of HIE on quality and cost-effectiveness, and the rates of HIE adoption and participation. Of the 32 articles, 25 studies investigated the financial and clinical impact of HIE. Overwhelmingly, HIE studies have reported positive findings for quality and cost-effectiveness of care. 15 of HIE studies (60%) demonstrated positive financial effects and 16 studies (64%) reported positive effects on quality improvement of patient care. However, the overall quality of the evidences was low. In this regard, cohort study (59.38%) was the most common used study design. Nine studies presented the rates of HIE adoption and participation. The lowest and highest participation rates were 15.7% and 79%, respectively. HIE can be considered as a superior potential for healthcare information system, resulting to promote patient care quality and reduce costs related to resource utilization. However, further researches are needed in order to provide a better understanding of this domain and accordingly attain new opportunities to increase users' participation and motivation for successfully adopting this technology. Copyright © 2018 Elsevier B.V. All rights reserved.

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana.

PubMed

Goodman, David M; Ramaswamy, Rohit; Jeuland, Marc; Srofenyoh, Emmanuel K; Engmann, Cyril M; Olufolabi, Adeyemi J; Owen, Medge D

2017-01-01

To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana. Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations. Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual. From 2007-2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218. QI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to encourage fiscal responsibility in the pursuit of improved maternal and child health.

Cost-Effectiveness of a Collaborative Care Depression and Anxiety Treatment Program in Patients with Acute Cardiac Illness.

PubMed

Celano, Christopher M; Healy, Brian; Suarez, Laura; Levy, Douglas E; Mastromauro, Carol; Januzzi, James L; Huffman, Jeff C

2016-01-01

To use data from a randomized trial to determine the cost-effectiveness of a collaborative care (CC) depression and anxiety treatment program and to assess effects of the CC program on health care utilization. The CC intervention's impact on health-related quality of life, depression-free days (DFDs), and anxiety-free days (AFDs) over the 24-week postdischarge period was calculated and compared with the enhanced usual care (EUC) condition using independent samples t tests and random-effects regression models. Costs for both the CC and EUC conditions were calculated on the basis of staff time, overhead expenses, and treatment materials. Using this information, incremental cost-effectiveness ratios were calculated. A cost-effectiveness acceptability plot was created using nonparametric bootstrapping with 10,000 replications, and the likelihood of the CC intervention's cost-effectiveness was assessed using standard cutoffs. As a secondary analysis, we determined whether the CC intervention led to reductions in postdischarge health care utilization and costs. The CC intervention was more costly than the EUC intervention ($209.86 vs. $34.59; z = -11.71; P < 0.001), but was associated with significantly greater increases in quality-adjusted life-years (t = -2.49; P = 0.01) and DFDs (t = -2.13; P = 0.03), but not AFDs (t = -1.92; P = 0.057). This translated into an incremental cost-effectiveness ratio of $3337.06 per quality-adjusted life-year saved, $13.36 per DFD, and $13.74 per AFD. Compared with the EUC intervention, the CC intervention was also associated with fewer emergency department visits but no differences in overall costs. This CC intervention was associated with clinically relevant improvements, was cost-effective, and was associated with fewer emergency department visits in the 24 weeks after discharge. Copyright © 2016. Published by Elsevier Inc.

Measuring the quality-of-life effects of diagnostic and screening tests.

PubMed

Swan, J Shannon; Miksad, Rebecca A

2009-08-01

Health-related quality of life (HRQL) is a central concept for understanding the outcomes of medical care. When used in cost-effectiveness analysis, HRQL is typically measured for conditions persisting over long time frames (years), and quality-adjusted life year (QALY) values are generated. Consequently, years are the basic unit of time for cost-effectiveness analysis results: dollars spent per QALY gained. However, shorter term components of health care may also affect HRQL, and there is increased interest in measuring and accounting for these events. In radiology, the short-term HRQL effects of screening and diagnostic testing may affect a test's cost-effectiveness, even though they may only last for days. The unique challenge in radiology HRQL assessment is to realistically tap into the testing and screening experience while remaining consistent with QALY theory. The authors review HRQL assessment and highlight methods developed to specifically address the short-term effects of radiologic screening and testing.

Integrated cost-effectiveness analysis of agri-environmental measures for water quality.

PubMed

Balana, Bedru B; Jackson-Blake, Leah; Martin-Ortega, Julia; Dunn, Sarah

2015-09-15

This paper presents an application of integrated methodological approach for identifying cost-effective combinations of agri-environmental measures to achieve water quality targets. The methodological approach involves linking hydro-chemical modelling with economic costs of mitigation measures. The utility of the approach was explored for the River Dee catchment in North East Scotland, examining the cost-effectiveness of mitigation measures for nitrogen (N) and phosphorus (P) pollutants. In-stream nitrate concentration was modelled using the STREAM-N and phosphorus using INCA-P model. Both models were first run for baseline conditions and then their effectiveness for changes in land management was simulated. Costs were based on farm income foregone, capital and operational expenditures. The costs and effects data were integrated using 'Risk Solver Platform' optimization in excel to produce the most cost-effective combination of measures by which target nutrient reductions could be attained at a minimum economic cost. The analysis identified different combination of measures as most cost-effective for the two pollutants. An important aspect of this paper is integration of model-based effectiveness estimates with economic cost of measures for cost-effectiveness analysis of land and water management options. The methodological approach developed is not limited to the two pollutants and the selected agri-environmental measures considered in the paper; the approach can be adapted to the cost-effectiveness analysis of any catchment-scale environmental management options. Copyright © 2015 Elsevier Ltd. All rights reserved.

Cost-effectiveness of preventive case management for parents with a mental illness: a randomized controlled trial from three economic perspectives.

PubMed

Wansink, Henny J; Drost, Ruben M W A; Paulus, Aggie T G; Ruwaard, Dirk; Hosman, Clemens M H; Janssens, Jan M A M; Evers, Silvia M A A

2016-07-07

The children of parents with a mental illness (COPMI) are at increased risk for developing costly psychiatric disorders because of multiple risk factors which threaten parenting quality and thereby child development. Preventive basic care management (PBCM) is an intervention aimed at reducing risk factors and addressing the needs of COPMI-families in different domains. The intervention may lead to financial consequences in the healthcare sector and in other sectors, also known as inter-sectoral costs and benefits (ICBs). The objective of this study was to assess the cost-effectiveness of PBCM from three perspectives: a narrow healthcare perspective, a social care perspective (including childcare costs) and a broad societal perspective (including all ICBs). Effects on parenting quality (as measured by the HOME) and costs during an 18-month period were studied in in a randomized controlled trial. Families received PBCM (n = 49) or care as usual (CAU) (n = 50). For all three perspectives, incremental cost-effectiveness ratios (ICERs) were calculated. Stochastic uncertainty in the data was dealt with using non-parametric bootstraps. Sensitivity analyses included calculating ICERs excluding cost outliers, and making an adjustment for baseline cost differences. Parenting quality improved in the PBCM group and declined in the CAU group, and PBCM was shown to be more costly than CAU. ICERs differ from 461 Euros (healthcare perspective) to 215 Euros (social care perspective) to 175 Euros (societal perspective) per one point improvement on the HOME T-score. The results of the sensitivity analyses, based on complete cases and excluding cost outliers, support the finding that the ICER is lower when adopting a broader perspective. The subgroup analysis and the analysis with baseline adjustments resulted in higher ICERs. This study is the first economic evaluation of family-focused preventive basic care management for COPMI in psychiatric and family services. The effects of the chosen perspective on determining the cost-effectiveness of PBCM underscore the importance of economic studies of interdepartmental policies. Future studies focusing on the cost-effectiveness of programs like PBCM in other sites and studies with more power are encouraged as this may improve the quality of information used in supporting decision making. NTR2569 , date of registration 2010-10-12.

Economics, health-related quality of life, and cost-effectiveness methods for the TACTICS (Treat Angina With Aggrastat [tirofiban

PubMed

Weintraub, W S; Culler, S D; Kosinski, A; Becker, E R; Mahoney, E; Burnette, J; Spertus, J A; Feeny, D; Cohen, D J; Krumholz, H; Ellis, S G; Demopoulos, L; Robertson, D; Boccuzzi, S J; Barr, E; Cannon, C P

1999-02-01

Concern over escalating health care costs has led to increasing focus on economics and assessment of outcome measures for expensive forms of therapy. This is being investigated in the Treat Angina With Aggrastat [tirofiban] and Determine Cost of Therapy with Invasive or Conservative Strategy (TACTICS)-TIMI 18 trial, a randomized trial comparing outcome of patients with unstable angina or non-Q-wave myocardial infarction treated with tirofiban and then randomized to an invasive versus a conservative strategy. Hospital and professional costs initially and over 6 months, including outpatient costs, will be assessed. Hospital costs will be determined for patients in the United States from the UB92 formulation of the hospital bill, with costs derived from charges using departmental cost to charge ratios. Professional costs will be determined by accounting for professional services and then converted to resource units using the Resource Based Relative Value Scale and then to costs using the Medicare conversion factor. Follow-up resource consumption, including medications, testing and office visits, will be carefully measured with a Patient Economic Form, and converted to costs from the Medicare fee schedule. Health-related quality of life will be assessed with a specific instrument, the Seattle Angina Questionnaire, and a general instrument, the Health Utilities Index at baseline, 1, and 6 months. The Health Utilities Index will also be used to construct a utility. By knowing utility and survival, quality-adjusted life years will be determined. These measures will permit the performance of a cost-effectiveness analysis, with the cost-effectiveness of the invasive strategy defined and the difference in cost between the invasive and conservative strategies divided by the difference in quality-adjusted life years. The economic and health-related quality of life aspects of TACTICS-TIMI 18 are an integral part of the study design and will provide a comprehensive understanding of the impact of invasive versus conservative management strategies on a broad range of outcomes after hospitalization for unstable angina or non-Q-wave myocardial infarction.

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy.

PubMed

Berghout, Caspar C; Zevalkink, Jolien; Hakkaart-van Roijen, Leona

2010-01-01

Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER--that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy--was estimated at 52,384 euros per QALY gained. Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish 'TeleCare North' cluster-randomised trial.

PubMed

Witt Udsen, Flemming; Lilholt, Pernille Heyckendorff; Hejlesen, Ole; Ehlers, Lars

2017-05-17

To investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care. A 12-month cost-utility analysis conducted alongside a cluster-randomised trial. Community-based setting in the geographical area of North Denmark Region in Denmark. 26 municipality districts define randomisation clusters with 13 districts in each arm. 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care. In addition to usual care, patients in the intervention group received a set of telehealthcare equipment and were monitored by a municipality-based healthcare team. Patients in the control group received usual care. Incremental costs per quality-adjusted life-years gained from baseline up to 12 months follow-up. From a healthcare and social sector perspective, the adjusted mean difference in total costs between telehealthcare and usual care was €728 (95% CI -754 to 2211) and the adjusted mean difference in quality-adjusted life-years gained was 0.0132 (95% CI -0.0083 to 0.0346). The incremental cost-effectiveness ratio was €55 327 per quality-adjusted life-year gained. Decision-makers should be willing to pay more than €55 000 to achieve a probability of cost-effectiveness >50%. This conclusion is robust to changes in the definition of hospital contacts and reduced intervention costs. Only in the most optimistic scenario combining the effects of all sensitivity analyses, does the incremental cost-effectiveness ratio fall below the UK thresholds values (€21 068 per quality-adjusted life-year). Telehealthcare is unlikely to be a cost-effective addition to usual care, if it is offered to all patients with chronic obstructive pulmonary disease and if the willingness-to-pay threshold values from the National Institute for Health and Care Excellence are applied. Clinicaltrials.gov, NCT01984840, 14 November 2013. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish ‘TeleCare North’ cluster-randomised trial

PubMed Central

Witt Udsen, Flemming; Lilholt, Pernille Heyckendorff; Hejlesen, Ole; Ehlers, Lars

2017-01-01

Objectives To investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care. Design A 12-month cost-utility analysis conducted alongside a cluster-randomised trial. Setting Community-based setting in the geographical area of North Denmark Region in Denmark. Participants 26 municipality districts define randomisation clusters with 13 districts in each arm. 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care. Interventions In addition to usual care, patients in the intervention group received a set of telehealthcare equipment and were monitored by a municipality-based healthcare team. Patients in the control group received usual care. Main outcome measure Incremental costs per quality-adjusted life-years gained from baseline up to 12 months follow-up. Results From a healthcare and social sector perspective, the adjusted mean difference in total costs between telehealthcare and usual care was €728 (95% CI −754 to 2211) and the adjusted mean difference in quality-adjusted life-years gained was 0.0132 (95% CI −0.0083 to 0.0346). The incremental cost-effectiveness ratio was €55 327 per quality-adjusted life-year gained. Decision-makers should be willing to pay more than €55 000 to achieve a probability of cost-effectiveness >50%. This conclusion is robust to changes in the definition of hospital contacts and reduced intervention costs. Only in the most optimistic scenario combining the effects of all sensitivity analyses, does the incremental cost-effectiveness ratio fall below the UK thresholds values (€21 068 per quality-adjusted life-year). Conclusions Telehealthcare is unlikely to be a cost-effective addition to usual care, if it is offered to all patients with chronic obstructive pulmonary disease and if the willingness-to-pay threshold values from the National Institute for Health and Care Excellence are applied. Trial registration Clinicaltrials.gov, NCT01984840, 14 November 2013. PMID:28515193

The principles of quality-associated costing: derivation from clinical transfusion practice.

PubMed

Trenchard, P M; Dixon, R

1997-01-01

As clinical transfusion practice works towards achieving cost-effectiveness, prescribers of blood and its derivatives must be certain that the prices of such products are based on real manufacturing costs and not market forces. Using clinical cost-benefit analysis as the context for the costing and pricing of blood products, this article identifies the following two principles: (1) the product price must equal the product cost (the "price = cost" rule) and (2) the product cost must equal the real cost of product manufacture. In addition, the article describes a new method of blood product costing, quality-associated costing (QAC), that will enable valid cost-benefit analysis of blood products.

Cost-Effectiveness of Ventricular Assist Device Destination Therapy for Advanced Heart Failure in Duchenne Muscular Dystrophy.

PubMed

Magnetta, Defne A; Kang, JaHyun; Wearden, Peter D; Smith, Kenneth J; Feingold, Brian

2018-05-17

Destination ventricular assist device therapy (DT-VAD) is well accepted in select adults with medically refractory heart failure (HF) who are not transplant candidates; however, its use in younger patients with progressive diseases is unclear. We sought to evaluate the cost-effectiveness of DT-VAD in Duchenne muscular dystrophy (DMD) patients with advanced HF. We created a Markov-state transition model (5-year horizon) to compare survival, costs, and quality of life (QOL) between medical management and DT-VAD in DMD with advanced HF. Model input parameters were derived from the literature. We used sensitivity analyses to explore uncertainty around model assumptions. DT-VAD had higher costs ($435,602 vs. $125,696), survival (3.13 vs. 0.60 years), and quality-adjusted survival (1.99 vs. 0.26 years) than medical management. The incremental cost-effectiveness ratio (ICER) for DT-VAD was $179,086 per quality-adjusted life year (QALY). In sensitivity analyses that were widely varied to account for uncertainty in model assumptions, the DT-VAD strategy generally remained more costly and effective than medical management. Only when VAD implantation costs were <$113,142 did the DT-VAD strategy fall below the $100,000/QALY willingness-to-pay threshold commonly considered to be "cost-effective." In this exploratory analysis, DT-VAD for patients with DMD and advanced HF exceeded societal expectations for cost-effectiveness but had an ICER similar to the accepted practice of DT-VAD in adult HF patients. While more experience and research in this population is needed, our analysis suggests that DT-VAD for advanced HF in DMD should not be dismissed solely based on cost.

Early prevention of pressure ulcers among elderly patients admitted through emergency departments: a cost-effectiveness analysis.

PubMed

Pham, Ba'; Teague, Laura; Mahoney, James; Goodman, Laurie; Paulden, Mike; Poss, Jeff; Li, Jianli; Ieraci, Luciano; Carcone, Steven; Krahn, Murray

2011-11-01

Every year, approximately 6.2 million hospital admissions through emergency departments (ED) involve elderly patients who are at risk of developing pressure ulcers. We evaluated the cost-effectiveness of pressure-redistribution foam mattresses on ED stretchers and beds for early prevention of pressure ulcers in elderly admitted ED patients. Using a Markov model, we evaluated the incremental effectiveness (quality-adjusted life-days) and incremental cost (hospital and home care costs) between early prevention and current practice (with standard hospital mattresses) from a health care payer perspective during a 1-year time horizon. The projected incidence of ED-acquired pressure ulcers was 1.90% with current practice and 1.48% with early prevention, corresponding to a number needed to treat of 238 patients. The average upgrading cost from standard to pressure-redistribution mattresses was $0.30 per patient. Compared with current practice, early prevention was more effective, with 0.0015 quality-adjusted life-days gained, and less costly, with a mean cost saving of $32 per patient. If decisionmakers are willing to pay $50,000 per quality-adjusted life-year gained, early prevention was cost-effective even for short ED stay (ie, 1 hour), low hospital-acquired pressure ulcer risk (1% prevalence), and high unit price of pressure-redistribution mattresses ($3,775). Taking input uncertainty into account, early prevention was 81% likely to be cost-effective. Expected value-of-information estimates supported additional randomized controlled trials of pressure-redistribution mattresses to eliminate the remaining decision uncertainty. The economic evidence supports early prevention with pressure-redistribution foam mattresses in the ED. Early prevention is likely to improve health for elderly patients and save hospital costs. Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Cost-effectiveness analysis of low-molecular-weight heparin versus aspirin thromboprophylaxis in patients newly diagnosed with multiple myeloma.

PubMed

Chalayer, Emilie; Bourmaud, Aurélie; Tinquaut, Fabien; Chauvin, Franck; Tardy, Bernard

2016-09-01

The aim of this study was to assess the cost-effectiveness of low molecular weight heparin versus aspirin as primary thromboprophylaxis throughout chemotherapy for newly diagnosed multiple myeloma patients treated with protocols including thalidomide from the perspective of French health care providers. We used a modeling approach combining data from the only randomized trial evaluating the efficacy of the two treatments and secondary sources for costs, and utility values. We performed a decision-tree analysis and our base case was a hypothetical cohort of 10,000 patients. A bootstrap resampling technique was used. The incremental cost-effectiveness ratio was calculated using estimated quality-adjusted life years as the efficacy outcome. Incremental costs and effectiveness were estimated for each strategy and the incremental cost-effectiveness ratio was calculated. One-way sensitivity analyses were performed. The number of quality-adjusted life years was estimated to be 0.300 with aspirin and 0.299 with heparin. The estimated gain with aspirin was therefore approximately one day. Over 6months, the mean total cost was € 1518 (SD=601) per patient in the heparin arm and € 273 (SD=1019) in the aspirin arm. This resulted in an incremental cost of € 1245 per patient treated with heparin. The incremental cost-effectiveness ratio for the aspirin versus heparin strategy was calculated to be - 687,398 € (95% CI, -13,457,369 to -225,385). Aspirin rather than heparin thromboprophylaxis, during the first six months of chemotherapy for myeloma, is associated with significant cost savings per patient and also with an unexpected slight increase in quality of life. Copyright © 2016 Elsevier Ltd. All rights reserved.

Cost-effectiveness of a physical exercise programme for residents of care homes: a pilot study.

PubMed

Verhoef, Talitha I; Doshi, Parita; Lehner, Dan; Morris, Stephen

2016-04-18

Oomph! Wellness organises interactive exercise and activity classes (Oomph! classes) for older people in care homes. We investigated the cost-effectiveness of Oomph! classes. Health-related quality of life was measured using the EQ-5D-5 L questionnaire at three time points; 3 months and 1 week prior to the start of the classes and after 3 months of Oomph! classes. Costs included the costs of organising the classes, training instructors and health service use (General Practitioner (GP) and hospital outpatient visits). To determine the cost-effectiveness of Oomph! classes, total costs and quality-adjusted life-years (QALYs) during the 3 months after initiation of the classes were compared to the total costs and QALYs of the 3 months prior to the classes and extrapolated to a 1-year time horizon. Uncertainty was taken into account using one-way and probabilistic sensitivity analysis. Sixteen residents completed all three EQ-5D-5 L questionnaires. There was a decrease in mean health related quality of life per participant in the 3 months before Oomph! classes (0.56 to 0.52, p = 0.26) and an increase in the 3 months after the start of Oomph! classes (0.52 to 0.60, p = 0.06), but the changes were not statistically significant. There were more GP visits after the start of Oomph! classes and fewer hospital outpatient visits, leading to a slight decrease in NHS costs (mean £132 vs £141 per participant), but the differences were not statistically significant (p = 0.79). In the base case scenario, total costs for Oomph! classes were £113 higher per participant than without Oomph! classes (£677 vs £564) and total QALYs were 0.074 higher (0.594 vs 0.520). The incremental costs per QALY gained were therefore £1531. The 95 % confidence intervals around the cost/QALY gained varied from dominant to dominated, meaning there was large uncertainty around the cost-effectiveness results. Given a willingness to pay threshold of £20,000 per QALY gained, Oomph! classes had a 62 %-86 % probability of being cost-effective depending on the scenario used. Preliminary evidence suggests that Oomph! classes may be cost-effective, but further evidence is needed about its impact on health-related quality of life and health service use.

Cost-effectiveness of supervised exercise, stenting, and optimal medical care for claudication: results from the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) trial.

PubMed

Reynolds, Matthew R; Apruzzese, Patricia; Galper, Benjamin Z; Murphy, Timothy P; Hirsch, Alan T; Cutlip, Donald E; Mohler, Emile R; Regensteiner, Judith G; Cohen, David J

2014-11-11

Both supervised exercise (SE) and stenting (ST) improve functional status, symptoms, and quality of life compared with optimal medical care (OMC) in patients with claudication. The relative cost-effectiveness of these strategies is not well defined. The Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) study randomized patients with claudication due to aortoiliac stenosis to a 6-month SE program, to ST, or to OMC. Participants who completed 6-month follow-up (n=98) were included in a health economic analysis through 18 months. Costs were assessed using resource-based methods and hospital billing data. Quality-adjusted life-years were estimated using the EQ-5D. Markov modeling based on the in-trial results was used to explore the impact of assumptions about the longer term durability of observed differences in quality of life. Through 18 months, mean healthcare costs were $5178, $9804, and $14 590 per patient for OMC, SE, and ST, respectively. Measured quality-adjusted life-years through 18 months were 1.04, 1.16, and 1.20. In our base case analysis, which assumed that observed differences in quality of life would dissipate after 5 years, the incremental cost-effectiveness ratios were $24 070 per quality-adjusted life-year gained for SE versus OMC, $41 376 for ST versus OMC, and $122 600 for ST versus SE. If the treatment effect of ST was assumed to be more durable than that of SE, the incremental cost-effectiveness ratio for ST versus SE became more favorable. Both SE and ST are economically attractive by US standards relative to OMC for the treatment of claudication in patients with aortoiliac disease. ST is more expensive than SE, with uncertain incremental benefit. www.clinicaltrials.gov, Unique identifier: NCT00132743. © 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Cost-effectiveness of integrated collaborative care for comorbid major depression in patients with cancer☆

PubMed Central

Duarte, A.; Walker, J.; Walker, S.; Richardson, G.; Holm Hansen, C.; Martin, P.; Murray, G.; Sculpher, M.; Sharpe, M.

2015-01-01

Objectives Comorbid major depression is associated with reduced quality of life and greater use of healthcare resources. A recent randomised trial (SMaRT, Symptom Management Research Trials, Oncology-2) found that a collaborative care treatment programme (Depression Care for People with Cancer, DCPC) was highly effective in treating depression in patients with cancer. This study aims to estimate the cost-effectiveness of DCPC compared with usual care from a health service perspective. Methods Costs were estimated using UK national unit cost estimates and health outcomes measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness of DCPC compared with usual care was calculated and scenario analyses performed to test alternative assumptions on costs and missing data. Uncertainty was characterised using cost-effectiveness acceptability curves. The probability of DCPC being cost-effective was determined using the UK National Institute for Health and Care Excellence's (NICE) cost-effectiveness threshold range of £20,000 to £30,000 per QALY gained. Results DCPC cost on average £631 more than usual care per patient, and resulted in a mean gain of 0.066 QALYs, yielding an incremental cost-effectiveness ratio of £9549 per QALY. The probability of DCPC being cost-effective was 0.9 or greater at cost-effectiveness thresholds above £20,000 per QALY for the base case and scenario analyses. Conclusions Compared with usual care, DCPC is likely to be cost-effective at the current thresholds used by NICE. This study adds to the weight of evidence that collaborative care treatment models are cost-effective for depression, and provides new evidence regarding their use in specialist medical settings. PMID:26652589

Cost Effectiveness of a Shingles Vaccine Booster for Currently Vaccinated Adults in the U.S.

PubMed

Le, Phuc; Rothberg, Michael B

2017-12-01

The Advisory Committee on Immunization Practices recommends a single dose of the live attenuated herpes zoster vaccine in people aged ≥60 years. Because vaccine-induced protection decreases to zero after 10 years, many vaccinated people will soon be subject to an increased risk of the disease. The study objective was to determine the cost effectiveness of a herpes zoster vaccine booster and its optimal timing among immunocompetent adults first vaccinated at aged ≥60 years. A Markov model was built to follow vaccinated individuals for a lifetime. From the societal perspective, costs and quality-adjusted life years were compared between no booster versus booster options. A booster was given any time between 1 and 20 years after the first dose, and for those who had the first dose at different ages: 60, 70, and 80 years. Because people entered the model already vaccinated, costs and side effects of the first dose were not included. The booster was assumed to have the same efficacy and waning rate as the initial vaccination. Model inputs were based on published literature. A cost effectiveness threshold of $100,000/quality-adjusted life year was used. The analysis was conducted in 2016. Cost effectiveness of a booster varied by age and time since vaccination. The booster cost <$100,000/quality-adjusted life year if given >5 years after the initial dose, but was most cost effective at around 10 years. The finding was robust to wide variations in model inputs. Under current assumptions, a booster dose of herpes zoster vaccine would be cost effective for all vaccinated people 10 years after initial vaccination. Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Cost-Effectiveness Model for Chemoimmunotherapy Options in Patients with Previously Untreated Chronic Lymphocytic Leukemia Unsuitable for Full-Dose Fludarabine-Based Therapy.

PubMed

Becker, Ursula; Briggs, Andrew H; Moreno, Santiago G; Ray, Joshua A; Ngo, Phuong; Samanta, Kunal

2016-06-01

To evaluate the cost-effectiveness of treatment with anti-CD20 monoclonal antibody obinutuzumab plus chlorambucil (GClb) in untreated patients with chronic lymphocytic leukemia unsuitable for full-dose fludarabine-based therapy. A Markov model was used to assess the cost-effectiveness of GClb versus other chemoimmunotherapy options. The model comprised three mutually exclusive health states: "progression-free survival (with/without therapy)", "progression (refractory/relapsed lines)", and "death". Each state was assigned a health utility value representing patients' quality of life and a specific cost value. Comparisons between GClb and rituximab plus chlorambucil or only chlorambucil were performed using patient-level clinical trial data; other comparisons were performed via a network meta-analysis using information gathered in a systematic literature review. To support the model, a utility elicitation study was conducted from the perspective of the UK National Health Service. There was good agreement between the model-predicted progression-free and overall survival and that from the CLL11 trial. On incorporating data from the indirect treatment comparisons, it was found that GClb was cost-effective with a range of incremental cost-effectiveness ratios below a threshold of £30,000 per quality-adjusted life-year gained, and remained so during deterministic and probabilistic sensitivity analyses under various scenarios. GClb was estimated to increase both quality-adjusted life expectancy and treatment costs compared with several commonly used therapies, with incremental cost-effectiveness ratios below commonly referenced UK thresholds. This article offers a real example of how to combine direct and indirect evidence in a cost-effectiveness analysis of oncology drugs. Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial.

PubMed

Sørensen, J; Primdahl, J; Horn, H C; Hørslev-Petersen, K

2015-01-01

To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA). In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations. Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability. Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.

Cost Effectiveness of Alectinib vs. Crizotinib in First-Line Anaplastic Lymphoma Kinase-Positive Advanced Non-Small-Cell Lung Cancer.

PubMed

Carlson, Josh J; Suh, Kangho; Orfanos, Panos; Wong, William

2018-04-01

The recently completed ALEX trial demonstrated that alectinib improved progression-free survival, and delayed time to central nervous system progression compared with crizotinib in patients with anaplastic lymphoma kinase-positive non-small-cell lung cancer. However, the long-term clinical and economic impact of using alectinib vs. crizotinib has not been evaluated. The objective of this study was to determine the potential cost utility of alectinib vs. crizotinib from a US payer perspective. A cost-utility model was developed using partition survival methods and three health states: progression-free, post-progression, and death. ALEX trial data informed the progression-free and overall survival estimates. Costs included drug treatments and supportive care (central nervous system and non-central nervous system). Utility values were obtained from trial data and literature. Sensitivity analyses included one-way and probabilistic sensitivity analyses. Treatment with alectinib vs. crizotinib resulted in a gain of 0.91 life-years, 0.87 quality-adjusted life-years, and incremental costs of US$34,151, resulting in an incremental cost-effectiveness ratio of US$39,312/quality-adjusted life-year. Drug costs and utilities in the progression-free health state were the main drivers of the model in the one-way sensitivity analysis. From the probabilistic sensitivity analysis, alectinib had a 64% probability of being cost effective at a willingness-to-pay threshold of US$100,000/quality adjusted life-year. Alectinib increased time in the progression-free state and quality-adjusted life-years vs. crizotinib. The marginal cost increase was reflective of longer treatment durations in the progression-free state. Central nervous system-related costs were considerably lower with alectinib. Our results suggest that compared with crizotinib, alectinib may be a cost-effective therapy for treatment-naïve patients with anaplastic lymphoma kinase-positive non-small-cell lung cancer.

A Quality-Based Payment Strategy for Nursing Home Care in Minnesota

ERIC Educational Resources Information Center

Kane, Robert L.; Arling, Greg; Mueller, Christine; Held, Robert; Cooke, Valerie

2007-01-01

This article describes a pay-for-performance system developed for Minnesota nursing homes. In effect, nursing homes can retain a greater proportion of the difference between their costs and the average costs on the basis of their quality scores. The quality score is a derived and weighted composite measure currently composed of five elements:…

Costs and cost-effectiveness of HIV community services: quantity and quality of studies published 1986-2011.

PubMed

Beck, Eduard J; Fasawe, Olufunke; Ongpin, Patricia; Ghys, Peter; Avilla, Carlos; De Lay, Paul

2013-06-01

Community services comprise an important part of a country's HIV response. English language cost and cost-effectiveness studies of HIV community services published between 1986 and 2011 were reviewed but only 74 suitable studies were identified, 66% of which were performed in five countries. Mean study scores by continent varied from 42 to 69% of the maximum score, reflecting variation in topics covered and the quality of coverage: 38% of studies covered key and 11% other vulnerable populations - a country's response is most effective and efficient if these populations are identified given they are key to a successful response. Unit costs were estimated using different costing methods and outcomes. Community services will need to routinely collect and analyze information on their use, cost, outcome and impact using standardized costing methods and outcomes. Cost estimates need to be disaggregated into relevant cost items and stratified by severity and existing comorbidities. Expenditure tracking and costing of services are complementary aspects of the health sector 'resource cycle' that feed into a country's investment framework and the development and implementation of national strategic plans.

Environmental quality alters female costs and benefits of evolving under enforced monogamy.

PubMed

Grazer, Vera M; Demont, Marco; Michalczyk, Łukasz; Gage, Matthew J G; Martin, Oliver Y

2014-02-05

Currently many habitats suffer from quality loss due to environmental change. As a consequence, evolutionary trajectories might shift due to environmental effects and potentially increase extinction risk of resident populations. Nevertheless, environmental variation has rarely been incorporated in studies of sexual selection and sexual conflict, although local environments and individuals' condition undoubtedly influence costs and benefits. Here, we utilise polyandrous and monogamous selection lines of flour beetles, which evolved in presence or absence of sexual selection for 39 generations. We specifically investigated effects of low vs. standard food quality (i.e. stressful vs. benign environments) on reproductive success of cross pairs between beetles from the contrasting female and male selection histories to assess gender effects driving fitness. We found a clear interaction of food quality, male selection history and female selection history. Monogamous females generally performed more poorly than polyandrous counterparts, but reproductive success was shaped by selection history of their mates and environmental quality. When monogamous females were paired with polyandrous males in the standard benign environment, females seemed to incur costs, possibly due to sexual conflict. In contrast, in the novel stressful environment, monogamous females profited from mating with polyandrous males, indicating benefits of sexual selection outweigh costs. Our findings suggest that costs and benefits of sexually selected adaptations in both sexes can be profoundly altered by environmental quality. With regard to understanding possible impacts of environmental change, our results further show that the ecology of mating systems and associated selection pressures should be considered in greater detail.

Effectiveness and Cost-Effectiveness of Antidepressants in Primary Care: A Multiple Treatment Comparison Meta-Analysis and Cost-Effectiveness Model

PubMed Central

Ramsberg, Joakim; Asseburg, Christian; Henriksson, Martin

2012-01-01

Objective To determine effectiveness and cost-effectiveness over a one-year time horizon of pharmacological first line treatment in primary care for patients with moderate to severe depression. Design A multiple treatment comparison meta-analysis was employed to determine the relative efficacy in terms of remission of 10 antidepressants (citalopram, duloxetine escitalopram, fluoxetine, fluvoxamine mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine). The estimated remission rates were then applied in a decision-analytic model in order to estimate costs and quality of life with different treatments at one year. Data Sources Meta-analyses of remission rates from randomised controlled trials, and cost and quality-of-life data from published sources. Results The most favourable pharmacological treatment in terms of remission was escitalopram with an 8- to 12-week probability of remission of 0.47. Despite a high acquisition cost, this clinical effectiveness translated into escitalopram being both more effective and having a lower total cost than all other comparators from a societal perspective. From a healthcare perspective, the cost per QALY of escitalopram was €3732 compared with venlafaxine. Conclusion Of the investigated antidepressants, escitalopram has the highest probability of remission and is the most effective and cost-effective pharmacological treatment in a primary care setting, when evaluated over a one year time-horizon. Small differences in remission rates may be important when assessing costs and cost-effectiveness of antidepressants. PMID:22876296

A pharmacoeconomic approach to assessing the costs and benefits of air quality interventions that improve health: a case study

PubMed Central

Lomas, James; Schmitt, Laetitia; Jones, Sally; McGeorge, Maureen; Bates, Elizabeth; Holland, Mike; Cooper, Duncan; Crowther, Richard; Ashmore, Mike; Rojas-Rueda, David; Weatherly, Helen; Richardson, Gerry; Bojke, Laura

2016-01-01

Objective This paper explores the use of pharmacoeconomic methods of valuation to health impacts resulting from exposure to poor air quality. In using such methods, interventions that reduce exposure to poor air quality can be directly compared, in terms of value for money (or cost-effectiveness), with competing demands for finite resources, including other public health interventions. Design Using results estimated as part of a health impact assessment regarding a West Yorkshire Low Emission Zone strategy, this paper quantifies cost-saving and health-improving implications of transport policy through its impact on air quality. Data source Estimates of health-related quality of life and the National Health Service (NHS)/Personal Social Services (PSS) costs for identified health events were based on data from Leeds and Bradford using peer-reviewed publications or Office for National Statistics releases. Population Inhabitants of the area within the outer ring roads of Leeds and Bradford. Main outcomes measures NHS and PSS costs and quality-adjusted life years (QALYs). Results Averting an all-cause mortality death generates 8.4 QALYs. Each coronary event avoided saves £28 000 in NHS/PSS costs and generates 1.1 QALYs. For every fewer case of childhood asthma, there will be NHS/PSS cost saving of £3000 and a health benefit of 0.9 QALYs. A single term, low birthweight birth avoided saves £2000 in NHS/PSS costs. Preventing a preterm birth saves £24 000 in NHS/PSS costs and generates 1.3 QALYs. A scenario modelled in the West Yorkshire Low Emission Zone Feasibility Study, where pre-EURO 4 buses and HGVs are upgraded to EURO 6 by 2016 generates an annual benefit of £2.08 million and a one-off benefit of £3.3 million compared with a net present value cost of implementation of £6.3 million. Conclusions Interventions to improve air quality and health should be evaluated and where improvement of population health is the primary objective, cost-effectiveness analysis using a NHS/PSS costs and QALYs framework is an appropriate methodology. PMID:27329439

Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review.

PubMed

Mangham-Jefferies, Lindsay; Pitt, Catherine; Cousens, Simon; Mills, Anne; Schellenberg, Joanna

2014-07-22

Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings. A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita. Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women's groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability. Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures. PROSPERO_ CRD42012003255.

Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective.

PubMed

Norton, Giulia; McDonough, Christine M; Cabral, Howard; Shwartz, Michael; Burgess, James F

2015-05-15

Markov cost-utility model. To evaluate the cost-utility of cognitive behavioral therapy (CBT) for the treatment of persistent nonspecific low back pain (LBP) from the perspective of US commercial payers. CBT is widely deemed clinically effective for LBP treatment. The evidence is suggestive of cost-effectiveness. We constructed and validated a Markov intention-to-treat model to estimate the cost-utility of CBT, with 1-year and 10-year time horizons. We applied likelihood of improvement and utilities from a randomized controlled trial assessing CBT to treat LBP. The trial randomized subjects to treatment but subjects freely sought health care services. We derived the cost of equivalent rates and types of services from US commercial claims for LBP for a similar population. For the 10-year estimates, we derived recurrence rates from the literature. The base case included medical and pharmaceutical services and assumed gradual loss of skill in applying CBT techniques. Sensitivity analyses assessed the distribution of service utilization, utility values, and rate of LBP recurrence. We compared health plan designs. Results are based on 5000 iterations of each model and expressed as an incremental cost per quality-adjusted life-year. The incremental cost-utility of CBT was $7197 per quality-adjusted life-year in the first year and $5855 per quality-adjusted life-year over 10 years. The results are robust across numerous sensitivity analyses. No change of parameter estimate resulted in a difference of more than 7% from the base case for either time horizon. Including chiropractic and/or acupuncture care did not substantively affect cost-effectiveness. The model with medical but no pharmaceutical costs was more cost-effective ($5238 for 1 yr and $3849 for 10 yr). CBT is a cost-effective approach to manage chronic LBP among commercial health plans members. Cost-effectiveness is demonstrated for multiple plan designs. 2.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

PubMed

Steuten, L M G; Vrijhoef, H J M; Landewé-Cleuren, S; Schaper, N; Van Merode, G G; Spreeuwenberg, C

2007-10-01

To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. Single-group, pre-post design with 2-year follow-up in 473 patients. Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

Cost-effectiveness analysis of a randomized trial comparing care models for chronic kidney disease.

PubMed

Hopkins, Robert B; Garg, Amit X; Levin, Adeera; Molzahn, Anita; Rigatto, Claudio; Singer, Joel; Soltys, George; Soroka, Steven; Parfrey, Patrick S; Barrett, Brendan J; Goeree, Ron

2011-06-01

Potential cost and effectiveness of a nephrologist/nurse-based multifaceted intervention for stage 3 to 4 chronic kidney disease are not known. This study examines the cost-effectiveness of a chronic disease management model for chronic kidney disease. Cost and cost-effectiveness were prospectively gathered alongside a multicenter trial. The Canadian Prevention of Renal and Cardiovascular Endpoints Trial (CanPREVENT) randomized 236 patients to receive usual care (controls) and another 238 patients to multifaceted nurse/nephrologist-supported care that targeted factors associated with development of kidney and cardiovascular disease (intervention). Cost and outcomes over 2 years were examined to determine the incremental cost-effectiveness of the intervention. Base-case analysis included disease-related costs, and sensitivity analysis included all costs. Consideration of all costs produced statistically significant differences. A lower number of days in hospital explained most of the cost difference. For both base-case and sensitivity analyses with all costs included, the intervention group required fewer resources and had higher quality of life. The direction of the results was unchanged to inclusion of various types of costs, consideration of payer or societal perspective, changes to the discount rate, and levels of GFR. The nephrologist/nurse-based multifaceted intervention represents good value for money because it reduces costs without reducing quality of life for patients with chronic kidney disease.

Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative.

PubMed

Ferket, Bart S; Feldman, Zachary; Zhou, Jing; Oei, Edwin H; Bierma-Zeinstra, Sita M A; Mazumdar, Madhu

2017-03-28

Objectives  To evaluate the impact of total knee replacement on quality of life in people with knee osteoarthritis and to estimate associated differences in lifetime costs and quality adjusted life years (QALYs) according to use by level of symptoms. Design  Marginal structural modeling and cost effectiveness analysis based on lifetime predictions for total knee replacement and death from population based cohort data. Setting  Data from two studies-Osteoarthritis Initiative (OAI) and the Multicenter Osteoarthritis Study (MOST)-within the US health system. Participants  4498 participants with or at high risk for knee osteoarthritis aged 45-79 from the OAI with no previous knee replacement (confirmed by baseline radiography) followed up for nine years. Validation cohort comprised 2907 patients from MOST with two year follow-up. Intervention  Scenarios ranging from current practice, defined as total knee replacement practice as performed in the OAI (with procedural rates estimated by a prediction model), to practice limited to patients with severe symptoms to no surgery. Main outcome measures  Generic (SF-12) and osteoarthritis specific quality of life measured over 96 months, model based QALYs, costs, and incremental cost effectiveness ratios over a lifetime horizon. Results  In the OAI, total knee replacement showed improvements in quality of life with small absolute changes when averaged across levels of confounding variables: 1.70 (95% uncertainty interval 0.26 to 3.57) for SF-12 physical component summary (PCS); -10.69 (-13.39 to -8.01) for Western Ontario and McMaster Universities arthritis index (WOMAC); and 9.16 (6.35 to 12.49) for knee injury and osteoarthritis outcome score (KOOS) quality of life subscale. These improvements became larger with decreasing functional status at baseline. Provision of total knee replacement to patients with SF-12 PCS scores <35 was the optimal scenario given a cost effectiveness threshold of $200 000/QALY, with cost savings of $6974 ($5789 to $8269) and a minimal loss of 0.008 (-0.056 to 0.043) QALYs compared with current practice. These findings were reproduced among patients with knee osteoarthritis from the MOST cohort and were robust against various scenarios including increased rates of total knee replacement and mortality and inclusion of non-healthcare costs but were sensitive to increased deterioration in quality of life without surgery. In a threshold analysis, total knee replacement would become cost effective in patients with SF-12 PCS scores ≤40 if the associated hospital admission costs fell below $14 000 given a cost effectiveness threshold of $200 000/QALY. Conclusion  Current practice of total knee replacement as performed in a recent US cohort of patients with knee osteoarthritis had minimal effects on quality of life and QALYs at the group level. If the procedure were restricted to more severely affected patients, its effectiveness would rise, with practice becoming economically more attractive than its current use. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Children's Mental Health: Strategies for Providing High Quality and Cost-Effective Care. North Carolina Family Impact Seminar

ERIC Educational Resources Information Center

Douglass, Nam, Ed.; Owen, Jenni, Ed.; Berlin, Lisa J., Ed.

2006-01-01

This report represents the second North Carolina Family Impact Seminar in a series designed to connect research and state policymaking. Family Impact Seminars analyze the impact an issue, policy, or program may have on families. This Family Impact Seminar briefing report discusses strategies for providing high quality and cost-effective children's…

Incremental cost-effectiveness of laser therapy for choroidal neovascularization associated with histoplasmosis.

PubMed

Brown, G C; Brown, M M; Sharma, S; Busbee, B; Brown, H

2000-01-01

Laser photocoagulation has been shown in a large clinical trial to be efficacious in reducing the degree of vision loss occurring secondary to choroidal neovascularization (CNV) associated with ocular histoplasmosis. Nevertheless, data are lacking concerning the impact of the therapy on quality of life and its value to stakeholders in health care. Recently, information concerning the utility value of visual states has become available. Accordingly, the authors undertook to ascertain the cost-effectiveness of laser photocoagulation for the treatment of extrafoveal CNV occurring in eyes with ocular histoplasmosis. Design--A computer simulation, econometric model is presented to evaluate the incremental cost-effectiveness of laser photocoagulation therapy, as compared with the natural course of the disease, for the treatment of patients with extrafoveal CNV associated with ocular histoplasmosis. The model applies long-term visual data from previous clinical trials, utility analysis (which reflects patient perceptions of quality of life), decision analysis with Markov modeling, and present value analysis with discounting to account for the time value of money. Outcome measure--Cost per quality-adjusted life-year gained from treatment. Laser photocoagulation therapy for extrafoveal CNV associated with ocular histoplasmosis costs $4167 1999 US dollars (at a 3% discount rate) for each quality-adjusted life-year gained from treatment. Sensitivity analysis shows that changing the discount rate substantially alters the cost-effectiveness, with a value of $1339 at a 0% discount rate and $56,250 at a 10% discount rate. Compared with therapeutic modalities for other disease entities, laser therapy for the treatment of extrafoveal CNV associated with ocular histoplasmosis appears to be a cost-effective treatment from the patient preference-based point of view.

Screening for gastric cancer and surveillance of premalignant lesions: a systematic review of cost-effectiveness studies.

PubMed

Areia, Miguel; Carvalho, Rita; Cadime, Ana Teresa; Rocha Gonçalves, Francisco; Dinis-Ribeiro, Mário

2013-10-01

Cost-effectiveness studies are highly dependent on the models, settings, and variables used and should be based on systematic reviews. We systematically reviewed cost-effectiveness studies that address screening for gastric cancer and/or surveillance of precancerous conditions and lesions. A systematic review of cost-effectiveness studies was performed by conducting a sensitive search in seven databases (PubMed, Scopus, Web of Science, Current Contents Connect, Centre for Reviews and Dissemination, Academic Search Complete, and CINAHL Plus), independently evaluated by two investigators. Articles were evaluated for type of study, perspective, model, intervention, incremental cost-effectiveness ratio, clinical or cost variables, and quality, according to published guidelines. From 2395 abstracts, 23 articles were included: 19 concerning population screening and 4 on following up premalignant lesions. Studies on Helicobacter pylori screening concluded that serology was cost-effective, depending on cancer incidence and endoscopy cost (incremental cost-effectiveness ratio: 6264-25,881), and eradication after endoscopic resection was also cost-effective (dominant) based on one study. Studies on imaging screening concluded that endoscopy was more cost-effective than no screening (incremental cost-effectiveness ratio: 3376-26,836). Articles on follow-up of premalignant lesions reported conflicting results (incremental cost-effectiveness ratio: 1868-72,519 for intestinal metaplasia; 18,600-39,800 for dysplasia). Quality assessment revealed a unanimous lack of a detailed systematic review and fulfillment of a median number of 23 items (20-26) of 35 possible ones. The available evidence shows that Helicobacter pylori serology or endoscopic population screening is cost-effective, while endoscopic surveillance of premalignant gastric lesions presents conflicting results. Better implementation of published guidelines and accomplishment of systematic detailed reviews are needed. © 2013 John Wiley & Sons Ltd.

Cost-effectiveness analysis of collaborative care management of major depression among low-income, predominantly Hispanics with diabetes.

PubMed

Hay, Joel W; Katon, Wayne J; Ell, Kathleen; Lee, Pey-Jiuan; Guterman, Jeffrey J

2012-01-01

To evaluate the cost-effectiveness of a socioculturally adapted collaborative depression care program among low-income Hispanics with diabetes. A randomized controlled trial of 387 patients with diabetes (96.5% Hispanic) with clinically significant depression followed over 18 months evaluated the cost-effectiveness of the Multifaceted Diabetes and Depression Program aimed at increasing patient exposure to evidence-based depression psychotherapy and/or pharmacotherapy in two public safety net clinics. Patient medical care costs and utilization were captured from Los Angeles County Department of Health Services claims records. Patient-reported outcomes included Short-Form Health Survey-12 and Patient Health Questionnaire-9-calculated depression-free days. Intervention patients had significantly greater Short-Form Health Survey-12 utility improvement from baseline compared with controls over the 18-month evaluation period (4.8%; P < 0.001) and a corresponding significant improvement in depression-free days (43.0; P < 0.001). Medical cost differences were not statistically significant in ordinary least squares and log-transformed cost regressions. The average costs of the Multifaceted Diabetes and Depression Program study intervention were $515 per patient. The program's cost-effectiveness averaged $4053 per quality-adjusted life-year per MDDP recipient and was more than 90% likely to fall below $12,000 per quality-adjusted life-year. Socioculturally adapted collaborative depression care improved utility and quality of life in predominantly low-income Hispanic patients with diabetes and was highly cost-effective. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Individual quality and age but not environmental or social conditions modulate costs of reproduction in a capital breeder.

PubMed

Debeffe, Lucie; Poissant, Jocelyn; McLoughlin, Philip D

2017-08-01

Costs associated with reproduction are widely known to play a role in the evolution of reproductive tactics with consequences to population and eco-evolutionary dynamics. Evaluating these costs as they pertain to species in the wild remains an important goal of evolutionary ecology. Individual heterogeneity, including differences in individual quality (i.e., among-individual differences in traits associated with survival and reproduction) or state, and variation in environmental and social conditions can modulate the costs of reproduction; however, few studies have considered effects of these factors simultaneously. Taking advantage of a detailed, long-term dataset for a population of feral horses (Sable Island, Nova Scotia, Canada), we address the question of how intrinsic (quality, age), environmental (winter severity, location), and social conditions (group size, composition, sex ratio, density) influence the costs of reproduction on subsequent reproduction. Individual quality was measured using a multivariate analysis on a combination of four static and dynamic traits expected to depict heterogeneity in individual performance. Female quality and age interacted with reproductive status of the previous year to determine current reproductive effort, while no effect of social or environmental covariates was found. High-quality females showed higher probabilities of giving birth and weaning their foal regardless of their reproductive status the previous year, while those of lower quality showed lower probabilities of producing foals in successive years. Middle-aged (prime) females had the highest probability of giving birth when they had not reproduced the year before, but no such relationship with age was found among females that had reproduced the previous year, indicating that prime-aged females bear higher costs of reproduction. We show that individual quality and age were key factors modulating the costs of reproduction in a capital breeder but that environmental or social conditions were not, highlighting the importance of considering multiple factors when studying costs of reproduction.

Adjuvant fluorouracil, epirubicin and cyclophosphamide in early breast cancer: is it cost-effective?

PubMed

Norum, Jan; Holtmon, Mari

2005-01-01

Adjuvant chemotherapy (ACT) in breast cancer exposes patients to morbidity, but improves survival. The FEC (fluorouracil, epirubicin, cyclophosphamide) regimen has taken over the prior role of CMF (cyclophosphamide, methotrexate, fluorouracil). In this model, efficacy, tolerability and quality of life (QoL) data from the literature were incorporated with Norwegian practice and cost data in a cost-effectiveness approach. The FEC efficacy was calculated 3-7% superior CMF. There was no difference in quality of life. An 80-100% dose intensity range was employed, one Euro was calculated NOK 8.78 and a 3% discount rate was used. The total cost of FEC employing the friction cost method on production loss, including amount spent on drugs, administration and travelling ranged between 3,278-3,850 Euros (human capital approach 12,143-12,715 Euros). Money spent on drugs alone constituted 15-48%, depending on method chosen. A cost-effectiveness analysis revealed a cost per life year (LY) saved replacing FEC by CMF of 3,575-15,125 Euros. Adjuvant FEC is cost effective in Norway.

A cost-constrained model of strategic service quality emphasis in nursing homes.

PubMed

Davis, M A; Provan, K G

1996-02-01

This study employed structural equation modeling to test the relationship between three aspects of the environmental context of nursing homes; Medicaid dependence, ownership status, and market demand, and two basic strategic orientations: low cost and differentiation based on service quality emphasis. Hypotheses were proposed and tested against data collected from a sample of nursing homes operating in a single state. Because of the overwhelming importance of cost control in the nursing home industry, a cost constrained strategy perspective was supported. Specifically, while the three contextual variables had no direct effect on service quality emphasis, the entire model was supported when cost control orientation was introduced as a mediating variable.

Cost-effectiveness of optimizing acute stroke care services for thrombolysis.

PubMed

Penaloza-Ramos, Maria Cristina; Sheppard, James P; Jowett, Sue; Barton, Pelham; Mant, Jonathan; Quinn, Tom; Mellor, Ruth M; Sims, Don; Sandler, David; McManus, Richard J

2014-02-01

Thrombolysis in acute stroke is effective up to 4.5 hours after symptom onset but relies on early recognition, prompt arrival in hospital, and timely brain scanning. This study aimed to establish the cost-effectiveness of increasing thrombolysis rates through a series of hypothetical change strategies designed to optimize the acute care pathway for stroke. A decision-tree model was constructed, which relates the acute management of patients with suspected stroke from symptom onset to outcome. Current practice was modeled and compared with 7 change strategies designed to facilitate wider eligibility for thrombolysis. The model basecase consisted of data from consenting patients following the acute stroke pathway recruited in participating hospitals with data on effectiveness of treatment and costs from published sources. All change strategies were cost saving while increasing quality-adjusted life years gained. Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46,000 per 100,000 population. All strategies increased the number of thrombolysed patients and the number requiring urgent brain imaging (by 9% to 21% dependent on the scenario). Assuming a willingness-to-pay of US $30,000 per quality-adjusted life year gained, the potential budget available to deliver the interventions in each strategy ranged from US $50,000 to US $144,000. These results suggest that any strategy that increases thrombolysis rates will result in cost savings and improved patient quality of life. Healthcare commissioners could consider this model when planning improvements in stroke care.

Health services research in urology.

PubMed

Yu, Hua-Yin; Ulmer, William; Kowalczyk, Keith J; Hu, Jim C

2011-06-01

Health services research (HSR) is increasingly important given the focus on patient-centered, cost-effective, high-quality health care. We examine how HSR affects contemporary evidence-based urologic practice and its role in shaping future urologic research and care. PubMed, urologic texts, and lay literature were reviewed for terms pertaining to HSR/outcomes research and urologic disease processes. HSR is a broad discipline that focuses on access, cost, and outcomes of Health care. Its use has been applied to a myriad of urologic conditions to identify deficiencies in access, to evaluate cost-effectiveness of therapies, and to evaluate structural, process, and outcome quality measures. HSR utilizes an evidence-based approach to identify the most effective ways to organize/manage, finance, and deliver high-quality urologic care and to tailor care optimized to individuals.

Radiofrequency ablation versus nephron-sparing surgery for small unilateral renal cell carcinoma: cost-effectiveness analysis.

PubMed

Pandharipande, Pari V; Gervais, Debra A; Mueller, Peter R; Hur, Chin; Gazelle, G Scott

2008-07-01

To evaluate the relative cost-effectiveness of percutaneous radiofrequency (RF) ablation versus nephron-sparing surgery (NSS) in patients with small (

Comparative effectiveness: its role in the healthcare system.

PubMed

Brown, Melissa M; Luo, Betsy; Brown, Heidi C; Brown, Gary C

2009-05-01

To describe comparative effectiveness and assess its role in crafting new healthcare policy. Senate Bill S.3408 would establish a nongovernment-affiliated Healthcare Comparative Effectiveness Research Institute that would work with healthcare experts and stakeholders in healthcare to prioritize interventions and services to be studied. A value-based medicine system of standardized comparative effectiveness and cost-effectiveness data using utilities would allow physicians to assess the total value (improvement in quality of life and/or length of life) conferred by interventions. Standardized comparativeness and cost-effectiveness data will give physicians an information system to identify the interventions that confer the greatest value to patients, and thus deliver higher quality care than possible with evidence-based data alone while allowing the most cost-effective care.

Cost-effectiveness analysis of acupuncture, counselling and usual care in treating patients with depression: the results of the ACUDep trial.

PubMed

Spackman, Eldon; Richmond, Stewart; Sculpher, Mark; Bland, Martin; Brealey, Stephen; Gabe, Rhian; Hopton, Ann; Keding, Ada; Lansdown, Harriet; Perren, Sara; Torgerson, David; Watt, Ian; MacPherson, Hugh

2014-01-01

New evidence on the clinical effectiveness of acupuncture plus usual care (acupuncture) and counselling plus usual care (counselling) for patients with depression suggests the need to investigate the health-related quality of life and costs of these treatments to understand whether they should be considered a good use of limited health resources. The cost-effectiveness analyses are based on the Acupuncture, Counselling or Usual care for Depression (ACUDep) trial results. Statistical analyses demonstrate a difference in mean quality adjusted life years (QALYs) and suggest differences in mean costs which are mainly due to the price of the interventions. Probabilistic sensitivity analysis is used to express decision uncertainty. Acupuncture and counselling are found to have higher mean QALYs and costs than usual care. In the base case analysis acupuncture has an incremental cost-effectiveness ratio (ICER) of £4,560 per additional QALY and is cost-effective with a probability of 0.62 at a cost-effectiveness threshold of £20,000 per QALY. Counselling compared with acupuncture is more effective and more costly with an ICER of £71,757 and a probability of being cost-effective of 0.36. A scenario analysis of counselling versus usual care, excluding acupuncture as a comparator, results in an ICER of £7,935 and a probability of 0.91. Acupuncture is cost-effective compared with counselling or usual care alone, although the ranking of counselling and acupuncture depends on the relative cost of delivering these interventions. For patients in whom acupuncture is unavailable or perhaps inappropriate, counselling has an ICER less than most cost-effectiveness thresholds. However, further research is needed to determine the most cost-effective treatment pathways for depressed patients when the full range of available interventions is considered.

Cost-utility analysis of individual psychosocial support interventions for breast cancer patients in a randomized controlled study.

PubMed

Arving, Cecilia; Brandberg, Yvonne; Feldman, Inna; Johansson, Birgitta; Glimelius, Bengt

2014-03-01

The aim was to explore the cost-utility in providing complementary individual psychosocial support to breast cancer patients compared with standard care (SC). Patients just starting adjuvant therapy (n = 168) at Uppsala University Hospital, Sweden, were consecutively included and randomized into three groups: psychosocial support from a specially trained nurse (INS), from a psychologist (IPS), or SC. Psychological effects and healthcare utilization were monitored during a 2-year period. The hospital billing system provided cost estimates. Quality-adjusted life years (QALYs) were calculated using health-related quality of life data from the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ C-30) translated into the Euro Quality of Life- 5-Dimensional classification. On the basis of the medical cost offset, a cost-utility analysis was performed. Health care utilization was mainly related to the breast cancer diagnosis and treatment. The intervention costs amounted to about €500 or 3% of the total costs. Total health care costs, including interventions cost, were lower in the INS (€18,670) and IPS (€20,419) groups than in the SC group (€25,800). The number of QALYs were also higher in the INS (1.52 QALY) and IPS (1.59 QALY) groups, compared with the SC group (1.43 QALY). The cost-utility analysis revealed that, during adjuvant treatment for breast cancer, the individual psychosocial support interventions provided here was cost effective because the health care costs were lower and QALYs were higher compared to SC alone. Copyright © 2013 John Wiley & Sons, Ltd.

Function after spinal treatment, exercise, and rehabilitation: cost-effectiveness analysis based on a randomized controlled trial.

PubMed

Morris, Stephen; Morris, Tim P; McGregor, Alison H; Doré, Caroline J; Jamrozik, Konrad

2011-10-01

Cost-effectiveness analysis alongside a factorial randomized controlled trial. To assess the cost-effectiveness of a rehabilitation program and/or an education booklet each compared with usual care for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery. There is little knowledge about the cost-effectiveness of postoperative management of patients after spinal surgery. A total of 338 patients were recruited into the study between June 2005 and March 2009. Patients were randomized to rehabilitation only, booklet only, rehabilitation plus booklet, or usual care only. Interactions between booklet and rehabilitation were nonsignificant; hence, we compare booklet versus no booklet and rehabilitation versus no rehabilitation. We adopt an English National Health Service and personal social services perspective. Data on outcomes and costs are based on patient level data from the trial. A 1-year time horizon was used. Outcomes were measured in terms of quality-adjusted life years. Health-related quality of life was reported by patients using the EuroQol-5D (EQ-5D). A comprehensive range of health service contacts were included in the cost analysis. There were no significant differences in costs or outcomes associated with either intervention. Mean incremental costs and mean quality-adjusted life years gained per patient of booklet versus no booklet were -£87 (95% CI: -£1221 to £1047) and -0.023 (95% CI: -0.068 to 0.023), respectively. Figures for rehabilitation versus no rehabilitation were £160 (95% CI: -£984 to £1304) and 0.002 (95% CI: -0.044 to 0.048), respectively. Neither intervention was cost-effective when compared with the threshold range commonly used to judge whether or not an intervention is cost-effective in the English National Health Service. Cost-effectiveness evidence does not support use of booklet over no booklet or rehabilitation over no rehabilitation for the postoperative management of patients after spinal surgery.

Cost-Effectiveness Analysis of Qsymia for Weight Loss.

PubMed

Finkelstein, Eric A; Kruger, Eliza; Karnawat, Sunil

2015-07-01

Phase 3 clinical trial results reveal that Qsymia is a clinically effective long-term treatment for obesity, but whether this treatment is cost-effective compared to a diet and lifestyle intervention has yet to be explored. To quantify the incremental cost-effectiveness of Qsymia (phentermine and topiramate extended-release) for health-related quality of life improvements. Estimates are based on cost and quality of life outcomes from a 56-week, multicenter, placebo-controlled, phase 3 clinical trial undertaken in 93 health centers in the US. Participants were overweight and obese adults (aged 18-70 years) with a body-mass index of 27-45 kg/m(2) and two or more comorbidities (hypertension, dyslipidemia, diabetes or pre-diabetes or abdominal obesity). The intervention was diet and lifestyle advice plus the recommended dose of Qsymia (phentermine 7.5 mg plus topiramate 46.0 mg) vs. control, which included diet and lifestyle advice plus placebo. The study was from the payer perspective. Costs included the prescription cost, medication cost offsets and physician appointment costs. Effectiveness was measured in terms of quality-adjusted life years gained (QALYs). The main outcome measure was incremental cost per QALY gained of the intervention relative to control. Our base-case model, in which participants take Qsymia for 1 year with benefits linearly decaying over the subsequent 2 years, generates an incremental cost-effectiveness ratio (ICER) of $48,340 per QALY gained. Using the base-case assumptions, probabilistic sensitivity analyses reveal that the ICER is below $50,000 per QALY in 54 % of simulations. However, results are highly dependent on the extent to which benefits are maintained post medication cessation. If benefits persist for only 1 year post cessation, the ICER increases to $74,480. Although base-case results suggest that Qsymia is cost-effective, this result hinges on the time on Qsymia and the extent to which benefits are maintained post medication cessation. This should be an area of future research.

Low-Cost Oil Quality Sensor Based on Changes in Complex Permittivity

PubMed Central

Pérez, Angel Torres; Hadfield, Mark

2011-01-01

Real time oil quality monitoring techniques help to protect important industry assets, minimize downtime and reduce maintenance costs. The measurement of a lubricant’s complex permittivity is an effective indicator of the oil degradation process and it can be useful in condition based maintenance (CBM) to select the most adequate oil replacement maintenance schedules. A discussion of the working principles of an oil quality sensor based on a marginal oscillator to monitor the losses of the dielectric at high frequencies (>1 MHz) is presented. An electronic design procedure is covered which results in a low cost, effective and ruggedized sensor implementation suitable for use in harsh environments. PMID:22346666

Cost-effectiveness of aftercare services for people with severe mental disorders: an analysis parallel to a randomised controlled clinical trial in Iran.

PubMed

Moradi-Lakeh, Maziar; Yaghoubi, Mohsen; Hajebi, Ahmad; Malakouti, Seyed Kazem; Vasfi, Mohamad Ghadiri

2017-05-01

Aftercare services are not part of the usual care for people with severe mental disorders in Iran. This study was performed to assess the cost-effectiveness of aftercare services, including telephone follow-up or home visit, in addition to caregivers' education and training of social skills, for all subjects during the 20 months after hospital discharge. An economic evaluation was performed along with a registered randomised controlled trial (IRCT201009052557N2) on two groups of 60 persons recruited between 2010 and 2012. Intervention's effectiveness was measured by psychopathology and quality of life indicators. Cost-effectiveness and cost-utility were analysed from the societal and Ministry of Health (MoH) perspectives. All indicators of psychopathology, quality of life and satisfaction with services in the intervention group were significantly different from the control group. Mean intervention costs was US$674 (95% confidence interval [CI]: 572-776) per subject in the intervention group. Average total direct costs were US$1445 (95% CI: 1086-1804) and US$1640 (95% CI: 1087-2093) per subject in the intervention and control groups respectively. From the societal perspective, intervention had more effects with lower costs. The ratios for incremental cost-effectiveness was US$8399.1 (95% CI: 8178.2-8620.0) per quality-adjusted life year (QALY) gained from the MoH perspective for 20 months of follow-up. This study showed that aftercare services can create opportunities to use hospital beds more efficiently for unmet needs of people with psychiatric disorders. Indirect and intangible costs were not considered in this study, if taken into account, they are likely to further increase the efficiency of intervention. © 2017 John Wiley & Sons Ltd.

End-user perspective of low-cost sensors for outdoor air pollution monitoring.

PubMed

Rai, Aakash C; Kumar, Prashant; Pilla, Francesco; Skouloudis, Andreas N; Di Sabatino, Silvana; Ratti, Carlo; Yasar, Ansar; Rickerby, David

2017-12-31

Low-cost sensor technology can potentially revolutionise the area of air pollution monitoring by providing high-density spatiotemporal pollution data. Such data can be utilised for supplementing traditional pollution monitoring, improving exposure estimates, and raising community awareness about air pollution. However, data quality remains a major concern that hinders the widespread adoption of low-cost sensor technology. Unreliable data may mislead unsuspecting users and potentially lead to alarming consequences such as reporting acceptable air pollutant levels when they are above the limits deemed safe for human health. This article provides scientific guidance to the end-users for effectively deploying low-cost sensors for monitoring air pollution and people's exposure, while ensuring reasonable data quality. We review the performance characteristics of several low-cost particle and gas monitoring sensors and provide recommendations to end-users for making proper sensor selection by summarizing the capabilities and limitations of such sensors. The challenges, best practices, and future outlook for effectively deploying low-cost sensors, and maintaining data quality are also discussed. For data quality assurance, a two-stage sensor calibration process is recommended, which includes laboratory calibration under controlled conditions by the manufacturer supplemented with routine calibration checks performed by the end-user under final deployment conditions. For large sensor networks where routine calibration checks are impractical, statistical techniques for data quality assurance should be utilised. Further advancements and adoption of sophisticated mathematical and statistical techniques for sensor calibration, fault detection, and data quality assurance can indeed help to realise the promised benefits of a low-cost air pollution sensor network. Copyright © 2017 Elsevier B.V. All rights reserved.

Value for money of changing healthcare services? Economic evaluation of quality improvement

PubMed Central

Severens, J

2003-01-01



 There are many instances of perceived or real inefficiencies in health service delivery. Both healthcare providers and policy makers need to know the impact and cost of applying strategies to change the behaviour of individuals or organisations. Quality improvement or implementation research is concerned with evaluating the methods of behavioural change. Addressing inefficiencies in healthcare services raises a series of issues, beginning with how inefficiency itself should be defined. The basic concepts of cost analysis and economic evaluations are explained and a model for working through the economic issues of quality improvement is discussed. This model combines the costs and benefits of corrected inefficiency with the costs and degree of behavioural change achieved by a quality improvement method in the policy maker's locality. It shows why it may not always be cost effective for policy makers to address suboptimal behaviour. Both the interpretation of quality improvement research findings and their local application need careful consideration. The limited availability of applicable quality improvement research may make it difficult to provide robust advice on the value for money of many behavioural quality improvement strategies. PMID:14532369

Quantitative estimates of the impact of sensitivity and specificity in mammographic screening in Germany.

PubMed Central

Warmerdam, P G; de Koning, H J; Boer, R; Beemsterboer, P M; Dierks, M L; Swart, E; Robra, B P

1997-01-01

STUDY OBJECTIVE: To estimate quantitatively the impact of the quality of mammographic screening (in terms of sensitivity and specificity) on the effects and costs of nationwide breast cancer screening. DESIGN: Three plausible "quality" scenarios for a biennial breast cancer screening programme for women aged 50-69 in Germany were analysed in terms of costs and effects using the Microsimulation Screening Analysis model on breast cancer screening and the natural history of breast cancer. Firstly, sensitivity and specificity in the expected situation (or "baseline" scenario) were estimated from a model based analysis of empirical data from 35,000 screening examinations in two German pilot projects. In the second "high quality" scenario, these properties were based on the more favourable diagnostic results from breast cancer screening projects and the nationwide programme in The Netherlands. Thirdly, a worst case, "low quality" hypothetical scenario with a 25% lower sensitivity than that experienced in The Netherlands was analysed. SETTING: The epidemiological and social situation in Germany in relation to mass screening for breast cancer. RESULTS: In the "baseline" scenario, an 11% reduction in breast cancer mortality was expected in the total German female population, ie 2100 breast cancer deaths would be prevented per year. It was estimated that the "high quality" scenario, based on Dutch experience, would lead to the prevention of an additional 200 deaths per year and would also cut the number of false positive biopsy results by half. The cost per life year gained varied from Deutsche mark (DM) 15,000 on the "high quality" scenario to DM 21,000 in the "low quality" setting. CONCLUSIONS: Up to 20% of the total costs of a screening programme can be spent on quality improvement in order to achieve a substantially higher reduction in mortality and reduce undesirable side effects while retaining the same cost effectiveness ratio as that estimated from the German data. PMID:9196649

Economic evaluations of clinical pharmacist interventions on hospital inpatients: a systematic review of recent literature.

PubMed

Gallagher, James; McCarthy, Suzanne; Byrne, Stephen

2014-12-01

Clinical and cost-effectiveness evidence are needed to justify the existence or extension of routine clinical pharmacy services in hospital settings. Previous reviews have indicated that clinical pharmacist interventions are likely to have a positive economic impact on hospital budgets but highlighted issues relating to the quality of studies. The primary aim of this review was to feature economic evaluations of clinical pharmacy services which targeted hospital inpatients. The review focused on the current cost-effectiveness status of different services, in addition to evaluating the quality of individual studies. Results of this systematic review were compared with cost-effectiveness and quality related findings of reviews which considered earlier time frames and alternative settings. A systematic review of the literature included a review of the following databases: Academic Search Complete, Cochrane Library, EconLit, Embase Elsevier, NHS Economic Evaluation Database and PubMed. Only studies with an economic assessment of a clinical pharmacy service provided in a hospital setting were included. Data relating to the cost-effectiveness was extracted from eligible studies. Methodologies employed and overall quality of the studies was also reviewed. A grading system was applied to determine the quality of studies. Consolidated Health Economic Evaluation Reporting Standards statement was employed to determine which aspects of a high quality health economic study were employed. Twenty studies were deemed eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15 %) were deemed to be "good-quality" studies. No 'novel'clinical pharmacist intervention was identified during the course of this review. Clinical pharmacy interventions continue to provide cost savings. However, the standard of studies published has stagnated or even deteriorated in comparison with those included in previous reviews. Utilisation of published guidelines at initial stages of future studies may help improve the overall quality of studies.

Cost-utility analysis comparing radioactive iodine, anti-thyroid drugs and total thyroidectomy for primary treatment of Graves' disease.

PubMed

Donovan, Peter J; McLeod, Donald S A; Little, Richard; Gordon, Louisa

2016-12-01

Little data is in existence about the most cost-effective primary treatment for Graves' disease. We performed a cost-utility analysis comparing radioactive iodine (RAI), anti-thyroid drugs (ATD) and total thyroidectomy (TT) as first-line therapy for Graves' disease in England and Australia. We used a Markov model to compare lifetime costs and benefits (quality-adjusted life-years (QALYs)). The model included efficacy, rates of relapse and major complications associated with each treatment, and alternative second-line therapies. Model parameters were obtained from published literature. One-way sensitivity analyses were conducted. Costs were presented in 2015£ or Australian Dollars (AUD). RAI was the least expensive therapy in both England (£5425; QALYs 34.73) and Australia (AUD5601; 30.97 QALYs). In base case results, in both countries, ATD was a cost-effective alternative to RAI (£16 866; 35.17 QALYs; incremental cost-effectiveness ratio (ICER) £26 279 per QALY gained England; AUD8924; 31.37 QALYs; ICER AUD9687 per QALY gained Australia), while RAI dominated TT (£7115; QALYs 33.93 England; AUD15 668; 30.25 QALYs Australia). In sensitivity analysis, base case results were stable to changes in most cost, transition probabilities and health-relative quality-of-life (HRQoL) weights; however, in England, the results were sensitive to changes in the HRQoL weights of hypothyroidism and euthyroidism on ATD. In this analysis, RAI is the least expensive choice for first-line treatment strategy for Graves' disease. In England and Australia, ATD is likely to be a cost-effective alternative, while TT is unlikely to be cost-effective. Further research into HRQoL in Graves' disease could improve the quality of future studies. © 2016 European Society of Endocrinology.

Effect of prospective reimbursement on nursing home costs.

PubMed Central

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-01-01

OBJECTIVE. This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems. PMID:8463109

Effect of prospective reimbursement on nursing home costs.

PubMed

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-04-01

This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

Medical therapy v. PCI in stable coronary artery disease: a cost-effectiveness analysis.

PubMed

Wijeysundera, Harindra C; Tomlinson, George; Ko, Dennis T; Dzavik, Vladimir; Krahn, Murray D

2013-10-01

Percutaneous coronary intervention (PCI) with either drug-eluting stents (DES) or bare metal stents (BMS) reduces angina and repeat procedures compared with optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset their increased costs and small increase in adverse events. Cost utility analysis of initial medical therapy v. PCI with either BMS or DES. . Markov cohort decision model. Data Sources. Propensity-matched observational data from Ontario, Canada, for baseline event rates. Effectiveness and utility data obtained from the published literature, with costs from the Ontario Case Costing Initiative. Patients with stable coronary artery disease, confirmed after angiography, stratified by risk of restenosis based on diabetic status, lesion size, and lesion length. Time Horizon. Lifetime. Perspective. Ontario Ministry of Health and Long Term Care. Interventions. Optimal medical therapy, PCI with BMS or DES. Lifetime costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). of Base Case Analysis. In the overall population, medical therapy had the lowest lifetime costs at $22,952 v. $25,081 and $25,536 for BMS and DES, respectively. Medical therapy had a quality-adjusted life expectancy of 10.1 v. 10.26 QALYs for BMS, producing an ICER of $13,271/QALY. The DES strategy had a quality-adjusted life expectancy of only 10.20 QALYs and was dominated by the BMS strategy. This ranking was consistent in all groups stratified by restenosis risk, except diabetic patients with long lesions in small arteries, in whom DES was cost-effective compared with medical therapy (ICER of $18,826/QALY). Limitations. There is the possibility of residual unobserved confounding. In patients with stable coronary artery disease, an initial BMS strategy is cost-effective.

Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA.

PubMed

Herzer, Kurt R; Niessen, Louis; Constenla, Dagna O; Ward, William J; Pronovost, Peter J

2014-09-25

To assess the cost-effectiveness of a multifaceted quality improvement programme focused on reducing central line-associated bloodstream infections in intensive care units. Cost-effectiveness analysis using a decision tree model to compare programme to non-programme intensive care units. USA. Adult patients in the intensive care unit. Economic costs of the programme and of central line-associated bloodstream infections were estimated from the perspective of the hospital and presented in 2013 US dollars. Central line-associated bloodstream infections prevented, deaths averted due to central line-associated bloodstream infections prevented, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was performed. Compared with current practice, the programme is strongly dominant and reduces bloodstream infections and deaths at no additional cost. The probabilistic sensitivity analysis showed that there was an almost 80% probability that the programme reduces bloodstream infections and the infections' economic costs to hospitals. The opportunity cost of a bloodstream infection to a hospital was the most important model parameter in these analyses. This multifaceted quality improvement programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programme's benefits should enhance implementation. The programme's implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

A pilot cost-effectiveness analysis of treatments in newly diagnosed high-grade gliomas: the example of 5-aminolevulinic Acid compared with white-light surgery.

PubMed

Esteves, Susana; Alves, Marta; Castel-Branco, Marta; Stummer, Walter

2015-05-01

High-grade gliomas are aggressive, incurable tumors characterized by extensive diffuse invasion of the normal brain parenchyma. Novel therapies at best prolong survival; their costs are formidable and benefit is marginal. Economic restrictions thus require knowledge of the cost-effectiveness of treatments. Here, we show the cost-effectiveness of enhanced resections in malignant glioma surgery using a well-characterized tool for intraoperative tumor visualization, 5-aminolevulinic acid (5-ALA). To evaluate the cost-effectiveness of 5-ALA fluorescence-guided neurosurgery compared with white-light surgery in adult patients with newly diagnosed high-grade glioma, adopting the perspective of the Portuguese National Health Service. We used a Markov model (cohort simulation). Transition probabilities were estimated with the use of data from 1 randomized clinical trial and 1 noninterventional prospective study. Utility values and resource use were obtained from published literature and expert opinion. Unit costs were taken from official Portuguese reimbursement lists (2012 values). The health outcomes considered were quality-adjusted life-years, life-years, and progression-free life-years. Extensive 1-way and probabilistic sensitivity analyses were performed. The incremental cost-effectiveness ratios are below &OV0556;10 000 in all evaluated outcomes, being around &OV0556;9100 per quality-adjusted life-year gained, &OV0556;6700 per life-year gained, and &OV0556;8800 per progression-free life-year gained. The probability of 5-ALA fluorescence-guided surgery cost-effectiveness at a threshold of &OV0556;20000 is 96.0% for quality-adjusted life-year, 99.6% for life-year, and 98.8% for progression-free life-year. 5-ALA fluorescence-guided surgery appears to be cost-effective in newly diagnosed high-grade gliomas compared with white-light surgery. This example demonstrates cost-effectiveness analyses for malignant glioma surgery to be feasible on the basis of existing data.

Cost-effectiveness of vaccination against herpes zoster.

PubMed

de Boer, Pieter T; Wilschut, Jan C; Postma, Maarten J

2014-01-01

Herpes zoster (HZ) is a common disease among elderly, which may develop into a severe pain syndrome labeled postherpetic neuralgia (PHN). A live-attenuated varicella zoster virus vaccine has been shown to be effective in reducing the incidence and burden of illness of HZ and PHN, providing the opportunity to prevent significant health-related and financial consequences of HZ. In this review, we summarize the available literature on cost-effectiveness of HZ vaccination and discuss critical parameters for cost-effectiveness results. A search in PubMed and EMBASE was performed to identify full cost-effectiveness studies published before April 2013. Fourteen cost-effectiveness studies were included, all performed in western countries. All studies evaluated cost-effectiveness among elderly above 50 years and used costs per quality-adjusted life year (QALY) gained as primary outcome. The vast majority of studies showed vaccination of 60- to 75-year-old individuals to be cost-effective, when duration of vaccine efficacy was longer than 10 years. Duration of vaccine efficacy, vaccine price, HZ incidence, HZ incidence and discount rates were influential to the incremental cost-effectiveness ratio (ICER). HZ vaccination may be a worthwhile intervention from a cost-effectiveness point of view. More extensive reporting on methodology and more detailed results of sensitivity analyses would be desirable to address uncertainty and to guarantee optimal comparability between studies, for example regarding model structure, discounting, vaccine characteristics and loss of quality of life due to HZ and PHN.

Cost-effectiveness of vaccination against herpes zoster

PubMed Central

de Boer, Pieter T; Wilschut, Jan C; Postma, Maarten J

2014-01-01

Herpes zoster (HZ) is a common disease among elderly, which may develop into a severe pain syndrome labeled postherpetic neuralgia (PHN). A live-attenuated varicella zoster virus vaccine has been shown to be effective in reducing the incidence and burden of illness of HZ and PHN, providing the opportunity to prevent significant health-related and financial consequences of HZ. In this review, we summarize the available literature on cost-effectiveness of HZ vaccination and discuss critical parameters for cost-effectiveness results. A search in PubMed and EMBASE was performed to identify full cost-effectiveness studies published before April 2013. Fourteen cost-effectiveness studies were included, all performed in western countries. All studies evaluated cost-effectiveness among elderly above 50 years and used costs per quality-adjusted life year (QALY) gained as primary outcome. The vast majority of studies showed vaccination of 60- to 75-year-old individuals to be cost-effective, when duration of vaccine efficacy was longer than 10 years. Duration of vaccine efficacy, vaccine price, HZ incidence, HZ incidence and discount rates were influential to the incremental cost-effectiveness ratio (ICER). HZ vaccination may be a worthwhile intervention from a cost-effectiveness point of view. More extensive reporting on methodology and more detailed results of sensitivity analyses would be desirable to address uncertainty and to guarantee optimal comparability between studies, for example regarding model structure, discounting, vaccine characteristics and loss of quality of life due to HZ and PHN. PMID:25424815

The 2-year cost-effectiveness of 3 options to treat lumbar spinal stenosis patients.

PubMed

Udeh, Belinda L; Costandi, Shrif; Dalton, Jarrod E; Ghosh, Raktim; Yousef, Hani; Mekhail, Nagy

2015-02-01

Lumbar spinal stenosis (LSS) may result from degenerative changes of the spine, which lead to neural ischemia, neurogenic claudication, and a significant decrease in quality of life. Treatments for LSS range from conservative management including epidural steroid injections (ESI) to laminectomy surgery. Treatments vary greatly in cost and success. ESI is the least costly treatment may be successful for early stages of LSS but often must be repeated frequently. Laminectomy surgery is more costly and has higher complication rates. Minimally invasive lumbar decompression (mild(®) ) is an alternative. Using a decision-analytic model from the Medicare perspective, a cost-effectiveness analysis was performed comparing mild(®) to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality-adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost-effectiveness ratios were determined, and sensitivity analysis conducted. The mild(®) strategy appears to be the most cost-effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost-effective ($125,985/QALY). © 2014 World Institute of Pain.

Low-cost foods: how do they compare with their brand name equivalents? A French study.

PubMed

Darmon, Nicole; Caillavet, France; Joly, Caroline; Maillot, Matthieu; Drewnowski, Adam

2009-06-01

Consumers are increasingly relying on low-cost foods, although it is not clear if the nutritional quality of these foods is fully maintained. The aim of the present work was to analyse the relationship between cost and quality within a given food category. The relationship was analysed between nutritional quality and cost for 220 food products belonging to seventeen different categories, controlling for package type and package size. Given that a summary of nutrient information was not available on the product label, a novel ingredient quality score was developed based on listed product ingredients. Within a given category, the lowest-priced foods were not different from the equivalent branded products in terms of overall energy or total fat content. Nevertheless, a positive relationship, small but significant, was observed between the price and the ingredient quality score. On average, the branded products cost 2.5 times more than the low-cost products, for an equivalent energy and lipid content, and had a slightly higher (1.3 times) ingredient quality score. More studies are necessary to evaluate the nutritional quality of low-cost foods. This evaluation would be facilitated if nutrition labelling was mandatory. Yet in view of the present results, it does not seem to be justified to divert consumers, especially the poorest, from low-cost foods because this may have an adverse effect on the nutritional quality of their diet, by reducing further the fraction of their food budget spent on fresh fruit and vegetables.

Low-cost oblique illumination: an image quality assessment.

PubMed

Ruiz-Santaquiteria, Jesus; Espinosa-Aranda, Jose Luis; Deniz, Oscar; Sanchez, Carlos; Borrego-Ramos, Maria; Blanco, Saul; Cristobal, Gabriel; Bueno, Gloria

2018-01-01

We study the effectiveness of several low-cost oblique illumination filters to improve overall image quality, in comparison with standard bright field imaging. For this purpose, a dataset composed of 3360 diatom images belonging to 21 taxa was acquired. Subjective and objective image quality assessments were done. The subjective evaluation was performed by a group of diatom experts by psychophysical test where resolution, focus, and contrast were assessed. Moreover, some objective nonreference image quality metrics were applied to the same image dataset to complete the study, together with the calculation of several texture features to analyze the effect of these filters in terms of textural properties. Both image quality evaluation methods, subjective and objective, showed better results for images acquired using these illumination filters in comparison with the no filtered image. These promising results confirm that this kind of illumination filters can be a practical way to improve the image quality, thanks to the simple and low cost of the design and manufacturing process. (2018) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE).

Surgical management of bilateral vocal fold paralysis: A cost-effectiveness comparison of two treatments.

PubMed

Naunheim, Matthew R; Song, Phillip C; Franco, Ramon A; Alkire, Blake C; Shrime, Mark G

2017-03-01

Endoscopic management of bilateral vocal fold paralysis (BVFP) includes cordotomy and arytenoidectomy, and has become a well-accepted alternative to tracheostomy. However, the costs and quality-of-life benefits of endoscopic management have not been examined with formal economic analysis. This study undertakes a cost-effectiveness analysis of tracheostomy versus endoscopic management of BVFP. Cost-effectiveness analysis. A literature review identified a range of costs and outcomes associated with surgical options for BVFP. Additional costs were derived from Medicare reimbursement data; all were adjusted to 2014 dollars. Cost-effectiveness analysis evaluated both therapeutic strategies in short-term and long-term scenarios. Probabilistic sensitivity analysis was used to assess confidence levels regarding the economic evaluation. The incremental cost effectiveness ratio for endoscopic management versus tracheostomy is $31,600.06 per quality-adjusted life year (QALY), indicating that endoscopic management is the cost-effective short-term strategy at a willingness-to-pay (WTP) threshold of $50,000/QALY. The probability that endoscopic management is more cost-effective than tracheostomy at this WTP is 65.1%. Threshold analysis demonstrated that the model is sensitive to both utilities and cost in the short-term scenario. When costs of long-term care are included, tracheostomy is dominated by endoscopic management, indicating the cost-effectiveness of endoscopic management at any WTP. Endoscopic management of BVFP appears to be more cost-effective than tracheostomy. Though endoscopic cordotomy and arytenoidectomy require expertise and specialized equipment, this model demonstrates utility gains and long-term cost advantages to an endoscopic strategy. These findings are limited by the relative paucity of robust utility data and emphasize the need for further economic analysis in otolaryngology. NA Laryngoscope, 127:691-697, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

A systematic review of cost-effectiveness analyses of drugs for postmenopausal osteoporosis.

PubMed

Hiligsmann, Mickaël; Evers, Silvia M; Ben Sedrine, Wafa; Kanis, John A; Ramaekers, Bram; Reginster, Jean-Yves; Silverman, Stuart; Wyers, Caroline E; Boonen, Annelies

2015-03-01

Given the limited availability of healthcare resources and the recent introduction of new anti-osteoporosis drugs, the interest in the cost effectiveness of drugs in postmenopausal osteoporosis remains and even increases. This study aims to identify all recent economic evaluations on drugs for postmenopausal osteoporosis, to critically appraise the reporting quality, and to summarize the results. A literature search using Medline, the National Health Service Economic Evaluation database and the Cost-Effectiveness Analysis Registry was undertaken to identify original articles published between January 1, 2008 and December 31, 2013. Studies that assessed cost effectiveness of drugs in postmenopausal osteoporosis were included. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement was used to assess the quality of reporting of these articles. Of 1,794 articles identified, 39 studies fulfilled the inclusion criteria. They were conducted in 14 different countries and nine active interventions were assessed. When compared with no treatment, active osteoporotic drugs were generally cost effective in postmenopausal women aged over 60-65 years with low bone mass, especially those with prior vertebral fractures. Key drivers of cost effectiveness included individual fracture risk, medication adherence, selected comparators and country-specific analyses. Quality of reporting varied between studies with an average score of 17.9 out of 24 (range 7-21.5). This review found a substantial number of published cost-effectiveness analyses of drugs in osteoporosis in the last 6 years. Results and critical appraisal of these articles can help decision makers when prioritizing health interventions and can inform the development of future economic evaluations.

Cost-effectiveness of quality improvement programs for patients with subthreshold depression or depressive disorder.

PubMed

Wells, Kenneth B; Schoenbaum, Michael; Duan, Naihua; Miranda, Jeanne; Tang, Lingqi; Sherbourne, Cathy

2007-10-01

This study explored the cost-effectiveness of quality-improvement interventions for depression in primary care, relative to usual care, among patients with subthreshold depression or depressive disorder. A total of 746 primary care patients in managed care organizations with 12-month depressive disorder and 502 with current depressive symptoms but no disorder (subthreshold depression) participated in a group-level randomized controlled trial initiated between June 1996 and March 1997. Matched clinics were randomly assigned to enhanced usual care or one of two quality improvement interventions that provided education to manage depression over time and resources to facilitate access to medication management or psychotherapy for six to 12 months. The cost-effectiveness ratio for the pooled intervention groups versus usual care was $2,028 for patients with subthreshold depression (95% confidence interval [CI]=-$17,225 to $21,282) and $53,716 for those with depressive disorder (CI=$14,194 to $93,238), by using a measure of quality-adjusted life years (QALY) based on the 12-Item Short Form Health Survey. Similar results were obtained when alternative QALY measures were used. Although precision was limited, even the upper limit of the 95% CIs suggests that such interventions are as cost-effective for patients with subthreshold depression as are many widely used medical therapies. Despite lack of evidence for efficacy of treatments for subthreshold depression, disease management programs that support clinical care decisions over time for patients with subthreshold depression or depressive disorder can yield cost-effectiveness ratios comparable to those of widely adopted medical therapies. Achieving greater certainty about average cost-effectiveness would require a much larger study.

48 CFR 7.101 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... produce quality systems. This includes ensuring that only necessary and cost-effective requirements are... that involve redesign of systems or subsystems. Life-cycle cost means the total cost to the Government...

48 CFR 7.101 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... produce quality systems. This includes ensuring that only necessary and cost-effective requirements are... that involve redesign of systems or subsystems. Life-cycle cost means the total cost to the Government...

End-of-Life Care Interventions: An Economic Analysis

PubMed Central

Pham, B; Krahn, M

2014-01-01

Background The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. Objective To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Data Sources Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. Review Methods We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. Results In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76–108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191–$385 million in health care costs. Results for the other interventions were uncertain. Limitations The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. Conclusions In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible. PMID:26339303

End-of-Life Care Interventions: An Economic Analysis.

PubMed

Pham, B; Krahn, M

2014-01-01

The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76-108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191-$385 million in health care costs. Results for the other interventions were uncertain. The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible.

Health economic analysis of allergen immunotherapy for the management of allergic rhinitis, asthma, food allergy and venom allergy: A systematic overview.

PubMed

Asaria, M; Dhami, S; van Ree, R; Gerth van Wijk, R; Muraro, A; Roberts, G; Sheikh, A

2018-02-01

The European Academy of Allergy and Clinical Immunology (EAACI) is developing guidelines for allergen immunotherapy (AIT) for the management of allergic rhinitis, allergic asthma, IgE-mediated food allergy and venom allergy. To inform the development of clinical recommendations, we undertook systematic reviews to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT for these conditions. This study focusses on synthesizing data and gaps in the evidence on the cost-effectiveness of AIT for these conditions. We produced summaries of evidence in each domain, and then, synthesized findings on health economic data identified from four recent systematic reviews on allergic rhinitis, asthma, food allergy and venom allergy, respectively. The quality of these studies was independently assessed using the Critical Appraisal Skills Programme tool for health economic evaluations. Twenty-three studies satisfied our inclusion criteria. Of these, 19 studies investigated the cost-effectiveness of AIT in allergic rhinitis, of which seven were based on data from randomized controlled trials with economic evaluations conducted from a health system perspective. This body of evidence suggested that sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) would be considered cost-effective using the (English) National Institute for Health and Clinical Excellence (NICE) cost-effectiveness threshold of £20 000/quality-adjusted life year (QALY). However, the quality of the studies and the general lack of attention to characterizing uncertainty and handling missing data should be taken into account when interpreting these results. For asthma, there were three eligible studies, all of which had significant methodological limitations; these suggested that SLIT, when used in patients with both asthma and allergic rhinitis, may be cost-effective with an incremental cost-effectiveness ratio (ICER) of £10 726 per QALY. We found one economic modelling study for venom allergy which, despite being based largely on expert opinion and plausible assumptions, suggested that AIT for bee and wasp venom allergy is only likely to be cost-effective for very high-risk groups who may be exposed to multiple exposures to venom/year (eg bee keepers). We found no eligible studies investigating the cost-effectiveness of AIT for food allergy. Overall, the evidence to support the cost-effectiveness of AIT is limited and of low methodological quality, but suggests that AIT may be cost-effective for people with allergic rhinitis with or without asthma and in high-risk subgroups for venom allergy. We were unable to draw any conclusions on the cost-effectiveness of AIT for food allergy. © 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.

An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care.

PubMed

Hibbard, Judith H; Greene, Jessica; Sofaer, Shoshanna; Firminger, Kirsten; Hirsh, Judith

2012-03-01

Advocates of health reform continue to pursue policies and tools that will make information about comparative costs and resource use available to consumers. Reformers expect that consumers will use the data to choose high-value providers-those who offer higher quality and lower prices-and thus contribute to the broader goal of controlling national health care spending. However, communicating this information effectively is more challenging than it might first appear. For example, consumers are more interested in the quality of health care than in its cost, and many perceive a low-cost provider to be substandard. In this study of 1,421 employees, we examined how different presentations of information affect the likelihood that consumers will make high-value choices. We found that a substantial minority of the respondents shied away from low-cost providers, and even consumers who pay a larger share of their health care costs themselves were likely to equate high cost with high quality. At the same time, we found that presenting cost data alongside easy-to-interpret quality information and highlighting high-value options improved the likelihood that consumers would choose those options. Reporting strategies that follow such a format will help consumers understand that a doctor who provides higher-quality care than other doctors does not necessarily cost more.

Estimating the cost-effectiveness of 54 weeks of infliximab for rheumatoid arthritis.

PubMed

Wong, John B; Singh, Gurkirpal; Kavanaugh, Arthur

2002-10-01

To estimate the cost-effectiveness of infliximab plus methotrexate for active, refractory rheumatoid arthritis. We projected the 54-week results from a randomized controlled trial of infliximab into lifetime economic and clinical outcomes using a Markov computer simulation model. Direct and indirect costs, quality of life, and disability estimates were based on trial results; Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) database outcomes; and published data. Results were discounted using the standard 3% rate. Because most well-accepted medical therapies have cost-effectiveness ratios below $50,000 to $100,000 per quality-adjusted life-year (QALY) gained, results below this range were considered to be "cost-effective." At 3 mg/kg, each infliximab infusion would cost $1393. When compared with methotrexate alone, 54 weeks of infliximab plus methotrexate decreased the likelihood of having advanced disability from 23% to 11% at the end of 54 weeks, which projected to a lifetime marginal cost-effectiveness ratio of $30,500 per discounted QALY gained, considering only direct medical costs. When applying a societal perspective and including indirect or productivity costs, the marginal cost-effectiveness ratio for infliximab was $9100 per discounted QALY gained. The results remained relatively unchanged with variation of model estimates over a broad range of values. Infliximab plus methotrexate for 54 weeks for rheumatoid arthritis should be cost-effective with its clinical benefit providing good value for the drug cost, especially when including productivity losses. Although infliximab beyond 54 weeks will likely be cost-effective, the economic and clinical benefit remains uncertain and will depend on long-term results of clinical trials.

Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement.

PubMed

Reynolds, Matthew R; Lei, Yang; Wang, Kaijun; Chinnakondepalli, Khaja; Vilain, Katherine A; Magnuson, Elizabeth A; Galper, Benjamin Z; Meduri, Christopher U; Arnold, Suzanne V; Baron, Suzanne J; Reardon, Michael J; Adams, David H; Popma, Jeffrey J; Cohen, David J

2016-01-05

Previous studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system. The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk. We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S. Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years ([QALY]; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ∼$1,650 would lead to an incremental cost-effectiveness ratio <$50,000/QALY gained. In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S. With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).

PubMed

Vilain, Katherine R; Magnuson, Elizabeth A; Li, Haiyan; Clark, Wayne M; Begg, Richard J; Sam, Albert D; Sternbergh, W Charles; Weaver, Fred A; Gray, William A; Voeks, Jenifer H; Brott, Thomas G; Cohen, David J

2012-09-01

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines. We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups. Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%. Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

Costs and Cost-Effectiveness of Carotid Stenting versus Endarterectomy for Patients at Standard Surgical Risk: Results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

PubMed Central

Vilain, Katherine R.; Magnuson, Elizabeth A.; Li, Haiyan; Clark, Wayne M.; Begg, Richard J.; Sam, Albert D.; Sternbergh, W. Charles; Weaver, Fred A.; Gray, William A.; Voeks, Jenifer H.; Brott, Thomas G.; Cohen, David J.

2012-01-01

Background The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite endpoint between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction (MI) was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for healthcare policy and treatment guidelines. Methods We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health utility scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups. Results Although initial procedural costs were $1025/patient higher with CAS, post-procedure costs and physician costs were lower, such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15,055 versus $14,816; mean difference $239/patient, 95% CI for difference, −$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50,000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%. Conclusions Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. PMID:22821614

Liquid-based cervical cytology using ThinPrep technology: weighing the pros and cons in a cost-effectiveness analysis.

PubMed

de Bekker-Grob, Esther W; de Kok, Inge M C M; Bulten, Johan; van Rosmalen, Joost; Vedder, Judith E M; Arbyn, Marc; Klinkhamer, Paul J J M; Siebers, Albertus G; van Ballegooijen, Marjolein

2012-08-01

Cervical cancer screening with liquid-based cytology (LBC) has been developed as an alternative to the conventional Papanicolaou (CP) smear. Cost-effectiveness is one of the issues when evaluating LBC. Based on the results of a Dutch randomised controlled trial, we conducted cost-effectiveness threshold analyses to investigate under what circumstances manually screened ThinPrep LBC is cost-effective for screening. The MISCAN-Cervix microsimulation model and data from the Dutch NETHCON trial (including 89,784 women) were used to estimate the costs and (quality-adjusted) life years ((QA)LYs) gained for EU screening schedules, varying cost-effectiveness threshold values. Screening strategies were primary cytological screening with LBC or CP, and triage with human papillomavirus (HPV) testing. Threshold analyses showed that screening with LBC as a primary test can be cost-effective if LBC is less than 3.2 more costly per test than CP, if the sensitivity of LBC is at least 3-5 % points higher than CP, if the quality of life for women in triage follow-up is only 0.39, or if the rate of inadequate CP smears is at least 16.2 %. Regarding test characteristics and costs of LBC and CP, only under certain conditions will a change from CP to manually screened ThinPrep LBC be cost-effective. If none of these conditions are met, implementation of manually screened ThinPrep LBC seems warranted only if there are advantages other than cost-effectiveness. Further research is needed to establish whether other LBC systems will be more favorable with regard to cost-effectiveness.

The costs and effects of contrast-enhanced magnetic resonance angiography and digital substraction angiography on quality of life in patients with peripheral arterial disease.

PubMed

Bosma, Jan; Dijksman, Lea M; Lam, Kayan; Wisselink, Willem; van Swijndregt, Alexander D Montauban; Vahl, Anco

2014-04-01

Contrast-enhanced magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) both have a high diagnostic performance in the imaging of peripheral arterial occlusive disease (PAOD). However, little is known about the effects of initial, preoperative imaging using MRA or DSA on quality of life (QoL) in relation to costs (cost-utility). To compare cost-utility of treatment strategies using either MRA or DSA as the principal imaging tool, related to QoL, in patients with PAOD. In a prospective subgroup analysis of patients randomized between MRA and DSA (n = 79) for preoperative imaging, QoL questionnaires (SF-36) were obtained at randomization and at 4-month follow-up. Cost-effectiveness from hospital perspective was subsequently compared between groups and the difference in gained or lost QoL per € spent assessed using bootstrap analysis. No difference in quality of life was found. A treatment trajectory employing MRA as the principal imaging modality was almost 20% cheaper, leading to a better cost-utility ratio in favor of MRA. A treatment plan for peripheral arterial occlusive disease employing MRA versus DSA as the principal imaging modality yields a better cost/QoL ratio for MRA.

Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi.

PubMed

Colbourn, Tim; Pulkki-Brännström, Anni-Maria; Nambiar, Bejoy; Kim, Sungwook; Bondo, Austin; Banda, Lumbani; Makwenda, Charles; Batura, Neha; Haghparast-Bidgoli, Hassan; Hunter, Rachael; Costello, Anthony; Baio, Gianluca; Skordis-Worrall, Jolene

2015-01-01

Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale. Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $. The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi. Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.

A Systematic Review and Narrative Synthesis of Health Economic Studies Conducted for Hereditary Haemochromatosis.

PubMed

de Graaff, Barbara; Neil, Amanda; Sanderson, Kristy; Si, Lei; Yee, Kwang Chien; Palmer, Andrew J

2015-10-01

Hereditary haemochromatosis (HH) is a common genetic condition amongst people of northern European heritage. HH is associated with increased iron absorption leading to parenchymal organ damage and multiple arthropathies. Early diagnosis and treatment prevents complications. Population screening may increase early diagnosis, but no programmes have been introduced internationally: a paucity of health economic data is often cited as a barrier. To conduct a systematic review of all health economic studies in HH. Studies were identified through electronic searching of economic/biomedical databases. Any study on HH with original economic component was included. Study quality was formally assessed. Health economic data were extracted and analysed through narrative synthesis. Thirty-eight studies met the inclusion criteria. The majority of papers reported on costs or cost effectiveness of screening programmes. Whilst most concluded screening was cost effective compared with no screening, methodological flaws limit the quality of these findings. Assumptions regarding clinical penetrance, effectiveness of screening, health-state utility values (HSUVs), exclusion of early symptomatology (such as fatigue, lethargy and multiple arthropathies) and quantification of costs associated with HH were identified as key limitations. Treatment studies concluded therapeutic venepuncture was the most cost-effective intervention. There is a paucity of high-quality health economic studies relating to HH. The development of a comprehensive HH cost-effectiveness model utilising HSUVs is required to determine whether screening is worthwhile.

Cost-effectiveness of Continuous Positive Airway Pressure Treatment in Moderate-Severe Obstructive Sleep Apnea Syndrome.

PubMed

Català, Raquel; Villoro, Renata; Merino, María; Sangenís, Sandra; Colomés, Lluís; Hernández Flix, Salvador; Pérez de Llano, Luis A

2016-09-01

The socioeconomic impact of obstructive sleep apnea-hypopnea syndrome (OSAHS) is considerable. The aim of this study was to evaluate the cost-effectiveness of treating OSAHS with continuous positive airway pressure (CPAP) and the impact of CPAP compliance. This was a retrospective, case-crossover study of 373 patients with OSAHS receiving CPAP. We compared changes in costs, Epworth score and health-related quality of life (EQ-5D questionnaires) between the year before treatment and the year after treatment. The incremental cost-effectiveness ratio (ICER) for the first year of treatment was estimated, and projections were made for the second year, using different effectiveness and cost scenarios. The visual analog scale score for the EQ-5D questionnaire increased by 5 points and the Epworth score fell by 10 points during the year of CPAP treatment. Mean gain in quality-adjusted life years (QALY) was 0.05 per patient per year (P<.001): 0.07 among compliers and -0.04 among non-compliers. ICER was €51,147/QALY during the first year of CPAP treatment and €1,544/QALY during the second year. CPAP treatment in patients with moderate-severe OSAHS improves the quality of life of compliant patients, and is cost-effective as of the second year. Copyright © 2016 SEPAR. Publicado por Elsevier España, S.L.U. All rights reserved.

Composite Tissue Transplant of Hand or Arm: A Health Technology Assessment.

PubMed

2016-01-01

Injuries to arms and legs following severe trauma can result in the loss of large regions of tissue, disrupting healing and function and sometimes leading to amputation of the damaged limb. People experiencing amputations of the hand or arm could potentially benefit from composite tissue transplant, which is being performed in some countries. Currently, there are no composite tissue transplant programs in Canada. We conducted a systematic review of the literature, with no restriction on study design, examining the effectiveness and cost-effectiveness of hand and arm transplant. We assessed the overall quality of the clinical evidence with GRADE. We developed a Markov decision analytic model to determine the cost-effectiveness of transplant versus standard care for a healthy adult with a hand amputation. Incremental cost-effectiveness ratios (ICERs) were calculated using a 30-year time horizon. We also estimated the impact on provincial health care costs if these transplants were publicly funded in Ontario. Compared to pre-transplant function, patients' post-transplant function was significantly better. For various reasons, 17% of transplanted limbs were amputated, 6.4% of patients died within the first year after the transplant, and 10.6% of patients experienced chronic rejections. GRADE quality of evidence for all outcomes was very low. In the cost-effectiveness analysis, single-hand transplant was dominated by standard care, with increased costs ($735,647 CAD vs. $61,429) and reduced quality-adjusted life-years (QALYs) (10.96 vs. 11.82). Double-hand transplant also had higher costs compared with standard care ($633,780), but it had an increased effectiveness of 0.17 QALYs, translating to an ICER of $3.8 million per QALY gained. In most sensitivity analyses, ICERs for bilateral hand transplant were greater than $1 million per QALY gained. A hand transplant program would lead to an estimated annual budget impact of $0.9 million to $1.2 million in the next 3 years, 2016 to 2018, to treat 3 adults per year. Composite tissue transplant of the hand or arm may improve a patient's ability to function, but because the overall quality of evidence is of very low quality, there is considerable uncertainty as to whether benefits outweigh harms. Compared with standard care, both single- and double-hand transplants are not cost-effective.

Composite Tissue Transplant of Hand or Arm: A Health Technology Assessment

PubMed Central

Lambrinos, Anna; Xie, Xuanqian; Higgins, Caroline; Holubowich, Corinne

2016-01-01

Background Injuries to arms and legs following severe trauma can result in the loss of large regions of tissue, disrupting healing and function and sometimes leading to amputation of the damaged limb. People experiencing amputations of the hand or arm could potentially benefit from composite tissue transplant, which is being performed in some countries. Currently, there are no composite tissue transplant programs in Canada. Methods We conducted a systematic review of the literature, with no restriction on study design, examining the effectiveness and cost-effectiveness of hand and arm transplant. We assessed the overall quality of the clinical evidence with GRADE. We developed a Markov decision analytic model to determine the cost-effectiveness of transplant versus standard care for a healthy adult with a hand amputation. Incremental cost-effectiveness ratios (ICERs) were calculated using a 30-year time horizon. We also estimated the impact on provincial health care costs if these transplants were publicly funded in Ontario. Results Compared to pre-transplant function, patients’ post-transplant function was significantly better. For various reasons, 17% of transplanted limbs were amputated, 6.4% of patients died within the first year after the transplant, and 10.6% of patients experienced chronic rejections. GRADE quality of evidence for all outcomes was very low. In the cost-effectiveness analysis, single-hand transplant was dominated by standard care, with increased costs ($735,647 CAD vs. $61,429) and reduced quality-adjusted life-years (QALYs) (10.96 vs. 11.82). Double-hand transplant also had higher costs compared with standard care ($633,780), but it had an increased effectiveness of 0.17 QALYs, translating to an ICER of $3.8 million per QALY gained. In most sensitivity analyses, ICERs for bilateral hand transplant were greater than $1 million per QALY gained. A hand transplant program would lead to an estimated annual budget impact of $0.9 million to $1.2 million in the next 3 years, 2016 to 2018, to treat 3 adults per year. Conclusions Composite tissue transplant of the hand or arm may improve a patient's ability to function, but because the overall quality of evidence is of very low quality, there is considerable uncertainty as to whether benefits outweigh harms. Compared with standard care, both single- and double-hand transplants are not cost-effective. PMID:27468324

Health economics of insomnia treatments: The return on investment for a good night's sleep.

PubMed

Wickwire, Emerson M; Shaya, Fadia T; Scharf, Steven M

2016-12-01

Chronic insomnia is the most common sleep disorder among adults and is associated with a wide range of negative outcomes. This article reviews the economic consequences of the disorder and the cost effectiveness of insomnia treatments. First, the total costs of insomnia are reviewed; in aggregate these costs exceed $100 billion USD per year, with the majority being spent on indirect costs such as poorer workplace performance, increased health care utilization, and increased accident risk. Next, the deleterious impact of insomnia on quality of life and the impact of treatment on quality of life are briefly considered. Finally, ten published studies evaluating the cost effectiveness of both pharmacological and behavioral treatments for insomnia are reviewed in detail. A significant majority of studies reviewed found that the cost of treating primary and comorbid insomnia is less than the cost of not treating it. Treatments were generally found to be cost-effective using commonly employed standards, with treatment costs being recouped within 6-12 mo. Copyright © 2015 Elsevier Ltd. All rights reserved.

Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

PubMed Central

Green, Colin; Richards, David A.; Hill, Jacqueline J.; Gask, Linda; Lovell, Karina; Chew-Graham, Carolyn; Bower, Peter; Cape, John; Pilling, Stephen; Araya, Ricardo; Kessler, David; Bland, J. Martin; Gilbody, Simon; Lewis, Glyn; Manning, Chris; Hughes-Morley, Adwoa; Barkham, Michael

2014-01-01

Background Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting. PMID:25121991

The cost-effectiveness of screening for colorectal cancer.

PubMed

Telford, Jennifer J; Levy, Adrian R; Sambrook, Jennifer C; Zou, Denise; Enns, Robert A

2010-09-07

Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy. We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50-year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars. Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of $9159, $611 and $6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit. Screening for colorectal cancer is cost-effective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada.

Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm.

PubMed

van Bochove, Cornelis A; Burgers, Laura T; Vahl, Anco C; Birnie, Erwin; van Schothorst, Marien G; Redekop, William K

2016-03-01

Patients with a large unruptured abdominal aortic aneurysm with a diameter >5.0 cm are treated with open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Because many studies have assessed the cost-effectiveness of these treatments with conflicting results, this systematic review examined published cost-effectiveness analyses of elective EVAR vs OSR in patients with abdominal aortic aneurysm. A systematic search strategy using three databases was conducted to find all relevant studies. Characteristics extracted from these studies included study characteristics (eg, age of the population), input parameters (eg, costs of the EVAR procedure), general results, and sensitivity analyses. The quality of each study was assessed using the Drummond checklist. The search identified 1141 potentially relevant studies, of which 13 studies met inclusion criteria. Most studies found that EVAR was more expensive and more effective than OSR. However, most studies concluded that the health gained from EVAR did not offset the higher total costs, leading to an unacceptably high incremental cost-effectiveness ratio. EVAR was considered more cost-effective in patient groups with a high surgical risk. The quality of most studies was judged as reasonably good. Overall, published cost-effectiveness analyses of EVAR do not provide a clear answer about whether elective EVAR is a cost-effective solution because the incremental cost-effectiveness ratio varies considerably among the studies. This answer can best be provided through a cost-effectiveness analysis of EVAR that incorporates more recent technologic advances and the improved experience that clinicians have with EVAR. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Cost-effectiveness of supervised exercise therapy in heart failure patients.

PubMed

Kühr, Eduardo M; Ribeiro, Rodrigo A; Rohde, Luis Eduardo P; Polanczyk, Carisi A

2011-01-01

Exercise therapy in heart failure (HF) patients is considered safe and has demonstrated modest reduction in hospitalization rates and death in recent trials. Previous cost-effectiveness analysis described favorable results considering long-term supervised exercise intervention and significant effectiveness of exercise therapy; however, these evidences are now no longer supported. To evaluate the cost-effectiveness of supervised exercise therapy in HF patients under the perspective of the Brazilian Public Healthcare System. We developed a Markov model to evaluate the incremental cost-effectiveness ratio of supervised exercise therapy compared to standard treatment in patients with New York Heart Association HF class II and III. Effectiveness was evaluated in quality-adjusted life years in a 10-year time horizon. We searched PUBMED for published clinical trials to estimate effectiveness, mortality, hospitalization, and utilities data. Treatment costs were obtained from published cohort updated to 2008 values. Exercise therapy intervention costs were obtained from a rehabilitation center. Model robustness was assessed through Monte Carlo simulation and sensitivity analysis. Cost were expressed as international dollars, applying the purchasing-power-parity conversion rate. Exercise therapy showed small reduction in hospitalization and mortality at a low cost, an incremental cost-effectiveness ratio of Int$26,462/quality-adjusted life year. Results were more sensitive to exercise therapy costs, standard treatment total costs, exercise therapy effectiveness, and medications costs. Considering a willingness-to-pay of Int$27,500, 55% of the trials fell below this value in the Monte Carlo simulation. In a Brazilian scenario, exercise therapy shows reasonable cost-effectiveness ratio, despite current evidence of limited benefit of this intervention. Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

The interaction between reproductive cost and individual quality is mediated by oceanic conditions in a long-lived bird.

PubMed

Robert, Alexandre; Paiva, Vitor H; Bolton, Mark; Jiguet, Frédéric; Bried, Joël

2012-08-01

Environmental variability, costs of reproduction, and heterogeneity in individual quality are three important sources of the temporal and interindividual variations in vital rates of wild populations. Based on an 18-year monitoring of an endangered, recently described, long-lived seabird, Monteiro's Storm-Petrel (Oceanodroma monteiroi), we designed multistate survival models to separate the effects of the reproductive cost (breeders vs. nonbreeders) and individual quality (successful vs. unsuccessful breeders) in relation to temporally variable demographic and oceanographic properties. The analysis revealed a gradient of individual quality from nonbreeders, to unsuccessful breeders, to successful breeders. The survival rates of unsuccessful breeders (0.90 +/- 0.023, mean +/- SE) tended to decrease in years of high average breeding success and were more sensitive to oceanographic variation than those of both (high-quality) successful breeders (0.97 +/- 0.015) and (low-quality) nonbreeders (0.83 +/- 0.028). Overall, our results indicate that reproductive costs act on individuals of intermediate quality and are mediated by environmental harshness.

Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure.

PubMed

Sandhu, Alexander T; Goldhaber-Fiebert, Jeremy D; Owens, Douglas K; Turakhia, Mintu P; Kaiser, Daniel W; Heidenreich, Paul A

2016-05-01

This study aimed to evaluate the cost-effectiveness of the CardioMEMS (CardioMEMS Heart Failure System, St Jude Medical Inc, Atlanta, Georgia) device in patients with chronic heart failure. The CardioMEMS device, an implantable pulmonary artery pressure monitor, was shown to reduce hospitalizations for heart failure and improve quality of life in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial. We developed a Markov model to determine the hospitalization, survival, quality of life, cost, and incremental cost-effectiveness ratio of CardioMEMS implantation compared with usual care among a CHAMPION trial cohort of patients with heart failure. We obtained event rates and utilities from published trial data; we used costs from literature estimates and Medicare reimbursement data. We performed subgroup analyses of preserved and reduced ejection fraction and an exploratory analysis in a lower-risk cohort on the basis of the CHARM (Candesartan in Heart failure: Reduction in Mortality and Morbidity) trials. CardioMEMS reduced lifetime hospitalizations (2.18 vs. 3.12), increased quality-adjusted life-years (QALYs) (2.74 vs. 2.46), and increased costs ($176,648 vs. $156,569), thus yielding a cost of $71,462 per QALY gained and $48,054 per life-year gained. The cost per QALY gained was $82,301 in patients with reduced ejection fraction and $47,768 in those with preserved ejection fraction. In the lower-risk CHARM cohort, the device would need to reduce hospitalizations for heart failure by 41% to cost <$100,000 per QALY gained. The cost-effectiveness was most sensitive to the device's durability. In populations similar to that of the CHAMPION trial, the CardioMEMS device is cost-effective if the trial effectiveness is sustained over long periods. Post-marketing surveillance data on durability will further clarify its value. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Electrical Stimulation for Pressure Injuries: A Health Technology Assessment.

PubMed

2017-01-01

Pressure injuries (bedsores) are common and reduce quality of life. They are also costly and difficult to treat. This health technology assessment evaluates the effectiveness, cost-effectiveness, budget impact, and lived experience of adding electrical stimulation to standard wound care for pressure injuries. We conducted a systematic search for studies published to December 7, 2016, limited to randomized and non-randomized controlled trials examining the effectiveness of electrical stimulation plus standard wound care versus standard wound care alone for patients with pressure injuries. We assessed the quality of evidence through Grading of Recommendations Assessment, Development, and Evaluation (GRADE). In addition, we conducted an economic literature review and a budget impact analysis to assess the cost-effectiveness and affordability of electrical stimulation for treatment of pressure ulcers in Ontario. Given uncertainties in clinical evidence and resource use, we did not conduct a primary economic evaluation. Finally, we conducted qualitative interviews with patients and caregivers about their experiences with pressure injuries, currently available treatments, and (if applicable) electrical stimulation. Nine randomized controlled trials and two non-randomized controlled trials were found from the systematic search. There was no significant difference in complete pressure injury healing between adjunct electrical stimulation and standard wound care. There was a significant difference in wound surface area reduction favouring electrical stimulation compared with standard wound care.The only study on cost-effectiveness of electrical stimulation was partially applicable to the patient population of interest. Therefore, the cost-effectiveness of electrical stimulation cannot be determined. We estimate that the cost of publicly funding electrical stimulation for pressure injuries would be $0.77 to $3.85 million yearly for the next 5 years.Patients and caregivers reported that pressure injuries were burdensome and reduced their quality of life. Patients and caregivers also noted that electrical stimulation seemed to reduce the time it took the wounds to heal. While electrical stimulation is safe to use (GRADE quality of evidence: high) there is uncertainty about whether it improves wound healing (GRADE quality of evidence: low). In Ontario, publicly funding electrical stimulation for pressure injuries could result in extra costs of $0.77 to $3.85 million yearly for the next 5 years.

7 CFR 634.24 - Cost sharing.

Code of Federal Regulations, 2010 CFR

2010-01-01

... designated management agency will annually set maximum individual BMP cost-share levels for the project area... offsite water quality, and (2) The matching share requirements would place a burden on the landowner or... shared must have a positive effect on water quality by reducing the amount of agricultural nonpoint...

7 CFR 634.24 - Cost sharing.

Code of Federal Regulations, 2011 CFR

2011-01-01

... designated management agency will annually set maximum individual BMP cost-share levels for the project area... offsite water quality, and (2) The matching share requirements would place a burden on the landowner or... shared must have a positive effect on water quality by reducing the amount of agricultural nonpoint...

A systematic review of Markov models evaluating multicomponent disease management programs in diabetes.

PubMed

Kirsch, Florian

2015-01-01

Diabetes is the most expensive chronic disease; therefore, disease management programs (DMPs) were introduced. The aim of this review is to determine whether Markov models are adequate to evaluate the cost-effectiveness of complex interventions such as DMPs. Additionally, the quality of the models was evaluated using Philips and Caro quality appraisals. The five reviewed models incorporated the DMP into the model differently: two models integrated effectiveness rates derived from one clinical trial/meta-analysis and three models combined interventions from different sources into a DMP. The results range from cost savings and a QALY gain to costs of US$85,087 per QALY. The Spearman's rank coefficient assesses no correlation between the quality appraisals. With restrictions to the data selection process, Markov models are adequate to determine the cost-effectiveness of DMPs; however, to allow prioritization of medical services, more flexibility in the models is necessary to enable the evaluation of single additional interventions.

Dementia Care Management in an Underserved Community: The Comparative Effectiveness of Two Different Approaches.

PubMed

Chodosh, Joshua; Colaiaco, Benjamin A; Connor, Karen Ilene; Cope, Dennis Wesley; Liu, Hangsheng; Ganz, David Avram; Richman, Mark Jason; Cherry, Debra Lynn; Blank, Joseph Moshe; Carbone, Raquel Del Pilar; Wolf, Sheldon Mark; Vickrey, Barbara Grace

2015-08-01

To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected. © The Author(s) 2015.

Cost-effectiveness of external cephalic version for term breech presentation.

PubMed

Tan, Jonathan M; Macario, Alex; Carvalho, Brendan; Druzin, Maurice L; El-Sayed, Yasser Y

2010-01-21

External cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation. A computer-based decision model (TreeAge Pro 2008, Tree Age Software, Inc.) was developed for a hypothetical base case parturient presenting with a term singleton breech fetus with no contraindications for vaginal delivery. The model incorporated actual hospital costs (e.g., $8,023 for cesarean and $5,581 for vaginal delivery), utilities to quantify health-related quality of life, and probabilities based on analysis of published literature of successful ECV trial, spontaneous reversion, mode of delivery, and need for unanticipated emergency cesarean delivery. The primary endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted year of life gained. A threshold of $50,000 per quality-adjusted life-years (QALY) was used to determine cost-effectiveness. The incremental cost-effectiveness of ECV, assuming a baseline 58% success rate, equaled $7,900/QALY. If the estimated probability of successful ECV is less than 32%, then ECV costs more to society and has poorer QALYs for the patient. However, as the probability of successful ECV was between 32% and 63%, ECV cost more than cesarean delivery but with greater associated QALY such that the cost-effectiveness ratio was less than $50,000/QALY. If the probability of successful ECV was greater than 63%, the computer modeling indicated that a trial of ECV is less costly and with better QALYs than a scheduled cesarean. The cost-effectiveness of a trial of ECV is most sensitive to its probability of success, and not to the probabilities of a cesarean after ECV, spontaneous reversion to breech, successful second ECV trial, or adverse outcome from emergency cesarean. From society's perspective, ECV trial is cost-effective when compared to a scheduled cesarean for breech presentation provided the probability of successful ECV is > 32%. Improved algorithms are needed to more precisely estimate the likelihood that a patient will have a successful ECV.

Cost-effectiveness of diabetes case management for low-income populations.

PubMed

Gilmer, Todd P; Roze, Stéphane; Valentine, William J; Emy-Albrecht, Katrina; Ray, Joshua A; Cobden, David; Nicklasson, Lars; Philis-Tsimikas, Athena; Palmer, Andrew J

2007-10-01

To evaluate the cost-effectiveness of Project Dulce, a culturally specific diabetes case management and self-management training program, in four cohorts defined by insurance status. Clinical and cost data on 3,893 persons with diabetes participating in Project Dulce were used as inputs into a diabetes simulation model. The Center for Outcomes Research Diabetes Model, a published, peer-reviewed and validated simulation model of diabetes, was used to evaluate life expectancy, quality-adjusted life expectancy (QALY), cumulative incidence of complications and direct medical costs over patient lifetimes (40-year time horizon) from a third-party payer perspective. Cohort characteristics, treatment effects, and case management costs were derived using a difference in difference design comparing data from the Project Dulce program to a cohort of historical controls. Long-term costs were derived from published U.S. sources. Costs and clinical benefits were discounted at 3.0 percent per annum. Sensitivity analyses were performed. Incremental cost-effectiveness ratios of $10,141, $24,584, $44,941, and $69,587 per QALY gained were estimated for Project Dulce participants versus control in the uninsured, County Medical Services, Medi-Cal, and commercial insurance cohorts, respectively. The Project Dulce diabetes case management program was associated with cost-effective improvements in quality-adjusted life expectancy and decreased incidence of diabetes-related complications over patient lifetimes. Diabetes case management may be particularly cost effective for low-income populations.

[Cost-effectiveness of two hospital care schemes for psychiatric disorders].

PubMed

Nevárez-Sida, Armando; Valencia-Huarte, Enrique; Escobedo-Islas, Octavio; Constantino-Casas, Patricia; Verduzco-Fragoso, Wázcar; León-González, Guillermo

2013-01-01

In Mexico, six of every twenty Mexicans suffer psychiatric disorders at some time in their lives. This disease ranks fifth in the country. The objective was to determine and compare the cost-effectiveness of two models for hospital care (partial and traditional) at a psychiatric hospital of Instituto Mexicano del Seguro Social (IMSS). a multicenter study with a prospective cohort of 374 patients was performed. We made a cost-effectiveness analysis from an institutional viewpoint with a six-month follow-up. Direct medical costs were analyzed, with quality of life gains as outcome measurement. A decision tree and a probabilistic sensitivity analysis were used. patient care in the partial model had a cost 50 % lower than the traditional one, with similar results in quality of life. The cost per successful unit in partial hospitalization was 3359 Mexican pesos while in the traditional it increased to 5470 Mexican pesos. treating patients in the partial hospitalization model is a cost-effective alternative compared with the traditional model. Therefore, the IMSS should promote the infrastructure that delivers the psychiatric services to the patient attending to who requires it.

Effects of Vascular and Nonvascular Adverse Events and of Extended-Release Niacin With Laropiprant on Health and Healthcare Costs.

PubMed

Kent, Seamus; Haynes, Richard; Hopewell, Jemma C; Parish, Sarah; Gray, Alastair; Landray, Martin J; Collins, Rory; Armitage, Jane; Mihaylova, Borislava

2016-07-01

Extended-release niacin with laropiprant did not significantly reduce the risk of major vascular events and increased the risk of serious adverse events in Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE), but its net effects on health and healthcare costs are unknown. 25 673 participants aged 50 to 80 years with previous cardiovascular disease were randomized to 2 g of extended-release niacin with 40 mg of laropiprant daily versus matching placebo, in addition to effective statin-based low-density lipoprotein cholesterol-lowering treatment. The net effects of niacin-laropiprant on quality-adjusted life years and hospital care costs (2012 UK £; converted into US $ using purchasing power parity index) during 4 years in HPS2-THRIVE were evaluated using estimates of the impact of serious adverse events on health-related quality of life and hospital care costs. During the study, participants assigned niacin-laropiprant experienced marginally but not statistically significantly lower survival (0.012 fewer years [standard error (SE) 0.007]), fewer quality-adjusted life years (0.023 [SE 0.007] fewer using UK EQ-5D scores; 0.020 [SE 0.006] fewer using US EQ-5D scores) and accrued greater hospital costs (UK £101 [SE £37]; US $145 [SE $53]). Stroke, heart failure, musculoskeletal events, gastrointestinal events, and infections were associated with significant decreases in health-related quality of life in both the year of the event and in subsequent years. All serious vascular and nonvascular events were associated with substantial increases in hospital care costs. In HPS2-THRIVE, the addition of extended-release niacin-laropiprant to statin-based therapy reduced quality of life-adjusted survival and increased hospital costs. URL: http://clinicaltrials.gov. Unique identifier: NCT00461630. © 2016 American Heart Association, Inc.

Optimizing staffing, quality, and cost in home healthcare nursing: theory synthesis.

PubMed

Park, Claire Su-Yeon

2017-08-01

To propose a new theory pinpointing the optimal nurse staffing threshold delivering the maximum quality of care relative to attendant costs in home health care. Little knowledge exists on the theoretical foundation addressing the inter-relationship among quality of care, nurse staffing, and cost. Theory synthesis. Cochrane Library, PubMed, CINAHL, EBSCOhost Web and Web of Science (25 February - 26 April 2013; 20 January - 22 March 2015). Most of the existing theories/models lacked the detail necessary to explain the relationship among quality of care, nurse staffing and cost. Two notable exceptions are: 'Production Function for Staffing and Quality in Nursing Homes,' which describes an S-shaped trajectory between quality of care and nurse staffing and 'Thirty-day Survival Isoquant and Estimated Costs According to the Nurse Staff Mix,' which depicts a positive quadric relationship between nurse staffing and cost according to quality of care. A synthesis of these theories led to an innovative multi-dimensional econometric theory helping to determine the maximum quality of care for patients while simultaneously delivering nurse staffing in the most cost-effective way. The theory-driven threshold, navigated by Mathematical Programming based on the Duality Theorem in Mathematical Economics, will help nurse executives defend sufficient nurse staffing with scientific justification to ensure optimal patient care; help stakeholders set an evidence-based reasonable economical goal; and facilitate patient-centred decision-making in choosing the institution which delivers the best quality of care. A new theory to determine the optimum nurse staffing maximizing quality of care relative to cost was proposed. © 2017 The Author. Journal of Advanced Nursing © John Wiley & Sons Ltd.

Relevance of Health Economics in Breast Cancer Treatment – the View of Certified Breast Centres and Their Patients

PubMed Central

Lux, Michael; Hildebrandt, Thomas; Beyer-Finkler, Elke; Bani, Mayada; Loehberg, Christian; Jud, Sebastian; Rauh, Claudia; Schrauder, Michael; Fasching, Peter; Beckmann, Matthias

2013-01-01

Summary Breast cancer centres – certified in accordance with the criteria of the German Cancer Association and the German Mastology Association – are established throughout Germany. Although the setting up of centres and the subsequent need for certification are associated with a marked increase in costs, initial data show positive effects on quality. Certified centres are cost-effective from the point of view of health economics – they lead to improved quality in processes and results without creating any increase in costs for the funding bodies. However, the organization of the necessary structures, with interdisciplinary treatment, documentation and quality-assurance measures, requires considerable resources. Increasing consolidation of inpatient services is also involved, while shortening of the patients’ hospitalization periods is leading to reduced remuneration from the funding bodies. The current cost deficits, which have resulted from the increased resources required, need to be recouped through additional charges. It will only be possible to maintain the high quality achieved if additional charges become available to cover the centres’ added costs. Good data are increasingly becoming available as a basis for negotiations on charges – e.g., with regard to the quality of results and the National Cancer Plan – as well as clear support from patients. PMID:24715838

A literature review to evaluate the economic value of ranolazine for the symptomatic treatment of chronic angina pectoris.

PubMed

Vellopoulou, Katerina; Kourlaba, Georgia; Maniadakis, Nikos; Vardas, Panagiotis

2016-05-15

To conduct a systematic review of the evidence regarding the economic value of ranolazine relative to standard-of-care (SOC) for the treatment of symptomatic chronic stable angina (CSA). Electronic databases were searched using relevant keywords. The identified studies were independently reviewed by two investigators against pre-determined inclusion and exclusion criteria. Their data were extracted using a relevant form and consequently were synthesized. Studies were also evaluated using the Quality of Health Economic Studies scale. The main outcomes considered were the cost and effectiveness for each comparator and the incremental cost per quality-adjusted-life year (QALY) gained. Six studies were included in the review. Five of these assessed the cost-utility of ranolazine added to SOC, compared to SOC alone, using decision trees or Markov models whereas one was a retrospective cost evaluation study. The analysis was conducted from a payer perspective in five studies and from a societal perspective in one study with the time horizon varying between six months and a year. The incremental cost-effectiveness ratio (ICER), ranged from €4000 to €15,000 per QALY gained. Ranolazine appears to be dominant or cost-effective, mainly due to its ability to decrease angina-related hospitalizations and also due to a marginal improvement in quality of life. The acquisition cost of ranolazine was the variable with the greatest impact upon the ICER. The existing evidence, although limited, indicates that ranolazine may be a dominant or cost-effective therapy option, for the treatment of patients with symptomatic CSA. Further research is required to evaluate the cost-effectiveness of ranolazine. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Cost-effectiveness of insulin aspart versus human soluble insulin in type 2 diabetes in four European countries: subgroup analyses from the PREDICTIVE study.

PubMed

Palmer, James L; Goodall, Gordon; Nielsen, Steffen; Kotchie, Robert W; Valentine, William J; Palmer, Andrew J; Roze, Stéphane

2008-05-01

To evaluate the long-term health economic outcomes associated with insulin aspart (IAsp) compared to human soluble insulin (HI) in type 2 diabetes patients on basal-bolus therapy in Sweden, Spain, Italy and Poland. A published computer simulation model of diabetes was used to predict life expectancy, quality-adjusted life expectancy and incidence of diabetes-related complications. Baseline cohort characteristics (age 61.6 years, duration of diabetes 13.2 years, 45.1% male, HbA(1c) 8.2%, BMI 29.8 kg/m(2)) and treatment effects were derived from the PREDICTIVE observational study. Country-specific complication costs were derived from published sources. The analyses were run over 35-year time horizons from third-party payer perspectives in Spain, Italy and Poland and from a societal perspective in Sweden. Future costs and clinical benefits were discounted at country-specific discount rates. Sensitivity analyses were performed. IAsp was associated with improvements in discounted life expectancy and quality-adjusted life expectancy, and a reduced incidence of most diabetes-related complications versus HI in all four settings. IAsp was associated with societal cost-savings in Sweden (SEK 2470), direct medical cost-savings in Sweden and Spain (SEK 8248 and euro 1382, respectively), but increased direct costs in Italy (euro 2235) and Poland (euro 743). IAsp was associated with improved quality-adjusted life expectancy in Sweden (0.077 QALYs), Spain (0.080 QALYs), Italy (0.120 QALYs) and Poland (0.003 QALYs). IAsp was dominant versus HI in both Sweden and Spain, would be considered cost-effective in Italy with an incremental cost-effectiveness ratio of euro 18,597 per QALY gained, but would not be considered cost-effective in Poland.

Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic sympathectomy - A quality of life and cost effectiveness analysis.

PubMed

Gibbons, John P; Nugent, Emmeline; O'Donohoe, Nollaig; Maher, Barry; Egan, Bridget; Feeley, Martin; Tierney, Sean

2016-10-01

To estimate cost-effectiveness of botulinum toxin therapy for axillary hyperhidrosis compared to the standard surgical intervention of endoscopic thoracic sympathectomy (ETS). The validated dermatology life quality index questionnaire was given to patients attending for treatment over a 4 month period, to assess their quality of life (QoL) over the preceding week (n = 44). Follow-up was performed 4-6 weeks later by telephone using the same questionnaire to validate the effectiveness of the treatment. The duration of effect of the botulinum toxin treatment was also recorded and this data was used as the basis for cost effectiveness analysis. Using HIPE data, the baseline cost for single intervention using botulinum toxin and ETS was retrieved. Using figures provided by HIPE and expert opinion of the costs of complications, a stochastic model for 10,000 patients was used to evaluate the total costs for ETS including the complications. The results from the QoL analysis show that botulinum toxin therapy is a successful therapy for improvement of symptoms. It was revealed that the mean interval before recurrence of original symptoms after botulinum toxin therapy was 5.6 months. The baseline cost for both treatments are €389 for botulinum toxin and €9389 for uncomplicated ETS. The stochastic model yields a mean cost of €11,390 for ETS including complications. Treatments reached cost equivalence after 13.3 years. However, given the efficacy of the botulinum toxin therapy and the low risk we propose that botulinum toxin therapy for hyperhidrosis should be considered the gold standard. Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Economic analysis of temperature-controlled laminar airflow (TLA) for the treatment of patients with severe persistent allergic asthma

PubMed Central

Brazier, Peter; Schauer, Uwe; Hamelmann, Eckard; Holmes, Steve; Pritchard, Clive; Warner, John O

2016-01-01

Introduction Chronic asthma is a significant burden for individual sufferers, adversely impacting their quality of working and social life, as well as being a major cost to the National Health Service (NHS). Temperature-controlled laminar airflow (TLA) therapy provides asthma patients at BTS/SIGN step 4/5 an add-on treatment option that is non-invasive and has been shown in clinical studies to improve quality of life for patients with poorly controlled allergic asthma. The objective of this study was to quantify the cost-effectiveness of TLA (Airsonett AB) technology as an add-on to standard asthma management drug therapy in the UK. Methods The main performance measure of interest is the incremental cost per quality-adjusted life year (QALY) for patients using TLA in addition to usual care versus usual care alone. The incremental cost of TLA use is based on an observational clinical study monitoring the incidence of exacerbations with treatment valued using NHS cost data. The clinical effectiveness, used to derive the incremental QALY data, is based on a randomised double-blind placebo-controlled clinical trial comprising participants with an equivalent asthma condition. Results For a clinical cohort of asthma patients as a whole, the incremental cost-effectiveness ratio (ICER) is £8998 per QALY gained, that is, within the £20 000/QALY cost-effectiveness benchmark used by the National Institute for Health and Care Excellence (NICE). Sensitivity analysis indicates that ICER values range from £18 883/QALY for the least severe patients through to TLA being dominant, that is, cost saving as well as improving quality of life, for individuals with the most severe and poorly controlled asthma. Conclusions Based on our results, Airsonett TLA is a cost-effective addition to treatment options for stage 4/5 patients. For high-risk individuals with more severe and less well controlled asthma, the use of TLA therapy to reduce incidence of hospitalisation would be a cost saving to the NHS. PMID:27026803

Cost-effectiveness analysis of genotyping for HLA-B*5801 and an enhanced safety program in gout patients starting allopurinol in Singapore.

PubMed

Dong, Di; Tan-Koi, Wei-Chuen; Teng, Gim Gee; Finkelstein, Eric; Sung, Cynthia

2015-11-01

Allopurinol is an efficacious urate-lowering therapy (ULT), but is associated with rare serious adverse drug reactions of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with higher risk among HLA-B*5801 carriers. We assessed the cost-effectiveness of HLA-B*5801 testing, an enhanced safety program or strategies with both components. The analysis adopted a health systems perspective and considered Singaporean patients with chronic gout, over a lifetime horizon, using allopurinol or probenecid. The model incorporated SJS/TEN and gout treatment outcomes, allele frequencies, drug prices and other medical costs. Based on cost-effectiveness threshold of US$50,000 per quality-adjusted life year, HLA-B*5801-guided ULT selection or enhanced safety program was not cost effective. Avoidance of ULTs was the least preferred strategy as uncontrolled gout leads to lower quality-adjusted life years and higher costs. The analysis underscores the need for biomarkers with higher positive predictive value for SJS/TEN, less expensive genetic tests or safety programs, or more effective gout drugs. .

Effectiveness and cost-effectiveness of a health coaching intervention to improve the lifestyle of patients with knee osteoarthritis: cluster randomized clinical trial.

PubMed

Carmona-Terés, Victoria; Lumillo-Gutiérrez, Iris; Jodar-Fernández, Lina; Rodriguez-Blanco, Teresa; Moix-Queraltó, Joanna; Pujol-Ribera, Enriqueta; Mas, Xavier; Batlle-Gualda, Enrique; Gobbo-Montoya, Milena; Berenguera, Anna

2015-02-25

The prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement. The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis. Methodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8-12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial. 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions. will receive standard care. quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1. If the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care. ISRCTN57405925. Registred 20 June 2014.

Re-evaluating cost effectiveness of universal meningitis vaccination (Bexsero) in England: modelling study.

PubMed

Christensen, Hannah; Trotter, Caroline L; Hickman, Matthew; Edmunds, W John

2014-10-09

To use mathematical and economic models to predict the epidemiological and economic impact of vaccination with Bexsero, designed to protect against group B meningococcal disease, to help inform vaccine policy in the United Kingdom. Modelling study. England. People aged 0-99. Incremental impact of introductory vaccine strategies simulated with a transmission dynamic model of meningococcal infection and vaccination including potential herd effects. Model parameters included recent evidence on the vaccine characteristics, disease burden, costs of care, litigation costs, and loss of quality of life from disease, including impacts on family and network members. The health impact of vaccination was assessed through cases averted and quality adjusted life years (QALYs) gained. Cases averted and cost per QALY gained through vaccination; programmes were deemed cost effective against a willingness to pay of £20,000 (€25,420, $32,677) per QALY gained from an NHS and personal and social services perspective. In the short term, case reduction is greatest with routine infant immunisation (26.3% of cases averted in the first five years). This strategy could be cost effective at £3 (€3.8, $4.9) a vaccine dose, given several favourable assumptions and the use of a quality of life adjustment factor. If the vaccine can disrupt meningococcal transmission more cases are prevented in the long term with an infant and adolescent combined programme (51.8% after 30 years), which could be cost effective at £4 a vaccine dose. Assuming the vaccine reduces acquisition by 30%, adolescent vaccination alone is the most favourable strategy economically, but takes more than 20 years to substantially reduce the number of cases. Routine infant vaccination is the most effective short term strategy and could be cost effective with a low vaccine price. Critically, if the vaccine reduces carriage acquisition in teenagers, the combination of infant and adolescent vaccination could result in substantial long term reductions in cases and be cost effective with competitive vaccine pricing. © Christensen et al 2014.

Cost-effectiveness of steroid (methylprednisolone) injections versus anaesthetic alone for the treatment of Morton's neuroma: economic evaluation alongside a randomised controlled trial (MortISE trial).

PubMed

Edwards, Rhiannon Tudor; Yeo, Seow Tien; Russell, Daphne; Thomson, Colin E; Beggs, Ian; Gibson, J N Alastair; McMillan, Diane; Martin, Denis J; Russell, Ian T

2015-01-01

Morton's neuroma is a common foot condition affecting health-related quality of life. Though its management frequently includes steroid injections, evidence of cost-effectiveness is sparse. So, we aimed to evaluate whether steroid injection is cost-effective in treating Morton's neuroma compared with anaesthetic injection alone. We undertook incremental cost-effectiveness and cost-utility analyses from the perspective of the National Health Service, alongside a patient-blinded pragmatic randomised trial in hospital-based orthopaedic outpatient clinics in Edinburgh, UK. Of the original randomised sample of 131 participants with Morton's neuroma (including 67 controls), economic analysis focused on 109 (including 55 controls). Both groups received injections guided by ultrasound. We estimated the incremental cost per point improvement in the area under the curve of the Foot Health Thermometer (FHT-AUC) until three months after injection. We also conducted cost-utility analyses using European Quality of life-5 Dimensions-3 Levels (EQ-5D-3L), enhanced by the Foot Health Thermometer (FHT), to estimate utility and thus quality-adjusted life years (QALYs). The unit cost of an ultrasound-guided steroid injection was £149. Over the three months of follow-up, the mean cost of National Health Service resources was £280 for intervention participants and £202 for control participants - a difference of £79 [bootstrapped 95% confidence interval (CI): £18 to £152]. The corresponding estimated incremental cost-effectiveness ratio was £32 per point improvement in the FHT-AUC (bootstrapped 95% CI: £7 to £100). If decision makers value improvement of one point at £100 (the upper limit of this CI), there is 97.5% probability that steroid injection is cost-effective. As EQ-5D-3L seems unresponsive to changes in foot health, we based secondary cost-utility analysis on the FHT-enhanced EQ-5D. This estimated the corresponding incremental cost-effectiveness ratio as £6,400 per QALY. Over the recommended UK threshold, ranging from £20,000 to £30,000 per QALY, there is 80%-85% probability that steroid injection is cost-effective. Steroid injections are effective and cost-effective in relieving foot pain measured by the FHT for three months. However, cost-utility analysis was initially inconclusive because the EQ-5D-3L is less responsive than the FHT to changes in foot health. By using the FHT to enhance the EQ-5D, we inferred that injections yield good value in cost per QALY. Current Controlled Trials ISRCTN13668166.

Cost effectiveness of a community-based crisis intervention program for people bereaved by suicide.

PubMed

Comans, Tracy; Visser, Victoria; Scuffham, Paul

2013-01-01

Postvention services aim to ameliorate distress and reduce future incidences of suicide. The StandBy Response Service is one such service operating in Australia for those bereaved through suicide. Few previous studies have reported estimates or evaluations of the economic impact and outcomes associated with the implementation of bereavement/grief interventions. To estimate the cost-effectiveness of a postvention service from a societal perspective. A Markov model was constructed to estimate the health outcomes, quality-adjusted life years, and associated costs such as medical costs and time off work. Data were obtained from a prospective cross-sectional study comparing previous clients of the StandBy service with a control group of people bereaved by suicide who had not had contact with StandBy. Costs and outcomes were measured at 1 year after suicide bereavement and an incremental cost-effectiveness ratio was calculated. The base case found that the StandBy service dominated usual care with a cost saving from providing the StandBy service of AUS $803 and an increase in quality-adjusted life years of 0.02. Probabilistic sensitivity analysis indicates there is an 81% chance the service would be cost-effective given a range of possible scenarios. Postvention services are a cost-effective strategy and may even be cost-saving if all costs to society from suicide are taken into account.

Individual cognitive stimulation therapy for dementia: a clinical effectiveness and cost-effectiveness pragmatic, multicentre, randomised controlled trial.

PubMed Central

Orgeta, Vasiliki; Leung, Phuong; Yates, Lauren; Kang, Sujin; Hoare, Zoe; Henderson, Catherine; Whitaker, Chris; Burns, Alistair; Knapp, Martin; Leroi, Iracema; Moniz-Cook, Esme D; Pearson, Stephen; Simpson, Stephen; Spector, Aimee; Roberts, Steven; Russell, Ian T; de Waal, Hugo; Woods, Robert T; Orrell, Martin

2015-01-01

BACKGROUND Group cognitive stimulation therapy programmes can benefit cognition and quality of life for people with dementia. Evidence for home-based, carer-led cognitive stimulation interventions is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of carer-delivered individual cognitive stimulation therapy (iCST) for people with dementia and their family carers, compared with treatment as usual (TAU). DESIGN A multicentre, single-blind, randomised controlled trial assessing clinical effectiveness and cost-effectiveness. Assessments were at baseline, 13 weeks and 26 weeks (primary end point). SETTING Participants were recruited through Memory Clinics and Community Mental Health Teams for older people. PARTICIPANTS A total of 356 caregiving dyads were recruited and 273 completed the trial. INTERVENTION iCST consisted of structured cognitive stimulation sessions for people with dementia, completed up to three times weekly over 25 weeks. Family carers were supported to deliver the sessions at home. MAIN OUTCOME MEASURES Primary outcomes for the person with dementia were cognition and quality of life. Secondary outcomes included behavioural and psychological symptoms, activities of daily living, depressive symptoms and relationship quality. The primary outcome for the family carers was mental/physical health (Short Form questionnaire-12 items). Health-related quality of life (European Quality of Life-5 Dimensions), mood symptoms, resilience and relationship quality comprised the secondary outcomes. Costs were estimated from health and social care and societal perspectives. RESULTS There were no differences in any of the primary outcomes for people with dementia between intervention and TAU [cognition: mean difference -0.55, 95% confidence interval (CI) -2.00 to 0.90; p-value = 0.45; self-reported quality of life: mean difference -0.02, 95% CI -1.22 to 0.82; p-value = 0.97 at the 6-month follow-up]. iCST did not improve mental/physical health for carers. People with dementia in the iCST group experienced better relationship quality with their carer, but there was no evidence that iCST improved their activities of daily living, depression or behavioural and psychological symptoms. iCST seemed to improve health-related quality of life for carers but did not benefit carers' resilience or their relationship quality with their relative. Carers conducting more sessions had fewer depressive symptoms. Qualitative data suggested that people with dementia and their carers experienced better communication owing to iCST. Adjusted mean costs were not significantly different between the groups. From the societal perspective, both health gains and cost savings were observed. CONCLUSIONS iCST did not improve cognition or quality of life for people with dementia, or carers' physical and mental health. Costs of the intervention were offset by some reductions in social care and other services. Although there was some evidence of improvement in terms of the caregiving relationship and carers' health-related quality of life, iCST does not appear to deliver clinical benefits for cognition and quality of life for people with dementia. Most people received fewer than the recommended number of iCST sessions. Further research is needed to ascertain the clinical effectiveness of carer-led cognitive stimulation interventions for people with dementia. TRIAL REGISTRATION Current Controlled Trials ISRCTN65945963. FUNDING This project was funded by the National Institute of Health Research (NIHR) Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 64. See the NIHR Journals Library website for further information. PMID:26292178

Cost-effectiveness and cost-utility of beclomethasone/formoterol versus fluticasone propionate/salmeterol in patients with moderate to severe asthma.

PubMed

Gerzeli, Simone; Rognoni, Carla; Quaglini, Silvana; Cavallo, Maria Caterina; Cremonesi, Giovanni; Papi, Alberto

2012-04-01

Asthma is a chronic disease characterized by acute symptomatic episodes with variable severity and duration. Pharmacological asthma management aims to achieve and maintain control without side effects, thus improving quality of life and reducing the economic impact. Recently, a clinical trial showed the non-inferiority of beclomethasone/formoterol (BDP/F) versus fluticasone propionate/salmeterol (FP/S) in adults with moderate to severe persistent asthma. However, this study did not provide evidence on costs and did not quantify quality-of-life parameters. The objective of the present study was to assess the cost effectiveness and cost utility of BDP/F versus FP/S in patients with moderate to severe asthma from the perspective of the Italian National Health Service (NHS). A Markov model (MM) was used, with five health states for the different levels of asthma control: successful control, sub-optimal control, outpatient-managed exacerbation, inpatient-managed exacerbation, and death. Model data were derived from the ICAT SE study and from expert panels. Three outcomes were considered: time spent in successful control state, costs and quality-adjusted life-years (QALYs). The model shows that BDP/F treatment led to a slight increase of weeks in successful control compared with FP/S, with a lower cost. The probabilistic sensitivity analysis highlights that in 64% and 68% of the Monte Carlo simulations, BDP/F outperformed FP/S in terms of weeks in successful control and QALYs. Considering the expected cost of the two strategies, in 90% of simulations BDP/F was the least expensive choice. In particular, BDP/F was cost saving as compared with FP/S in about 63% and 59% of simulations as shown by the cost-utility and cost-effectiveness analysis, respectively. Overall, from the Italian NHS perspective, BDP/F treatment is associated with a reduction in cost and offers a slight increase of effectiveness in terms of weeks spent in successful control and QALYs. © 2012 Adis Data Information BV. All rights reserved.

Cost-effectiveness of extraperitoneal laparoscopic inguinal hernia repair: a randomized comparison with conventional herniorrhaphy. Coala trial group.

PubMed Central

Liem, M S; Halsema, J A; van der Graaf, Y; Schrijvers, A J; van Vroonhoven, T J

1997-01-01

OBJECTIVE: To determine the cost-effectiveness of laparoscopic inguinal hernia repair. SUMMARY BACKGROUND DATA: Laparoscopic inguinal hernia repair seems superior to open techniques with respect to short-term results. An issue yet to be studied in depth remains the cost-effectiveness of the procedure. As part of a multicenter randomized study in which >1000 patients were included, a cost-effectiveness analysis from a societal point of view was performed. METHODS: After informed consent, all resource costs, both in and outside the hospital, for patients between August 1994 and July 1995 were recorded prospectively. Actual costs were calculated in a standardized fashion according to international guidelines. The main measures used for the evaluation of inguinal hernia repair were the number of averted recurrences and quality of life measured with the Short Form 36 questionnaire. RESULTS: Resource costs were recorded for 273 patients, 139 in the open and 134 in the laparoscopic group. Both groups were comparable at baseline. Average total hospital costs were Dfl 1384.91 (standard deviation: Dfl 440.15) for the open repair group and Dfl 2417.24 (standard deviation: Dfl 577.10) for laparoscopic repair, including a disposable kit of Dfl 676. Societal costs, including costs for days of sick leave, were lower for the laparoscopic repair and offset the hospital costs by Dfl 780.83 (75.6%), leaving the laparoscopic repair Dfl 251.50 more expensive (Dfl 4665 versus Dfl 4916.50). At present, the recurrence rate is 2.6% lower after laparoscopic repair. Thus, 38 laparoscopic repairs, costing an additional Dfl 9,557, prevent the occurrence of one recurrent hernia. Quality of life was better after laparoscopic repair. CONCLUSION: A better quality of life in the recovery period and the possibility of replacing parts of the disposable kit with reusable instruments may result in the laparoscopic repair becoming dominantly better--that is, less expensive and more effective from a societal perspective. PMID:9409566

Effectiveness and costs of overland skid trail BMPs

Treesearch

Clay Sawyers; W. Michael Aust; M. Chad Bolding; William A. Lakel III

2012-01-01

Forestry Best Management Practices (BMPs) are designed to protect water quality; however, little data exists comparing the efficacy and costs of different BMP options for skid trail closure. Study objectives were to evaluate erosion control effectiveness and implementation costs of five overland skid trail closure techniques. Closure techniques were: waterbar only (...

Summarized Costs, Placement Of Quality Stars, And Other Online Displays Can Help Consumers Select High-Value Health Plans.

PubMed

Greene, Jessica; Hibbard, Judith H; Sacks, Rebecca M

2016-04-01

Starting in 2017, all state and federal health insurance exchanges will present quality data on health plans in addition to cost information. We analyzed variations in the current design of information on state exchanges to identify presentation approaches that encourage consumers to take quality as well as cost into account when selecting a health plan. Using an online sample of 1,025 adults, we randomly assigned participants to view the same comparative information on health plans, displayed in different ways. We found that consumers were much more likely to select a high-value plan when cost information was summarized instead of detailed, when quality stars were displayed adjacent to cost information, when consumers understood that quality stars signified the quality of medical care, and when high-value plans were highlighted with a check mark or blue ribbon. These approaches, which were equally effective for participants with higher and lower numeracy, can inform the development of future displays of plan information in the exchanges. Project HOPE—The People-to-People Health Foundation, Inc.

Optimizing chronic disease management mega-analysis: economic evaluation.

PubMed

2013-01-01

As Ontario's population ages, chronic diseases are becoming increasingly common. There is growing interest in services and care models designed to optimize the management of chronic disease. To evaluate the cost-effectiveness and expected budget impact of interventions in chronic disease cohorts evaluated as part of the Optimizing Chronic Disease Management mega-analysis. Sector-specific costs, disease incidence, and mortality were calculated for each condition using administrative databases from the Institute for Clinical Evaluative Sciences. Intervention outcomes were based on literature identified in the evidence-based analyses. Quality-of-life and disease prevalence data were obtained from the literature. Analyses were restricted to interventions that showed significant benefit for resource use or mortality from the evidence-based analyses. An Ontario cohort of patients with each chronic disease was constructed and followed over 5 years (2006-2011). A phase-based approach was used to estimate costs across all sectors of the health care system. Utility values identified in the literature and effect estimates for resource use and mortality obtained from the evidence-based analyses were applied to calculate incremental costs and quality-adjusted life-years (QALYs). Given uncertainty about how many patients would benefit from each intervention, a system-wide budget impact was not determined. Instead, the difference in lifetime cost between an individual-administered intervention and no intervention was presented. Of 70 potential cost-effectiveness analyses, 8 met our inclusion criteria. All were found to result in QALY gains and cost savings compared with usual care. The models were robust to the majority of sensitivity analyses undertaken, but due to structural limitations and time constraints, few sensitivity analyses were conducted. Incremental cost savings per patient who received intervention ranged between $15 per diabetic patient with specialized nursing to $10,665 per patient wth congestive heart failure receiving in-home care. Evidence used to inform estimates of effect was often limited to a single trial with limited generalizability across populations, interventions, and health care systems. Because of the low clinical fidelity of health administrative data sets, intermediate clinical outcomes could not be included. Cohort costs included an average of all health care costs and were not restricted to costs associated with the disease. Intervention costs were based on resource use specified in clinical trials. Applying estimates of effect from the evidence-based analyses to real-world resource use resulted in cost savings for all interventions. On the basis of quality-of-life data identified in the literature, all interventions were found to result in a greater QALY gain than usual care would. Implementation of all interventions could offer significant cost reductions. However, this analysis was subject to important limitations. Chronic diseases are the leading cause of death and disability in Ontario. They account for a third of direct health care costs across the province. This study aims to evaluate the cost-effectiveness of health care interventions that might improve the management of chronic diseases. The evaluated interventions led to lower costs and better quality of life than usual care. Offering these options could reduce costs per patient. However, the studies used in this analysis were of medium to very low quality, and the methods had many limitations.

EOS 2D/3D X-ray imaging system: a systematic review and economic evaluation.

PubMed

McKenna, C; Wade, R; Faria, R; Yang, H; Stirk, L; Gummerson, N; Sculpher, M; Woolacott, N

2012-01-01

EOS is a biplane X-ray imaging system manufactured by EOS Imaging (formerly Biospace Med, Paris, France). It uses slot-scanning technology to produce a high-quality image with less irradiation than standard imaging techniques. To determine the clinical effectiveness and cost-effectiveness of EOS two-dimensional (2D)/three-dimensional (3D) X-ray imaging system for the evaluation and monitoring of scoliosis and other relevant orthopaedic conditions. For the systematic review of EOS, electronic databases (MEDLINE, Allied and Complementary Medicine Database, BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, EMBASE, Health Management Information Consortium, Inspec, ISI Science Citation Index and PASCAL), clinical trials registries and the manufacturer's website were searched from 1993 to November 2010. A systematic review of studies comparing EOS with standard X-ray [film, computed radiography (CR) or digital radiography] in any orthopaedic condition was performed. A narrative synthesis was undertaken. A decision-analytic model was developed to assess the cost-effectiveness of EOS in the relevant indications compared with standard X-ray and incorporated the clinical effectiveness of EOS and the adverse effects of radiation. The model incorporated a lifetime horizon to estimate outcomes in terms of quality-adjusted life-years (QALYs) and costs from the perspective of the NHS. Three studies met the inclusion criteria for the review. Two studies compared EOS with film X-ray and one study compared EOS with CR. The three included studies were small and of limited quality. One study used an earlier version of the technology, the Charpak system. Both studies comparing EOS with film X-ray found image quality to be comparable or better with EOS overall. Radiation dose was considerably lower with EOS: ratio of means for posteroanterior spine was 5.2 (13.1 for the study using the Charpak system); ratio of means for the lateral spine was 6.2 (15.1 for the study using the Charpak system). The study comparing EOS with CR found image quality to be comparable or better with EOS. Radiation dose was considerably lower with EOS than CR; ratio of means for the centre of the back was 5.9 and for the proximal lateral point 8.8. The lowest ratio of means was at the nape of the neck, which was 2.9. No other outcomes were assessed in the included studies, such as implications for patient management from the nature and quality of the image. Patient throughput is the major determinant of the cost-effectiveness of EOS. The average cost per procedure of EOS decreases with utilisation. Using estimates of patient throughput at national level from Hospital Episode Statistics data suggests that EOS is not cost-effective for the indications considered. Throughput in the region of 15,100 to 26,500 (corresponding to a workload of 60 to 106 patient appointments per working day) for EOS compared with a throughput of only 7530 for CR (30 patient appointments per working day) is needed to achieve an incremental cost-effectiveness ratio of £30,000 per QALY. EOS can be shown to be cost-effective only when compared with CR if the utilisation for EOS is about double the utilisation of CR. The main limitation of the systematic review of the clinical effectiveness of EOS was the limited number and quality of the data available. In particular, there were no studies assessing the potential health benefits arising from the quality and nature of the image, over and above those associated with reduced radiation exposure. Uncertainty in the model inputs was not fully explored owing to a lack of reporting of standard deviations or confidence intervals in the published literature for most of the parameters. As a result, uncertainty in the cost-effectiveness results was not presented. Radiation dose is considerably lower with EOS than standard X-ray, whereas image quality remains comparable or better with EOS. However, the long-term health benefits from reduced radiation exposure with EOS are very small and there was a lack of data on other potential patient health benefits. The implications of any changes in the quality and nature of the EOS image compared with standard X-ray, for patient health outcomes, needs to be assessed. Given the higher cost of an EOS machine, utilisation is the major determinant of cost-effectiveness. Estimates of patient throughput at national level suggest that EOS is not cost-effective. The National Institute for Health Research Health Technology Assessment programme.

Evidence on the cost and cost-effectiveness of palliative care: a literature review.

PubMed

Smith, Samantha; Brick, Aoife; O'Hara, Sinéad; Normand, Charles

2014-02-01

In the context of limited resources, evidence on costs and cost-effectiveness of alternative methods of delivering health-care services is increasingly important to facilitate appropriate resource allocation. Palliative care services have been expanding worldwide with the aim of improving the experience of patients with terminal illness at the end of life through better symptom control, coordination of care and improved communication between professionals and the patient and family. To present results from a comprehensive literature review of available international evidence on the costs and cost-effectiveness of palliative care interventions in any setting (e.g. hospital-based, home-based and hospice care) over the period 2002-2011. Key bibliographic and review databases were searched. Quality of retrieved papers was assessed against a set of 31 indicators developed for this review. PubMed, EURONHEED, the Applied Social Sciences Index and the Cochrane library of databases. A total of 46 papers met the criteria for inclusion in the review, examining the cost and/or utilisation implications of a palliative care intervention with some form of comparator. The main focus of these studies was on direct costs with little focus on informal care or out-of-pocket costs. The overall quality of the studies is mixed, although a number of cohort studies do undertake multivariate regression analysis. Despite wide variation in study type, characteristic and study quality, there are consistent patterns in the results. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant.

The Effects of Source Water Quality on Drinking Water Treatment Costs: A Review and Synthesis of Empirical Literature - Ecological Economics

EPA Science Inventory

Watershed protection, and associated in situ water quality improvements, has received considerable attention as a means of mitigating health risks and avoiding expenditures at drinking water treatment plants (DWTPs). This study reviews the extant cost function literature linking ...

Achieving the Quality Difference: Making Customers Count

DTIC Science & Technology

1989-06-02

Involve Unions in the Quality Im provem ent Process .................................................... 53 Workshop 11 How to Develop an Effective ...quality and cost effective products and services to the American public. Proper management of this require- ment calls for enlightened approaches. To...potential rewards for all of us are enormous. A culture that is dedicated to quality will result in more profitable companies, more effective public

Costs and Effectiveness of Mindfulness-Based Art Therapy versus Standard Breast Cancer Support Group for Women with Cancer.

PubMed

Prioli, Katherine M; Pizzi, Laura T; Kash, Kathryn M; Newberg, Andrew B; Morlino, Anna Marie; Matthews, Michael J; Monti, Daniel A

2017-09-01

The results of several studies have demonstrated that women and men with a cancer diagnosis benefit from interventions to reduce distress and improve quality of life (QOL). However, little is known about the costs and effectiveness of such interventions. Identifying a stress-reduction program that is low cost and effective is important for payers, employers, and healthcare professionals, as well as for patients with cancer. To evaluate the direct costs and effectiveness of the mindfulness-based art therapy (MBAT) program compared with the cost and effectiveness of a breast cancer support group (BCSG). This economic pilot study evaluated the direct costs and effectiveness of a mindfulness-based intervention for stress reduction in patients with breast cancer who are receiving care versus the cost of a usual care support group used as the comparator. The cost variables for each cohort included the cost of program delivery (ie, staff and supplies), mileage reimbursements, medication costs, and healthcare utilization costs. Effectiveness was measured by a change in quality-adjusted life-year derived from the 36-Item Short-Form Health Survey (SF-36) QOL battery. Overall, the cost for 191 participants in the MBAT intervention group was $992.49 per participant compared with $562.71 per participant for the BCSG intervention. Both interventions achieved a similar change in healthcare utilization based on the SF-36 QOL battery. Although the MBAT intervention was more costly than a BCSG intervention, sensitivity analysis showed that the cost-effectiveness of the MBAT intervention could achieve parity with that of a BCSG if some intervention-related costs, such as staff time and supplies, were reduced. As psychosocial cancer care becomes more refined with time, it will be important to determine the best and most cost-effective interventions for patients with cancer, particularly in light of healthcare reform. Information from this study could help inform payers, employers, and other stakeholders regarding which interventions would be least costly and most effective for patients with cancer.

The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children.

PubMed

Dretzke, J; Frew, E; Davenport, C; Barlow, J; Stewart-Brown, S; Sandercock, J; Bayliss, S; Raftery, J; Hyde, C; Taylor, R

2005-12-01

To assess the clinical and cost-effectiveness of parent training programmes for the treatment of children with conduct disorder (CD) up to the age of 18 years. Electronic databases. For the effectiveness review, relevant studies were identified and evaluated. A quantitative synthesis of behavioural outcomes across trials was also undertaken using two approaches: vote counting and meta-analysis. The economic analysis consisted of reviewing previous economic/cost evaluations of parent training/education programmes and the economic information within sponsor's submissions; carrying out a detailed exploration of costs of parent training/education programmes; and a de novo modelling assessment of the cost-effectiveness of parent training/education programmes. The potential budget impact to the health service of implementing such programmes was also considered. Many of the 37 randomised controlled trials that met the review inclusion and exclusion criteria were assessed as being of poor methodological quality. Studies were clinically heterogeneous in terms of the population, type of parent training/education programme and content, setting, delivery, length and child behaviour outcomes used. Both vote counting and meta-analysis revealed a consistent trend across all studies towards short-term effectiveness (up to 4 months) of parent training/education programmes (compared with control) as measured by a change in child behaviour. Pooled estimates showed a statistically significant improvement on the Eyberg Child Behaviour Inventory frequency and intensity scales, the Dyadic Parent-Child Interaction Coding System and the Child Behaviour Checklist. No studies reported a statistically significant result favouring control over parent training/education programmes. There were few statistically significant differences between different parent training/education programmes, although there was a trend towards more intensive interventions (e.g. longer contact hours, additional child involvement) being more effective. The cost of treating CD is high, with costs incurred by many agencies. A recent study suggested that by age 28, costs for individuals with CD were around 10 times higher than for those with no problems, with a mean cost of 70,019 pounds sterling. Criminality incurs the greatest cost, followed by educational provision, foster and residential care and state benefits. Only a small proportion of these costs fall on health services. Using a 'bottom-up' costing approach, the costs per family of providing parent training/education programmes range from 629 pounds sterling to 3839 pounds sterling depending on the type and style of delivery. Using the conservative assumption that there are no cost savings from treatment, a total lifetime quality of life gain of 0.1 would give a cost per quality-adjusted life-year of between 38,393 pounds sterling and 6288 pounds sterling depending on the type of programme delivery and setting. Parent training/education programmes appear to be an effective and potentially cost-effective therapy for children with CD. However, the relative effectiveness and cost-effectiveness of different models (such as therapy intensity and setting) require further investigation. Further research is required on the impact of parent training/education programmes on the quality of life of children with CD and their parents/carers, as well as on longer term child outcomes.

Multi-criteria analysis for PM10 planning

NASA Astrophysics Data System (ADS)

Pisoni, Enrico; Carnevale, Claudio; Volta, Marialuisa

To implement sound air quality policies, Regulatory Agencies require tools to evaluate outcomes and costs associated to different emission reduction strategies. These tools are even more useful when considering atmospheric PM10 concentrations due to the complex nonlinear processes that affect production and accumulation of the secondary fraction of this pollutant. The approaches presented in the literature (Integrated Assessment Modeling) are mainly cost-benefit and cost-effective analysis. In this work, the formulation of a multi-objective problem to control particulate matter is proposed. The methodology defines: (a) the control objectives (the air quality indicator and the emission reduction cost functions); (b) the decision variables (precursor emission reductions); (c) the problem constraints (maximum feasible technology reductions). The cause-effect relations between air quality indicators and decision variables are identified tuning nonlinear source-receptor models. The multi-objective problem solution provides to the decision maker a set of not-dominated scenarios representing the efficient trade-off between the air quality benefit and the internal costs (emission reduction technology costs). The methodology has been implemented for Northern Italy, often affected by high long-term exposure to PM10. The source-receptor models used in the multi-objective analysis are identified processing long-term simulations of GAMES multiphase modeling system, performed in the framework of CAFE-Citydelta project.

Process, cost, and clinical quality: the initial oral contraceptive visit.

PubMed

McMullen, Michael J; Woolford, Samuel W; Moore, Charles L; Berger, Barry M

2013-01-01

To demonstrate how the analysis of clinical process, cost, and outcomes can identify healthcare improvements that reduce cost without sacrificing quality, using the example of the initial visit associated with oral contraceptive pill use. Cross-sectional study using data collected by HealthMETRICS between 1996 and 2009. Using data collected from 106 sites in 24 states, the unintended pregnancy (UIP) rate, effectiveness of patient education, and unit visit cost were calculated. Staff type providing education and placement of education were recorded. Two-way analysis of variance models were created and tested for significance to identify differences between groups. Sites using nonclinical staff to provide education outside the exam were associated with lower cost, higher education scores, and a UIP rate no different from that of sites using clinical staff. Sites also providing patient education during the physical examination were associated with higher cost, lower education scores, and a UIP rate no lower than that of sites providing education outside of the exam. Through analyzing process, cost, and quality, lower-cost processes that did not reduce clinical quality were identified. This methodology is applicable to other clinical services for identifying low-cost processes that do not result in lower clinical quality. By using nonclinical staff educators to provide education outside of the physical examination, sites could save an average of 32% of the total cost of the visit.

Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

PubMed Central

2014-01-01

Background Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings. Methods A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita. Results Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women’s groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability. Conclusion Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures. Trial registration PROSPERO_ CRD42012003255. PMID:25052536

A pharmacoeconomic approach to assessing the costs and benefits of air quality interventions that improve health: a case study.

PubMed

Lomas, James; Schmitt, Laetitia; Jones, Sally; McGeorge, Maureen; Bates, Elizabeth; Holland, Mike; Cooper, Duncan; Crowther, Richard; Ashmore, Mike; Rojas-Rueda, David; Weatherly, Helen; Richardson, Gerry; Bojke, Laura

2016-06-21

This paper explores the use of pharmacoeconomic methods of valuation to health impacts resulting from exposure to poor air quality. In using such methods, interventions that reduce exposure to poor air quality can be directly compared, in terms of value for money (or cost-effectiveness), with competing demands for finite resources, including other public health interventions. Using results estimated as part of a health impact assessment regarding a West Yorkshire Low Emission Zone strategy, this paper quantifies cost-saving and health-improving implications of transport policy through its impact on air quality. Estimates of health-related quality of life and the National Health Service (NHS)/Personal Social Services (PSS) costs for identified health events were based on data from Leeds and Bradford using peer-reviewed publications or Office for National Statistics releases. Inhabitants of the area within the outer ring roads of Leeds and Bradford. NHS and PSS costs and quality-adjusted life years (QALYs). Averting an all-cause mortality death generates 8.4 QALYs. Each coronary event avoided saves £28 000 in NHS/PSS costs and generates 1.1 QALYs. For every fewer case of childhood asthma, there will be NHS/PSS cost saving of £3000 and a health benefit of 0.9 QALYs. A single term, low birthweight birth avoided saves £2000 in NHS/PSS costs. Preventing a preterm birth saves £24 000 in NHS/PSS costs and generates 1.3 QALYs. A scenario modelled in the West Yorkshire Low Emission Zone Feasibility Study, where pre-EURO 4 buses and HGVs are upgraded to EURO 6 by 2016 generates an annual benefit of £2.08 million and a one-off benefit of £3.3 million compared with a net present value cost of implementation of £6.3 million. Interventions to improve air quality and health should be evaluated and where improvement of population health is the primary objective, cost-effectiveness analysis using a NHS/PSS costs and QALYs framework is an appropriate methodology. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Evaluation of the long-term cost-effectiveness of liraglutide therapy for patients with type 2 diabetes in France.

PubMed

Roussel, Ronan; Martinez, Luc; Vandebrouck, Tom; Douik, Habiba; Emiel, Patrick; Guery, Matthieu; Hunt, Barnaby; Valentine, William J

2016-01-01

The present study aimed to compare the projected long-term clinical and cost implications associated with liraglutide, sitagliptin and glimepiride in patients with type 2 diabetes mellitus failing to achieve glycemic control on metformin monotherapy in France. Clinical input data for the modeling analysis were taken from two randomized, controlled trials (LIRA-DPP4 and LEAD-2). Long-term (patient lifetime) projections of clinical outcomes and direct costs (2013 Euros; €) were made using a validated computer simulation model of type 2 diabetes. Costs were taken from published France-specific sources. Future costs and clinical benefits were discounted at 3% annually. Sensitivity analyses were performed. Liraglutide was associated with an increase in quality-adjusted life expectancy of 0.25 quality-adjusted life years (QALYs) and an increase in mean direct healthcare costs of €2558 per patient compared with sitagliptin. In the comparison with glimepiride, liraglutide was associated with an increase in quality-adjusted life expectancy of 0.23 QALYs and an increase in direct costs of €4695. Based on these estimates, liraglutide was associated with an incremental cost-effectiveness ratio (ICER) of €10,275 per QALY gained vs sitagliptin and €20,709 per QALY gained vs glimepiride in France. Calculated ICERs for both comparisons fell below the commonly quoted willingness-to-pay threshold of €30,000 per QALY gained. Therefore, liraglutide is likely to be cost-effective vs sitagliptin and glimepiride from a healthcare payer perspective in France.

Cost-utility analysis of case management for frail older people: effects of a randomised controlled trial.

PubMed

Sandberg, Magnus; Jakobsson, Ulf; Midlöv, Patrik; Kristensson, Jimmie

2015-12-01

To evaluate the effects of a case management intervention for frail older people (aged 65+ years) by cost and utility. One hundred and fifty-three frail older people living at home were randomly assigned to either an intervention (n = 80) or a control group (n = 73). The 1-year intervention was carried out by nurses and physiotherapists working as case managers, who undertook home visits at least once a month. Differences in costs and quality-adjusted life years (QALYs) based on the health-related quality-of-life instruments EQ-5D and EQ-VAS, and also the incremental cost-effectiveness ratio were investigated. All analyses used the intention-to-treat principle. There were no significant differences between the intervention group and control group for total cost, EQ-5D-based QALY or EQ-VAS-based QALY for the 1-year study. Incremental cost-effectiveness ratio was not conducted because no significant differences were found for either EQ-5D- or EQ-VAS-based QALY, or costs. However, the intervention group had significantly lower levels of informal care and help with instrumental activities of daily living both as costs (3,927 vs. 6,550, p = 0.037) and provided hours (200 vs. 333 hours per year, p = 0.037). The intervention was cost neutral and does not seem to have affected health-related quality of life for the 1-year study, which may be because the follow-up period was too short. The intervention seems to have reduced hours and cost of informal care and help required with instrumental activities of daily living. This suggests that the intervention provides relief to informal caregivers.

Passenger aircraft cabin air quality: trends, effects, societal costs, proposals.

PubMed

Hocking, M B

2000-08-01

As aircraft operators have sought to substantially reduce propulsion fuel cost by flying at higher altitudes, the energy cost of providing adequate outside air for ventilation has increased. This has lead to a significant decrease in the amount of outside air provided to the passenger cabin, partly compensated for by recirculation of filtered cabin air. The purpose of this review paper is to assemble the available measured air quality data and some calculated estimates of the air quality for aircraft passenger cabins to highlight the trend of the last 25 years. The influence of filter efficiencies on air quality, and a few medically documented and anecdotal cases of illness transmission aboard aircraft are discussed. Cost information has been collected from the perspective of both the airlines and passengers. Suggestions for air quality improvement are given which should help to result in a net, multistakeholder savings and improved passenger comfort.

Total quality management in orthodontic practice.

PubMed

Atta, A E

1999-12-01

Quality is the buzz word for the new Millennium. Patients demand it, and we must serve it. Yet one must identify it. Quality is not imaging or public relations; it is a business process. This short article presents quality as a balance of three critical notions: core clinical competence, perceived values that our patients seek and want, and the cost of quality. Customer satisfaction is a variable that must be identified for each practice. In my practice, patients perceive quality as communication and time, be it treatment or waiting time. Time is a value and cost that must be managed effectively. Total quality management is a business function; it involves diagnosis, design, implementation, and measurement of the process, the people, and the service. Kazien is a function that reduces value services, eliminates waste, and manages time and cost in the process. Total quality management is a total commitment for continuous improvement.

Treatment of multiple sclerosis with interferon β: an appraisal of cost-effectiveness and quality of life

PubMed Central

Parkin, D.; Jacoby, A.; McNamee, P.; Miller, P.; Thomas, S.; Bates, D.

2000-01-01

OBJECTIVE—To evaluate the cost-effectiveness of interferon beta-1b (IFβ-1b) for relapsing-remitting multiple sclerosis (RRMS).
METHODS—Construction of a cost-effectiveness model using published data on IFβ-1b effectiveness and the natural history of RRMS, and new data on costs and quality of life (QoL) from a sample of 102patients with RRMS and resident in northern England.
RESULTS—Poorer QoL was found for patients with multiple sclerosis compared with the general population; those who had had a relapse; those with worse states identified by a clinical measure (expanded disability status scale (EDSS)). Relapses have effects over several months. Health state valuations were higher than in the general population. Costs were higher in relapse than remission and for worse EDSS states. IFβ-1b costs were larger than cost savings. The best cost-effectiveness estimate was £28 700 per relapse avoided, which is £809 900 per QALY gained; or £328 300 per QALY gained allowing for effects of progression over 5 years. Estimates were robust to changes in assumptions.
CONCLUSIONS—The impact of multiple sclerosis on QoL is substantial. Future trials should base outcomes measurement on QoL and be better linked to natural history and cost data. IFβ-1b produces important occasional short term QoL gains, but small gains in QALYs overall and large additional costs.

 PMID:10644777

Cost-effectiveness of osteo-odonto keratoprosthesis in Singapore.

PubMed

Dong, Di; Tan, Anna; Mehta, Jodhbir S; Tan, Donald; Finkelstein, Eric Andrew

2014-01-01

To determine the long-term cost-effectiveness of osteo-odonto keratoprosthesis (OOKP) relative to no treatment among patients with end-stage corneal and ocular surface diseases in Singapore. Cost-effectiveness analysis based on data from a retrospective cohort study. From a health system perspective, we calculated the incremental cost-effectiveness ratio of OOKP treatment relative to no treatment over a 30-year horizon, based on data from a cohort of 23 patients who underwent OOKP surgery between 2004 and 2009 at Singapore National Eye Centre. Preoperative and postoperative vision-related quality-of-life values were estimated from patients' visual outcomes and were used to calculate the gain in quality-adjusted life years (QALYs) resulting from OOKP treatment. Unsubsidized costs for surgery, consultations, examinations, medications, follow-up visits, and treatments for complications were retrieved from patients' bills to estimate the total costs associated with OOKP treatment. Sensitivity analyses were conducted to test the robustness of the model. Over a 30-year period, OOKP treatment, compared with no treatment, improved QALYs by 3.991 among patients with end-stage corneal and ocular surface diseases at an additional cost of S$67 840 (US$55 150), resulting in an incremental cost-effectiveness ratio of S$17 000/QALY (US$13 820/QALY). Based on commonly cited cost-effectiveness benchmarks, the OOKP is a cost-effective treatment for patients with end-stage corneal and ocular surface diseases. Copyright © 2014 Elsevier Inc. All rights reserved.

Cost-effectiveness of exercise as a therapy for behavioural and psychological symptoms of dementia within the EVIDEM-E randomised controlled trial.

PubMed

D'Amico, Francesco; Rehill, Amritpal; Knapp, Martin; Lowery, David; Cerga-Pashoja, Arlinda; Griffin, Mark; Iliffe, Steve; Warner, James

2016-06-01

Although available evidence is modest, exercise could be beneficial in reducing behavioural and psychological symptoms of dementia. We aim to evaluate the cost-effectiveness of a dyadic exercise regimen for individuals with dementia and their main carer as therapy for behavioural and psychological symptoms of dementia. Cost-effectiveness analysis within a two-arm, pragmatic, randomised, controlled, single-blind, parallel-group trial of a dyadic exercise regimen (individually tailored, for 20-30 min at least five times per week). The study randomised 131 community-dwelling individuals with dementia and clinically significant behavioural and psychological symptoms with a carer willing and able to participate in the exercise regimen; 52 dyads provided sufficient cost data for analyses. Mean intervention cost was £284 per dyad. For the subsample of 52 dyads, the intervention group had significantly higher mean cost from a societal perspective (mean difference £2728.60, p = 0.05), but costs were not significantly different from a health and social care perspective. The exercise intervention was more cost-effective than treatment as usual from both societal and health and social care perspectives for the measure of behavioural and psychological symptoms (Neuropsychiatric Inventory). It does not appear cost-effective in terms of cost per quality-adjusted life year gain. The exercise intervention has the potential to be seen as cost-effective when considering behavioural and psychological symptoms but did not appear cost-effective when considering quality-adjusted life year gains. Copyright © 2015 John Wiley & Sons, Ltd.

Chronic obstructive pulmonary disease case finding by community pharmacists: a potential cost-effective public health intervention.

PubMed

Wright, David; Twigg, Michael; Thornley, Tracey

2015-02-01

This study aims to pilot a community pharmacy chronic obstructive pulmonary disease (COPD) case finding service in England, estimating costs and effects. Patients potentially at risk of COPD were screened with validated tools. Smoking cessation was offered to all smokers identified as potentially having undiagnosed COPD. Cost and effects of the service were estimated. Twenty-one community pharmacies screened 238 patients over 9 months. One hundred thirty-five patients were identified with potentially undiagnosed COPD; 88 were smokers. Smoking cessation initiation provided a project gain of 38.62 life years, 19.92 quality-adjusted life years and a cost saving of £392.67 per patient screened. COPD case finding by community pharmacists potentially provides cost-savings and improves quality of life. © 2014 The Authors. International Journal of Pharmacy Practice published by John Wiley & Sons Ltd on behalf of Royal Pharmaceutical Society.

Cost-Effectiveness Analysis of Percutaneous Vertebroplasty for Osteoporotic Compression Fractures.

PubMed

Takura, Tomoyuki; Yoshimatsu, Misako; Sugimori, Hiroki; Takizawa, Kenji; Furumatsu, Yoshiyuki; Ikeda, Hirotaka; Kato, Hiroshi; Ogawa, Yukihisa; Hamaguchi, Shingo; Fujikawa, Atsuko; Satoh, Toshihiko; Nakajima, Yasuo

2017-04-01

Single-center, single-arm, prospective time-series study. To assess the cost-effectiveness and improvement in quality of life (QOL) of percutaneous vertebroplasty (PVP). PVP is known to relieve back pain and increase QOL for osteoporotic compression fractures. However, the economic value of PVP has never been evaluated in Japan where universal health care system is adopted. We prospectively followed up 163 patients with acute vertebral osteoporotic compression fractures, 44 males aged 76.4±6.0 years and 119 females aged 76.8±7.1 years, who underwent PVP. To measure health-related QOL and pain during 52 weeks observation, we used the European Quality of Life-5 Dimensions (EQ-5D), the Rolland-Morris Disability Questionnaire (RMD), the 8-item Short-Form health survey (SF-8), and visual analogue scale (VAS). Quality-adjusted life years (QALY) were calculated using the change of health utility of EQ-5D. The direct medical cost was calculated by accounting system of the hospital and Japanese health insurance system. Cost-effectiveness was analyzed using incremental cost-effectiveness ratio (ICER): Δ medical cost/Δ QALY. After PVP, improvement in EQ-5D, RMD, SF-8, and VAS scores were observed. The gain of QALY until 52 weeks was 0.162. The estimated lifetime gain of QALY reached 1.421. The direct medical cost for PVP was ¥286,740 (about 3061 US dollars). Cost-effectiveness analysis using ICER showed that lifetime medical cost for a gain of 1 QALY was ¥201,748 (about 2154 US dollars). Correlations between changes in EQ-5D scores and other parameters such as RMD, SF-8, and VAS were observed during most of the study period, which might support the reliability and applicability to measure health utilities by EQ-5D for osteoporotic compression fractures in Japan as well. PVP may improve QOL and ameliorate pain for acute osteoporotic compression fractures and be cost-effective in Japan.

Cost-effectiveness of a pragmatic structured education intervention for the prevention of type 2 diabetes: economic evaluation of data from the Let's Prevent Diabetes cluster-randomised controlled trial

PubMed Central

Ahrabian, D; Davies, M J; Khunti, K; Yates, T; Gray, A M

2017-01-01

Objectives Prevention of type 2 diabetes mellitus (TD2M) is a priority for healthcare systems. We estimated the cost-effectiveness compared with standard care of a structured education programme (Let's Prevent) targeting lifestyle and behaviour change to prevent progression to T2DM in people with prediabetes. Design Cost-effectiveness analysis alongside randomised controlled trial. Setting 44 general practices in Leicestershire, England. Participants 880 participants with prediabetes randomised to receive either standard care or a 6-hour group structured education programme with follow-up sessions in a primary care setting. Main outcome measure Incremental cost utility from the UK National Health Service (NHS) perspective. Quality of life and resource use measured from baseline and during the 36 months follow-up using the EuroQoL EQ-5D and 15D instruments and an economic questionnaire. Outcomes measured using quality-adjusted life years (QALYs) and healthcare costs calculated in 2012–2013 prices. Results After accounting for clustering and missing data, the intervention group was found to have a net gain of 0.046 (95% CI −0.0171 to 0.109) QALYs over 3 years, adjusted for baseline utility, at an additional cost of £168 (95% CI −395 to 732) per patient compared with the standard care group. The incremental cost-effectiveness ratio is £3643/QALY with an 86% probability of being cost-effective at a willingness to pay threshold of £20 000/QALY. Conclusions The education programme had higher costs and higher quality of life compared with the standard care group. The Let's Prevent programme is very likely to be cost-effective at a willingness to pay threshold of £20 000/QALY gained. Trial registration number ISRCTN80605705. PMID:28069625

Cost-effectiveness of a pragmatic structured education intervention for the prevention of type 2 diabetes: economic evaluation of data from the Let's Prevent Diabetes cluster-randomised controlled trial.

PubMed

Leal, J; Ahrabian, D; Davies, M J; Gray, L J; Khunti, K; Yates, T; Gray, A M

2017-01-09

Prevention of type 2 diabetes mellitus (TD2M) is a priority for healthcare systems. We estimated the cost-effectiveness compared with standard care of a structured education programme (Let's Prevent) targeting lifestyle and behaviour change to prevent progression to T2DM in people with prediabetes. Cost-effectiveness analysis alongside randomised controlled trial. 44 general practices in Leicestershire, England. 880 participants with prediabetes randomised to receive either standard care or a 6-hour group structured education programme with follow-up sessions in a primary care setting. Incremental cost utility from the UK National Health Service (NHS) perspective. Quality of life and resource use measured from baseline and during the 36 months follow-up using the EuroQoL EQ-5D and 15D instruments and an economic questionnaire. Outcomes measured using quality-adjusted life years (QALYs) and healthcare costs calculated in 2012-2013 prices. After accounting for clustering and missing data, the intervention group was found to have a net gain of 0.046 (95% CI -0.0171 to 0.109) QALYs over 3 years, adjusted for baseline utility, at an additional cost of £168 (95% CI -395 to 732) per patient compared with the standard care group. The incremental cost-effectiveness ratio is £3643/QALY with an 86% probability of being cost-effective at a willingness to pay threshold of £20 000/QALY. The education programme had higher costs and higher quality of life compared with the standard care group. The Let's Prevent programme is very likely to be cost-effective at a willingness to pay threshold of £20 000/QALY gained. ISRCTN80605705. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Costs and consequences of automated algorithms versus manual grading for the detection of referable diabetic retinopathy.

PubMed

Scotland, G S; McNamee, P; Fleming, A D; Goatman, K A; Philip, S; Prescott, G J; Sharp, P F; Williams, G J; Wykes, W; Leese, G P; Olson, J A

2010-06-01

To assess the cost-effectiveness of an improved automated grading algorithm for diabetic retinopathy against a previously described algorithm, and in comparison with manual grading. Efficacy of the alternative algorithms was assessed using a reference graded set of images from three screening centres in Scotland (1253 cases with observable/referable retinopathy and 6333 individuals with mild or no retinopathy). Screening outcomes and grading and diagnosis costs were modelled for a cohort of 180 000 people, with prevalence of referable retinopathy at 4%. Algorithm (b), which combines image quality assessment with detection algorithms for microaneurysms (MA), blot haemorrhages and exudates, was compared with a simpler algorithm (a) (using image quality assessment and MA/dot haemorrhage (DH) detection), and the current practice of manual grading. Compared with algorithm (a), algorithm (b) would identify an additional 113 cases of referable retinopathy for an incremental cost of pound 68 per additional case. Compared with manual grading, automated grading would be expected to identify between 54 and 123 fewer referable cases, for a grading cost saving between pound 3834 and pound 1727 per case missed. Extrapolation modelling over a 20-year time horizon suggests manual grading would cost between pound 25,676 and pound 267,115 per additional quality adjusted life year gained. Algorithm (b) is more cost-effective than the algorithm based on quality assessment and MA/DH detection. With respect to the value of introducing automated detection systems into screening programmes, automated grading operates within the recommended national standards in Scotland and is likely to be considered a cost-effective alternative to manual disease/no disease grading.

Economic evaluation of a psychological intervention for high distress cancer patients and carers: costs and quality-adjusted life years.

PubMed

Chatterton, Mary Lou; Chambers, Suzanne; Occhipinti, Stefano; Girgis, Afaf; Dunn, Jeffrey; Carter, Rob; Shih, Sophy; Mihalopoulos, Cathrine

2016-07-01

This study compared the cost-effectiveness of a psychologist-led, individualised cognitive behavioural intervention (PI) to a nurse-led, minimal contact self-management condition for highly distressed cancer patients and carers. This was an economic evaluation conducted alongside a randomised trial of highly distressed adult cancer patients and carers calling cancer helplines. Services used by participants were measured using a resource use questionnaire, and quality-adjusted life years were measured using the assessment of quality of life - eight-dimension - instrument collected through a computer-assisted telephone interview. The base case analysis stratified participants based on the baseline score on the Brief Symptom Inventory. Incremental cost-effectiveness ratio confidence intervals were calculated with a nonparametric bootstrap to reflect sampling uncertainty. The results were subjected to sensitivity analysis by varying unit costs for resource use and the method for handling missing data. No significant differences were found in overall total costs or quality-adjusted life years (QALYs) between intervention groups. Bootstrapped data suggest the PI had a higher probability of lower cost and greater QALYs for both carers and patients with high distress at baseline. For patients with low levels of distress at baseline, the PI had a higher probability of greater QALYs but at additional cost. Sensitivity analysis showed the results were robust. The PI may be cost-effective compared with the nurse-led, minimal contact self-management condition for highly distressed cancer patients and carers. More intensive psychological intervention for patients with greater levels of distress appears warranted. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury.

PubMed

Alali, Aziz S; Naimark, David M J; Wilson, Jefferson R; Fowler, Robert A; Scales, Damon C; Golan, Eyal; Mainprize, Todd G; Ray, Joel G; Nathens, Avery B

2014-10-01

Decompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context. We performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research. Trauma centers in the United States. Base case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury. We compared two treatment strategies: decompressive craniectomy and barbiturate coma. Decompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of $9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is $50,000/quality-adjusted life year and 82% of cases at a threshold of $100,000/quality-adjusted life year. At older age, decompressive craniectomy continued to increase survival but at higher cost (incremental cost-effectiveness ratio = $197,906/quality-adjusted life year at mean age = 85 yr). Based on available evidence, decompressive craniectomy for the treatment of refractory intracranial hypertension following traumatic brain injury provides better value in terms of costs and health gains than barbiturate coma. However, decompressive craniectomy might be less economically attractive for older patients. Further research, particularly on natural history of severe traumatic brain injury patients, is needed to make more informed treatment decisions.

Lack of Cost-Effectiveness Analyses to Address Healthy People 2020 Priority Areas.

PubMed

Neumann, Peter J; Farquhar, Megan; Wilkinson, Colby L; Lowry, Mackenzie; Gold, Marthe

2016-12-01

To examine the extent to which recently published cost-utility analyses (cost-effectiveness analyses using quality-adjusted life-years to measure health benefits) have covered the leading health concerns in the US Department of Health and Human Services Healthy People 2020 report. We examined data in the Tufts Medical Center Cost-Effectiveness Analysis Registry, a database containing 5000 published cost-utility analyses published in the MEDLINE literature through 2014. We focused on US-based cost-utility analyses published from 2011 through 2014 (n = 687). Two reviewers scanned abstracts and met for a consensus on categorization of cost-utility analyses that addressed the specific priorities listed in the 12 Healthy People 2020 areas (n = 120). Although 7.3% of recently published cost-utility analyses addressed key clinical preventive services, only about 2% of recently published cost-utility analyses covered each of the following Healthy People 2020 topics: reproductive and sexual health, nutrition/physical activity/obesity, maternal and infant health, and tobacco. Fewer than 1% addressed priorities such as injuries and violence, mental health or substance abuse, environmental quality, and oral health. Few cost-utility analyses have addressed Healthy People 2020 priority areas.

Cost-effectiveness analysis of IDegLira versus basal-bolus insulin for patients with type 2 diabetes in the Slovak health system

PubMed Central

Psota, Marek; Psenkova, Maria Bucek; Racekova, Natalia; Ramirez de Arellano, Antonio; Vandebrouck, Tom; Hunt, Barnaby

2017-01-01

Aims To investigate the cost-effectiveness of once-daily insulin degludec/liraglutide (IDegLira) versus basal-bolus therapy in patients with type 2 diabetes not meeting glycemic targets on basal insulin from a healthcare payer perspective in Slovakia. Methods Long-term clinical and economic outcomes for patients receiving IDegLira and basal-bolus therapy were estimated using the IMS CORE Diabetes Model based on a published pooled analysis of patient-level data. Results IDegLira was associated with an improvement in quality-adjusted life expectancy of 0.29 quality-adjusted life years (QALYs) compared with basal-bolus therapy. The average lifetime cost per patient in the IDegLira arm was EUR 2,449 higher than in the basal-bolus therapy arm. Increased treatment costs with IDegLira were partially offset by cost savings from avoided diabetes-related complications. IDegLira was highly cost-effective versus basal-bolus therapy with an incremental cost-effectiveness ratio of EUR 8,590 per QALY gained, which is well below the cost-effectiveness threshold set by the law in Slovakia. Conclusion IDegLira is cost-effective in Slovakia, providing a simple option for intensification of basal insulin therapy without increasing the risk of hypoglycemia or weight gain and with fewer daily injections than a basal-bolus regimen. PMID:29276398

Cost-effectiveness of homograft heart valve replacement surgery: an introductory study.

PubMed

Yaghoubi, Mohsen; Aghayan, Hamid Reza; Arjmand, Babak; Emami-Razavi, Seyed Hassan

2011-05-01

The clinical effectiveness of heart valve replacement surgery has been well documented. Mechanical and homograft valves are used routinely for replacement of damaged heart valves. Homograft valves are produced in our country but we import the mechanical valves. To our knowledge the cost-effectiveness of homograft valve has not been assessed. The objective of the present study was to compare the cost-effectiveness of homograft valve replacement with mechanical valve replacement surgery. Our samples were selected from 200 patients that underwent homograft and mechanical heart valve replacement surgery in Imam-Khomeini hospital (2000-2005). In each group we enrolled 30 patients. Quality of life was measured using the SF-36 questionnaire and utility was measured in quality-adjusted life years (QALYs). For each group we calculated the price of heart valve and hospitalization charges. Finally the cost-effectiveness of each treatment modalities were summarized as costs per QALYs gained. Forty male and twenty female participated in the study. The mean score of quality of life was 66.06 (SD = 9.22) in homograft group and 57.85 (SD = 11.30) in mechanical group (P < 0.05). The mean QALYs gained in homograft group was 0.67 more than mechanical group. The incremental cost-effectiveness ratio (ICER) revealed a cost savings of 1,067 US$ for each QALY gained in homograft group. Despite limitation of this introductory study, we concluded that homograft valve replacement was more effective and less expensive than mechanical valve. These findings can encourage healthcare managers and policy makers to support the production of homograft valves and allocate more recourse for developing such activities.

Cost-Effectiveness Analysis of Radiation Therapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

PubMed

Rodin, Danielle; Caulley, Lisa; Burger, Emily; Kim, Jane; Johnson-Obaseki, Stephanie; Palma, David; Louie, Alexander V; Hansen, Aaron; O'Sullivan, Brian

2017-03-15

The objective of this study was to compare the cost-effectiveness of transoral robotic surgery (TORS) versus the standard treatment modality for oropharyngeal squamous cell carcinoma (OPSCC), radiation therapy (RT), in a subset of patients with early-stage OPSCC. We developed a microsimulation state-transition model associated with RT and TORS for patients with clinically staged T1N0M0 to T2N1M0 OPSCC. Transition probabilities, utilities, and costs for each health state were estimated from recently published data and discounted by 3% annually over a lifetime time horizon. Model outcomes included lifetime costs (in 2014 US dollars), health benefits (quality-adjusted life-years [QALYs]), and cost-effectiveness ratios from a societal perspective. Under base-case assumptions, TORS was associated with modest gains in QALYs. RT yielded 10.43 QALYs at a cost of $123,410 per patient, whereas TORS yielded 11.10 QALYs at a cost of $178,480. This resulted in an incremental cost-effectiveness ratio of $82,190/QALY gained. The incremental cost-effectiveness ratio was most sensitive to the need for adjuvant therapy, cost of late toxicity, age at diagnosis, disease state utilities, and discount rate. Accounting for joint parameter uncertainty, RT had a higher probability of demonstrating a cost-effective profile compared with TORS, at 54% compared with 46%. By use of standard benchmarks for cost-effectiveness in the United States, TORS may be a cost-effective alternative for the subset of patients with early-stage OPSCC but demonstrates considerable sensitivity to assumptions around quality of life. Copyright © 2016. Published by Elsevier Inc.

Cost-effectiveness analysis for a tele-based health coaching program for chronic disease in primary care.

PubMed

Oksman, Erja; Linna, Miika; Hörhammer, Iiris; Lammintakanen, Johanna; Talja, Martti

2017-02-15

The burden of chronic disease and multimorbidity is rapidly increasing. Self-management support interventions are effective in reduce cost, especially when targeted at a single disease group; however, economical evidence of such complex interventions remains scarce. The objective of this study was to evaluate a cost-effectiveness analysis of a tele-based health-coaching intervention among patients with type 2 diabetes (T2D), coronary artery disease (CAD) and congestive heart failure (CHF). A total of 1570 patients were blindly randomized to intervention (n = 970) and control (n = 470) groups. The intervention group received monthly individual health coaching by telephone from a specially trained nurse for 12-months in addition to routine social and healthcare. Patients in the control group received routine social and health care. Quality of life was assessed at the beginning of the intervention and follow-up measurements were made after 12 months health coaching. The cost included all direct health-care costs supplemented with home care and nursing home-care costs in social care. Utility was based on a Health Related Quality of Life (HRQoL) measurement (15D instrument), and cost effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). The cost-effectiveness of health coaching was highest in the T2D group (ICER €20,000 per Quality-Adjusted Life Years [QALY]). The ICER for the CAD group was more modest (€40,278 per QALY), and in the CHF group, costs increased with no marked effect on QoL. Probabilistic sensitivity analysis indicated that at the societal willingness to pay threshold of €50,000 per QALY, the probability of health coaching being cost effective was 55% in the whole study group. The cost effectiveness of health coaching may vary substantially across patient groups, and thus interventions should be targeted at selected subgroups of chronically ill. Based on the results of this study, health coaching improved the QoL of T2D and CAD patients with moderate costs. However, the results are grounded on a short follow-up period, and more evidence is needed to evaluate the long-term outcomes of health-coaching programs. NCT00552903 [Prospectively registered, registration date 1 st November 2007, last updated 3 rd February 2009].

Pain, Itch, Quality of Life, and Costs after Herpes Zoster.

PubMed

van Wijck, Albert J M; Aerssens, Yannick R

2017-07-01

Herpes zoster (HZ) and postherpetic neuralgia are known to have a profound effect on the patient's quality of life, but the incidence and severity of itch and its relation with pain and quality of life in the long term are still relatively unknown. The aim of this study was to measure the presence and severity of pain and itch and impact on quality of life in patients over 50 years old with HZ. We enrolled 661 patients with HZ in this 12-month observational study. Patient data were collected via a web-based questionnaire. Outcomes were pain, itch, burden of illness, impact on patient's daily life, impact on quality of life, and healthcare costs. At inclusion, 94% of patients reported any pain, 74.3% significant pain, and 26% severe pain. After 3 months, 18.8% of patients suffered from postherpetic neuralgia. At inclusion, 70.8% of patients had any itch, 39.2% significant itch, and 7.3% severe itch. The occurrence of pain increases costs and has a high impact on the quality of life, lowering EQ-5D scores by an average of 18%. In contrast, itch has little effect on the quality of life. Pain and itch are highly prevalent months after HZ. Pain caused by HZ has a large impact on quality of life, burden of illness, impact on daily life, and health care costs for these patients. The impact of itch on quality of life is relatively small. © 2016 World Institute of Pain.

Cost-Effectiveness of Collaborative Care for the Treatment of Depressive Disorders in Primary Care: A Systematic Review

PubMed Central

Grochtdreis, Thomas; Brettschneider, Christian; Wegener, Annemarie; Watzke, Birgit; Riedel-Heller, Steffi; Härter, Martin; König, Hans-Helmut

2015-01-01

Background For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care. Purpose To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care. Methods A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration’s tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP). Results In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562. Conclusion Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year. PMID:25993034

The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics.

PubMed

Sathe, Neha A; Nocon, Robert S; Hughes, Brenna; Peek, Monica E; Chin, Marshall H; Huang, Elbert S

2016-01-01

Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs. The costs over the first four years-from June 2009 through May 2013-of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago's South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases. Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%-88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5-$51), Year 2 ($11-$84), Year 3 ($4-$57), to Year 4 ($4-$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4. Cost experiences of QICs in clinics were di- verse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care.

Cost-effectiveness of population based BRCA testing with varying Ashkenazi Jewish ancestry.

PubMed

Manchanda, Ranjit; Patel, Shreeya; Antoniou, Antonis C; Levy-Lahad, Ephrat; Turnbull, Clare; Evans, D Gareth; Hopper, John L; Macinnis, Robert J; Menon, Usha; Jacobs, Ian; Legood, Rosa

2017-11-01

Population-based BRCA1/BRCA2 testing has been found to be cost-effective compared with family history-based testing in Ashkenazi-Jewish women were >30 years old with 4 Ashkenazi-Jewish grandparents. However, individuals may have 1, 2, or 3 Ashkenazi-Jewish grandparents, and cost-effectiveness data are lacking at these lower BRCA prevalence estimates. We present an updated cost-effectiveness analysis of population BRCA1/BRCA2 testing for women with 1, 2, and 3 Ashkenazi-Jewish grandparents. Decision analysis model. Lifetime costs and effects of population and family history-based testing were compared with the use of a decision analysis model. 56% BRCA carriers are missed by family history criteria alone. Analyses were conducted for United Kingdom and United States populations. Model parameters were obtained from the Genetic Cancer Prediction through Population Screening trial and published literature. Model parameters and BRCA population prevalence for individuals with 3, 2, or 1 Ashkenazi-Jewish grandparent were adjusted for the relative frequency of BRCA mutations in the Ashkenazi-Jewish and general populations. Incremental cost-effectiveness ratios were calculated for all Ashkenazi-Jewish grandparent scenarios. Costs, along with outcomes, were discounted at 3.5%. The time horizon of the analysis is "life-time," and perspective is "payer." Probabilistic sensitivity analysis evaluated model uncertainty. Population testing for BRCA mutations is cost-saving in Ashkenazi-Jewish women with 2, 3, or 4 grandparents (22-33 days life-gained) in the United Kingdom and 1, 2, 3, or 4 grandparents (12-26 days life-gained) in the United States populations, respectively. It is also extremely cost-effective in women in the United Kingdom with just 1 Ashkenazi-Jewish grandparent with an incremental cost-effectiveness ratio of £863 per quality-adjusted life-years and 15 days life gained. Results show that population-testing remains cost-effective at the £20,000-30000 per quality-adjusted life-years and $100,000 per quality-adjusted life-years willingness-to-pay thresholds for all 4 Ashkenazi-Jewish grandparent scenarios, with ≥95% simulations found to be cost-effective on probabilistic sensitivity analysis. Population-testing remains cost-effective in the absence of reduction in breast cancer risk from oophorectomy and at lower risk-reducing mastectomy (13%) or risk-reducing salpingo-oophorectomy (20%) rates. Population testing for BRCA mutations with varying levels of Ashkenazi-Jewish ancestry is cost-effective in the United Kingdom and the United States. These results support population testing in Ashkenazi-Jewish women with 1-4 Ashkenazi-Jewish grandparent ancestry. Copyright © 2017 Elsevier Inc. All rights reserved.

Cost-effectiveness analysis of a low-dose contraceptive levonorgestrel intrauterine system in Sweden.

PubMed

Henry, Nathaniel; Hawes, Charlie; Lowin, Julia; Lekander, Ingrid; Filonenko, Anna; Kallner, Helena K

2015-08-01

To evaluate the cost-effectiveness of a novel intrauterine system, levonorgestrel intrauterine system 13.5 mg vs. oral contraception, in women at risk of unintended pregnancy. Cost-effectiveness model using efficacy and discontinuation data from published articles. Societal perspective including direct and indirect costs. Women at risk of unintended pregnancy using reversible contraception. An economic analysis was conducted by modeling the different health states of women using contraception over a 3-year period. Typical use efficacy rates from published articles were used to determine unintended pregnancy events. Discontinuation rates were used to account for method switching. Cost-effectiveness was evaluated in terms of the incremental cost per unintended pregnancy avoided. In addition, the incremental cost per quality-adjusted life-year was calculated. Levonorgestrel intrauterine system 13.5 mg generated costs savings of € 311,000 in a cohort of 1000 women aged 15-44 years. In addition, there were fewer unintended pregnancies (55 vs. 294) compared with women using oral contraception. Levonorgestrel intrauterine system 13.5 mg is a cost-effective method when compared with oral contraception. A shift in contraceptive use from oral contraception to long-acting reversible contraception methods could result in fewer unintended pregnancies, quality-adjusted life-year gains, as well as cost savings. © 2015 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).

Is the Venner-PneuX Endotracheal Tube System A Cost-Effective Option For Post Cardiac Surgery Care?

PubMed

Andronis, Lazaros; Oppong, Raymond A; Manga, Na'ngono; Senanayake, Eshan; Gopal, Shameer; Charman, Susan; Giri, Ramesh; Luckraz, Heyman

2018-04-27

Ventilator-associated pneumonia (VAP) is common and costly. In a recent randomized controlled trial, the Venner-PneuX (VPX) endotracheal tube system was found to be superior to standard endotracheal tubes (SET) in preventing VAP. However, VPX is considerably more expensive. We evaluated the costs and benefits of VPX to determine whether replacing SET with VPX is a cost-effective option for intensive care units. We developed a decision analytic model to compare intubation with VPX or SET for patients requiring mechanical ventilation post cardiac surgery. The model was populated with existing evidence on costs, effectiveness and quality of life. Cost-effectiveness and cost-utility analyses were conducted from an NHS hospital perspective. Uncertainty was assessed through deterministic and probabilistic sensitivity analyses. Compared to SET, VPX is associated with an expected cost saving of £738 per patient. VPX led to a small increase in quality-adjusted life years (QALYs), indicating that the device is overall less costly and more effective than SET. The probability of VPX being cost-effective at £30,000 per QALY is 97%. VPX would cease to be cost-effective if (i) it led to a risk reduction smaller than 0.02 compared to SET, (ii) the acquisition cost of VPX was as high as £890 or, (iii) the cost of treating a case of VAP was lower than £1,450. VPX resulted in improved outcomes and savings which far offset the cost of the device, suggesting that replacing SET with VPX is overall beneficial. Findings were robust to extreme values of key parameters. Copyright © 2018. Published by Elsevier Inc.

Portable electronic vision enhancement systems in comparison with optical magnifiers for near vision activities: an economic evaluation alongside a randomized crossover trial.

PubMed

Bray, Nathan; Brand, Andrew; Taylor, John; Hoare, Zoe; Dickinson, Christine; Edwards, Rhiannon T

2017-08-01

To determine the incremental cost-effectiveness of portable electronic vision enhancement system (p-EVES) devices compared with optical low vision aids (LVAs), for improving near vision visual function, quality of life and well-being of people with a visual impairment. An AB/BA randomized crossover trial design was used. Eighty-two participants completed the study. Participants were current users of optical LVAs who had not tried a p-EVES device before and had a stable visual impairment. The trial intervention was the addition of a p-EVES device to the participant's existing optical LVA(s) for 2 months, and the control intervention was optical LVA use only, for 2 months. Cost-effectiveness and cost-utility analyses were conducted from a societal perspective. The mean cost of the p-EVES intervention was £448. Carer costs were £30 (4.46 hr) less for the p-EVES intervention compared with the LVA only control. The mean difference in total costs was £417. Bootstrapping gave an incremental cost-effectiveness ratio (ICER) of £736 (95% CI £481 to £1525) for a 7% improvement in near vision visual function. Cost per quality-adjusted life year (QALY) ranged from £56 991 (lower 95% CI = £19 801) to £66 490 (lower 95% CI = £23 055). Sensitivity analysis varying the commercial price of the p-EVES device reduced ICERs by up to 75%, with cost per QALYs falling below £30 000. Portable electronic vision enhancement system (p-EVES) devices are likely to be a cost-effective use of healthcare resources for improving near vision visual function, but this does not translate into cost-effective improvements in quality of life, capability or well-being. © 2016 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation and European Association for Vision & Eye Research.

Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement

PubMed Central

Reynolds, Matthew R.; Lei, Yang; Wang, Kaijun; Chinnakondepalli, Khaja; Vilain, Katherine A.; Magnuson, Elizabeth A.; Galper, Benjamin Z.; Meduri, Christopher U.; Arnold, Suzanne V.; Baron, Suzanne J.; Reardon, Michael J.; Adams, David H.; Popma, Jeffrey J.; Cohen, David J.

2016-01-01

Background Prior studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system. Objectives The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk. Methods We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk pivotal trial. Empirical data regarding survival and quality of life (QOL) over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S. perspective. Results Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month QOL. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years (QALYs; 0.41 life-years [LYs]) with 3% discounting. Lifetime incremental cost-effectiveness ratios (ICERs) were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ~$1,650 would lead to an ICER <$50,000/QALY gained. Conclusions In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S. standards. With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. PMID:26764063

The economics of improving medication adherence in osteoporosis: validation and application of a simulation model.

PubMed

Patrick, Amanda R; Schousboe, John T; Losina, Elena; Solomon, Daniel H

2011-09-01

Adherence to osteoporosis treatment is low. Although new therapies and behavioral interventions may improve medication adherence, questions are likely to arise regarding their cost-effectiveness. Our objectives were to develop and validate a model to simulate the clinical outcomes and costs arising from various osteoporosis medication adherence patterns among women initiating bisphosphonate treatment and to estimate the cost-effectiveness of a hypothetical intervention to improve medication adherence. We constructed a computer simulation using estimates of fracture rates, bisphosphonate treatment effects, costs, and utilities for health states drawn from the published literature. Probabilities of transitioning on and off treatment were estimated from administrative claims data. Patients were women initiating bisphosphonate therapy from the general community. We evaluated a hypothetical behavioral intervention to improve medication adherence. Changes in 10-yr fracture rates and incremental cost-effectiveness ratios were evaluated. A hypothetical intervention with a one-time cost of $250 and reducing bisphosphonate discontinuation by 30% had an incremental cost-effectiveness ratio (ICER) of $29,571 per quality-adjusted life year in 65-yr-old women initiating bisphosphonates. Although the ICER depended on patient age, intervention effectiveness, and intervention cost, the ICERs were less than $50,000 per quality-adjusted life year for the majority of intervention cost and effectiveness scenarios evaluated. Results were sensitive to bisphosphonate cost and effectiveness and assumptions about the rate at which intervention and treatment effects decline over time. Our results suggests that behavioral interventions to improve osteoporosis medication adherence will likely have favorable ICERs if their efficacy can be sustained.

Cost-effectiveness and Budget Impact of Routine Use of Fractional Exhaled Nitric Oxide Monitoring for the Management of Adult Asthma Patients in Spain.

PubMed

Sabatelli, L; Seppälä, U; Sastre, J; Crater, G

Fractional exhaled nitric oxide (FeNO) is a marker for type 2 airway inflammation. The objective of this study was to evaluate the cost-effectiveness and budget impact of FeNO monitoring for management of adult asthma in Spain. A cost-effectiveness analysis model was used to evaluate the effect on costs of adding FeNO monitoring to asthma management. Over a 1-year period, the model estimated the incremental cost per quality-adjusted life year and incremental number of exacerbations avoided when FeNO monitoring was added to standard guideline-driven asthma care compared with standard care alone. Univariate and multivariate sensitivity analyses were applied to explore uncertainty in the model. A budget impact model was used to examine the impact of FeNO monitoring on primary care costs across the Spanish health system. The results showed that adding FeNO to standard asthma care saved €62.53 per patient-year in the adult population and improved quality-adjusted life years by 0.026 per patient-year. The budget impact analysis revealed a potential net yearly saving of €129 million if FeNO monitoring had been used in primary care settings in Spain. The present economic model shows that adding FeNO to the treatment algorithm can considerably reduce costs and improve quality of life when used to manage asthma in combination with current treatment guidelines.

At-Home Versus In-Clinic INR Monitoring: A Cost-Utility Analysis from The Home INR Study (THINRS).

PubMed

Phibbs, Ciaran S; Love, Sean R; Jacobson, Alan K; Edson, Robert; Su, Pon; Uyeda, Lauren; Matchar, David B

2016-09-01

Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. PST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, -$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.

Technology and surgery. Dilemma of the gimmick, true advances, and cost effectiveness.

PubMed

Traverso, L W

1996-02-01

The key to evaluating a procedure in regard to a true advance versus a gimmick is to determine its value. This can be done only by physicians cognizant of a disease process. The value is determined by assessing a procedure's utilization, outcomes, and costs. Utilization allows early treatment and avoids neglected disease. Therefore, the appropriateness of the utilization can be determined only by an outcome study. An outcome study is another term for quality assessment. Outcomes deal with morbidity, mortality, and also the long- and short-term effects of the procedure on the disease. Overall, an increase of quality in a global perspective decreases the costs of the procedure to the health care community. Costs must remain secondary to outcomes. An attempt to decrease costs directly is a maneuver that, when applied by nonmedical individuals, will most likely decrease quality. When the quality can be maintained (as assessed only by a practitioner), then a decrease in global costs will increase value. The concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system must learn in our ever-challenging medical environment. Is a new procedure a gimmick or a true advance? The decision is made jointly by the stakeholders in our health care system--the patient, provider, payer, employer, and industry. If the procedure does not receive negative votes, then its adoption is almost assured. Comparing two procedures through these perspectives ultimately allows us to determine the potential for new procedures. A procedure not adopted through this method could be called a gimmick.

Cost-effectiveness analysis of prophylactic cervical cancer vaccination in Japanese women.

PubMed

Konno, Ryo; Sasagawa, Toshiyuki; Fukuda, Takashi; Van Kriekinge, Georges; Demarteau, Nadia

2010-04-01

The incidence of cervical cancer (CC) is high in Japan and is further increasing among women younger than 30 years. This burden could be reduced by the implementation of a CC vaccine, but its cost-effectiveness is unknown. We quantified the clinical impact and assessed the cost-effectiveness of adding CC vaccination at age 12 to the current screening in place in Japan with a lifetime Markov model adapted to the Japanese setting. Transition probabilities and utility values were obtained from public databases. Direct costs for treatment and screening were estimated using Japanese medical fees. Annual costs and benefits were discounted at 3%. Sensitivity analyses were conducted on the age at vaccination, the vaccine characteristics, the discount rates, the proportion of human papillomavirus types 16/18 in cancer, and the screening coverage. Vaccinating a 12-year-old cohort was predicted to reduce CC incidence and deaths from CC by 73%. These clinical effects were associated with an incremental cost-effectiveness ratio of yen1.8 million per quality-adjusted life year gained. The incremental cost-effectiveness ratio of vaccinating all 10- to 45-year-old women was yen2.8 million per quality-adjusted life year, still below the threshold value. The implementation of a CC vaccination in Japan could reduce the CC burden in a very cost-effective manner for women up to 45 years.

Economic evaluation of Varicella vaccination: results of a systematic review

PubMed Central

Unim, Brigid; Saulle, Rosella; Boccalini, Sara; Taddei, Cristina; Ceccherini, Vega; Boccia, Antonio; Bonanni, Paolo; La Torre, Giuseppe

2013-01-01

Introduction: The aim of the present study is to review the economic burden of varicella disease and the benefit of universal varicella vaccination in different settings pending its implementation in all Italian regions. Materials and Methods: Research was conducted using PubMed, Scopus and ISI databases. Score quality and data extraction were performed for all included studies. Results: Twenty-three articles met the criteria: 15 cost-effectiveness, 8 cost-benefit and one cost-utility analysis. Varicella vaccination could save the society from €637,762 (infant strategy) to 53 million annually (combined infant and adolescent strategy). The median and the mean quality scores resulted in 91.8% and 85.4% respectively; 11 studies were considered of high quality and 12 of low quality. Discussion: The studies are favorable to the introduction of universal varicella vaccination in Italy, being cost saving and having a positive impact on morbidity. The quality score of the studies varied greatly: recent analyses were of comparable quality to older studies. PMID:23823940

THE COST-EFFECTIVENESS OF COGNITIVE BEHAVIOR THERAPY FOR BORDERLINE PERSONALITY DISORDER: RESULTS FROM THE BOSCOT TRIAL

PubMed Central

Palmer, Stephen; Davidson, Kate; Tyrer, Peter; Gumley, Andrew; Tata, Philip; Norrie, John; Murray, Heather; Seivewright, Helen

2007-01-01

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (−£689), although this group also reported a lower quality of life (−0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study. PMID:17032159

A model to estimate the cost effectiveness of the indoorenvironment improvements in office work

DOE Office of Scientific and Technical Information (OSTI.GOV)

Seppanen, Olli; Fisk, William J.

2004-06-01

Deteriorated indoor climate is commonly related to increases in sick building syndrome symptoms, respiratory illnesses, sick leave, reduced comfort and losses in productivity. The cost of deteriorated indoor climate for the society is high. Some calculations show that the cost is higher than the heating energy costs of the same buildings. Also building-level calculations have shown that many measures taken to improve indoor air quality and climate are cost-effective when the potential monetary savings resulting from an improved indoor climate are included as benefits gained. As an initial step towards systemizing these building level calculations we have developed a conceptualmore » model to estimate the cost-effectiveness of various measures. The model shows the links between the improvements in the indoor environment and the following potential financial benefits: reduced medical care cost, reduced sick leave, better performance of work, lower turn over of employees, and lower cost of building maintenance due to fewer complaints about indoor air quality and climate. The pathways to these potential benefits from changes in building technology and practices go via several human responses to the indoor environment such as infectious diseases, allergies and asthma, sick building syndrome symptoms, perceived air quality, and thermal environment. The model also includes the annual cost of investments, operation costs, and cost savings of improved indoor climate. The conceptual model illustrates how various factors are linked to each other. SBS symptoms are probably the most commonly assessed health responses in IEQ studies and have been linked to several characteristics of buildings and IEQ. While the available evidence indicates that SBS symptoms can affect these outcomes and suspects that such a linkage exists, at present we can not quantify the relationships sufficiently for cost-benefit modeling. New research and analyses of existing data to quantify the financial importance of SBS symptoms would enable more widespread consideration of the effects of IEQ in cost benefit calculations.« less

Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis.

PubMed

Łaski, Dariusz; Hać, Stanisław; Marek, Iwona; Kobiela, Jarosław; Kostro, Justyna; Adrych, Krystian; Śledziński, Zbigniew

2018-03-01

Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland - NFZ) and the national insurance system (Poland - ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment. The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung's duct within the Polish health care system. In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality. From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months.

Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis

PubMed Central

Hać, Stanisław; Marek, Iwona; Kobiela, Jarosław; Kostro, Justyna; Adrych, Krystian; Śledziński, Zbigniew

2018-01-01

Introduction Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland – NFZ) and the national insurance system (Poland – ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment. Aim The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung’s duct within the Polish health care system. Results In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality. Conclusions From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months. PMID:29643954

Cost-effectiveness of a classification-based system for sub-acute and chronic low back pain.

PubMed

Apeldoorn, Adri T; Bosmans, Judith E; Ostelo, Raymond W; de Vet, Henrica C W; van Tulder, Maurits W

2012-07-01

Identifying relevant subgroups in patients with low back pain (LBP) is considered important to guide physical therapy practice and to improve outcomes. The aim of the present study was to assess the cost-effectiveness of a modified version of Delitto's classification-based treatment approach compared with usual physical therapy care in patients with sub-acute and chronic LBP with 1 year follow-up. All patients were classified using the modified version of Delitto's classification-based system and then randomly assigned to receive either classification-based treatment or usual physical therapy care. The main clinical outcomes measured were; global perceived effect, intensity of pain, functional disability and quality of life. Costs were measured from a societal perspective. Multiple imputations were used for missing data. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated. In total, 156 patients were included. The outcome analyses showed a significantly better outcome on global perceived effect favoring the classification-based approach, and no differences between the groups on pain, disability and quality-adjusted life-years. Mean total societal costs for the classification-based group were 2,287, and for the usual physical therapy care group 2,020. The difference was 266 (95% CI -720 to 1,612) and not statistically significant. Cost-effectiveness analyses showed that the classification-based approach was not cost-effective in comparison with usual physical therapy care for any clinical outcome measure. The classification-based treatment approach as used in this study was not cost-effective in comparison with usual physical therapy care in a population of patients with sub-acute and chronic LBP.

Cost Effectiveness of Candida Polymerase Chain Reaction Detection and Empirical Antifungal Treatment among Patients with Suspected Fungal Peritonitis in the Intensive Care Unit.

PubMed

Pagès, Arnaud; Iriart, Xavier; Molinier, Laurent; Georges, Bernard; Berry, Antoine; Massip, Patrice; Juillard-Condat, Blandine

2017-12-01

Mortality from intra-abdominal candidiasis in intensive care units (ICUs) is high. It takes many days for peritoneal-fluid fungal culture to become positive, and the recommended empirical antifungal therapy involves excessive costs. Polymerase chain reaction (PCR) should produce results more rapidly than fungal culture. To perform a cost-effectiveness analysis of the combination of several diagnostic and therapeutic strategies to manage Candida peritonitis in non-neutropenic adult patients in ICUs. We constructed a decision tree model to evaluate the cost effectiveness. Cost and effectiveness were taken into account in a 1-year time horizon and from the French National Health Insurance perspective. Six strategies were compared: fluconazole or echinocandin as an empirical therapy, plus diagnosis by fungal culture or detection by PCR of all Candida species, or use of PCR to detect most fluconazole-resistant Candida species (i.e., Candida krusei and Candida glabrata). The use of fluconazole empirical treatment and PCR to detect all Candida species is more cost effective than using fluconazole empirical treatment without PCR (incremental cost-effectiveness ratio of €40,055/quality-adjusted life-year). Empirical treatment with echinocandin plus PCR to detect C. krusei and C. glabrata is the most effective strategy, but has an incremental cost-effectiveness ratio of €93,776/quality-adjusted life-year. If the cost of echinocandin decreases, then strategies involving PCR plus empirical echinocandin become more cost-effective. Detection by PCR of all Candida species and of most fluconazole-resistant Candida species could improve the cost-effectiveness of fluconazole and echinocandin given to non-neutropenic patients with suspected peritoneal candidiasis in ICUs. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Treatments for Metastatic Prostate Cancer (mPC): A Review of Costing Evidence.

PubMed

Norum, Jan; Nieder, Carsten

2017-12-01

Prostate cancer (PC) is the most common cancer in Western countries. More than one third of PC patients develop metastatic disease, and the 5-year expected survival in distant disease is about 35%. During the last few years, new treatments have been launched for metastatic castrate-resistant prostate cancer (mCRPC). We aimed to review the current literature on health economic analysis on the treatment of metastatic prostate cancer (mPC), compare the studies, summarize the findings and make the results available to administrators and decision makers. A systematic literature search was done for economic evaluations (cost-minimization, cost-effectiveness, cost-utility, cost-of-illness, cost-of-drug, and cost-benefit analyses). We employed the PubMed ® search engine and searched for publications published between 2012 and 2016. The terms used were "prostate cancer", "metastatic" and "cost". An initial screening of all headlines was performed, selected abstracts were analysed, and finally the full papers investigated. Study characteristics, treatment and comparator, country, type of evaluation, perspective, year of value, time horizon, efficacy data, discount rate, total costs and sensitivity analysis were analysed. The quality was assessed using the Quality of Health Economic Studies (QHES) instrument. A total of 227 publications were detected and screened, 58 selected for full-text assessment and 31 included in the final analyses. Despite the significant international literature on the treatment of mCRPC, there were only 15 studies focusing on cost-effectiveness analysis (CEA). Medical treatment constituted two thirds of the selected studies. Significant costs in the treatment of mCRPC were disclosed. In the pre-docetaxel setting, both abiraterone acetate (AA) and enzalutamide were concluded beyond accepted cost/quality-adjusted life year limits. In the docetaxel refractory setting, most studies concluded that enzalutamide was cost-effective and superior to AA. In most studies, cabazitaxel was not recommended, because of high cost. Looking at bone-targeting drugs, generic zoledronic acid (ZA) was recommended. External beam radiotherapy (EBRT) was analysed in three studies, and single fraction radiotherapy was concluded to be cost saving. Radium-223 was documented as beneficial, but costly. The quality of the studies was generally good, but sensitivity analyses, discounting and the measurement of health outcomes were present in less than two thirds of the selected studies. The treatment of mCRPC was associated with significant cost. In the post-docetaxel setting, single fraction radiotherapy and enzalutamide were considered cost-effective in most studies. Generic ZA was the recommended bone-targeting therapy.

Extending the cost-benefit model of thermoregulation: high-temperature environments.

PubMed

Vickers, Mathew; Manicom, Carryn; Schwarzkopf, Lin

2011-04-01

The classic cost-benefit model of ectothermic thermoregulation compares energetic costs and benefits, providing a critical framework for understanding this process (Huey and Slatkin 1976 ). It considers the case where environmental temperature (T(e)) is less than the selected temperature of the organism (T(sel)), and it predicts that, to minimize increasing energetic costs of thermoregulation as habitat thermal quality declines, thermoregulatory effort should decrease until the lizard thermoconforms. We extended this model to include the case where T(e) exceeds T(sel), and we redefine costs and benefits in terms of fitness to include effects of body temperature (T(b)) on performance and survival. Our extended model predicts that lizards will increase thermoregulatory effort as habitat thermal quality declines, gaining the fitness benefits of optimal T(b) and maximizing the net benefit of activity. Further, to offset the disproportionately high fitness costs of high T(e) compared with low T(e), we predicted that lizards would thermoregulate more effectively at high values of T(e) than at low ones. We tested our predictions on three sympatric skink species (Carlia rostralis, Carlia rubrigularis, and Carlia storri) in hot savanna woodlands and found that thermoregulatory effort increased as thermal quality declined and that lizards thermoregulated most effectively at high values of T(e).

Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis.

PubMed

Kaambwa, Billingsley; Bryan, Stirling; Jowett, Sue; Mant, Jonathan; Bray, Emma P; Hobbs, F D Richard; Holder, Roger; Jones, Miren I; Little, Paul; Williams, Bryan; McManus, Richard J

2014-12-01

Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective. A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management. In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women. Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources. © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Watchful waiting with periodic liver biopsy versus immediate empirical therapy for histologically mild chronic hepatitis C. A cost-effectiveness analysis.

PubMed

Wong, J B; Koff, R S

2000-11-07

Not all patients with histologically mild chronic hepatitis C progress to cirrhosis. To compare no antiviral treatment, periodic liver biopsy with subsequent antiviral treatment for moderate hepatitis or cirrhosis, and immediate antiviral therapy. Cost-effectiveness analysis. Clinical trial data and published studies. Hepatitis C virus-infected patients with histologically mild hepatitis. Lifetime. Societal. Immediate combination antiviral treatment or biopsy every 3 years plus combination antiviral therapy for moderate hepatitis or cirrhosis. Life expectancy, quality-adjusted life expectancy, and costs. Over 20 years, biopsy every 3 years with treatment of moderate hepatitis would avoid treatment in 50% of the cohort and would result in an 18% likelihood of cirrhosis compared with 16% for immediate treatment and 27% for no antiviral therapy. Immediate antiviral treatment should increase life expectancy by 1.0 quality-adjusted life-year compared with biopsy management. Over an average lifetime, biopsy management would lead to six liver biopsies costing $6200; immediate antiviral treatment would cost $5100 less than biopsy management because of savings related to biopsy and prevention of future hepatitis C-related morbidity. Immediate therapy was cost-effective compared with biopsy management and had a cost-effectiveness ratio of $7000 compared with no antiviral therapy. When age, sex, genotype, and estimates of histologic progression or compliance with follow-up are varied, immediate therapy should result in an increase of at least 0. 8 quality-adjusted life-year compared with biopsy management. For histologically mild chronic hepatitis C, initial combination treatment compared with periodic liver biopsy should reduce the future risk for cirrhosis, prolong life, and be cost-effective.

Economic Evaluation Plan (EEP) for A Very Early Rehabilitation Trial (AVERT): An international trial to compare the costs and cost-effectiveness of commencing out of bed standing and walking training (very early mobilization) within 24 h of stroke onset with usual stroke unit care.

PubMed

Sheppard, Lauren; Dewey, Helen; Bernhardt, Julie; Collier, Janice M; Ellery, Fiona; Churilov, Leonid; Tay-Teo, Kiu; Wu, Olivia; Moodie, Marj

2016-06-01

A key objective of A Very Early Rehabilitation Trial is to determine if the intervention, very early mobilisation following stroke, is cost-effective. Resource use data were collected to enable an economic evaluation to be undertaken and a plan for the main economic analyses was written prior to the completion of follow up data collection. To report methods used to collect resource use data, pre-specify the main economic evaluation analyses and report other intended exploratory analyses of resource use data. Recruitment to the trial has been completed. A total of 2,104 participants from 56 stroke units across three geographic regions participated in the trial. Resource use data were collected prospectively alongside the trial using standardised tools. The primary economic evaluation method is a cost-effectiveness analysis to compare resource use over 12 months with health outcomes of the intervention measured against a usual care comparator. A cost-utility analysis is also intended. The primary outcome in the cost-effectiveness analysis will be favourable outcome (modified Rankin Scale score 0-2) at 12 months. Cost-utility analysis will use health-related quality of life, reported as quality-adjusted life years gained over a 12 month period, as measured by the modified Rankin Scale and the Assessment of Quality of Life. Outcomes of the economic evaluation analysis will inform the cost-effectiveness of very early mobilisation following stroke when compared to usual care. The exploratory analysis will report patterns of resource use in the first year following stroke. © 2016 World Stroke Organization.

Cost-effectiveness of implementing computed tomography screening for lung cancer in Taiwan.

PubMed

Yang, Szu-Chun; Lai, Wu-Wei; Lin, Chien-Chung; Su, Wu-Chou; Ku, Li-Jung; Hwang, Jing-Shiang; Wang, Jung-Der

2017-06-01

A screening program for lung cancer requires more empirical evidence. Based on the experience of the National Lung Screening Trial (NLST), we developed a method to adjust lead-time bias and quality-of-life changes for estimating the cost-effectiveness of implementing computed tomography (CT) screening in Taiwan. The target population was high-risk (≥30 pack-years) smokers between 55 and 75 years of age. From a nation-wide, 13-year follow-up cohort, we estimated quality-adjusted life expectancy (QALE), loss-of-QALE, and lifetime healthcare expenditures per case of lung cancer stratified by pathology and stage. Cumulative stage distributions for CT-screening and no-screening were assumed equal to those for CT-screening and radiography-screening in the NLST to estimate the savings of loss-of-QALE and additional costs of lifetime healthcare expenditures after CT screening. Costs attributable to screen-negative subjects, false-positive cases and radiation-induced lung cancer were included to obtain the incremental cost-effectiveness ratio from the public payer's perspective. The incremental costs were US$22,755 per person. After dividing this by savings of loss-of-QALE (1.16 quality-adjusted life year (QALY)), the incremental cost-effectiveness ratio was US$19,683 per QALY. This ratio would fall to US$10,947 per QALY if the stage distribution for CT-screening was the same as that of screen-detected cancers in the NELSON trial. Low-dose CT screening for lung cancer among high-risk smokers would be cost-effective in Taiwan. As only about 5% of our women are smokers, future research is necessary to identify the high-risk groups among non-smokers and increase the coverage. Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.

A randomised controlled equivalence trial to determine the effectiveness and cost-utility of manual chest physiotherapy techniques in the management of exacerbations of chronic obstructive pulmonary disease (MATREX).

PubMed

Cross, J; Elender, F; Barton, G; Clark, A; Shepstone, L; Blyth, A; Bachmann, M; Harvey, I

2010-05-01

To estimate the effect, if any, of manual chest physiotherapy (MCP) administered to patients hospitalised with chronic obstructive pulmonary disease (COPD) exacerbation on both disease-specific and generic health-related quality of life. To compare the health service costs for those receiving and not receiving MCP. A pragmatic, randomised controlled trial powered for equivalence. It was not possible to blind participants, clinicians or research staff to study arm allocation during the intervention. Four UK hospitals in Norwich, Great Yarmouth, King's Lynn and Liverpool. 526 participants aged 34-91 years were recruited between November 2005 and April 2008; of these, 372 provided evaluable data for the primary outcome. All persons hospitalised with COPD exacerbation and evidence of sputum production on examination were eligible for the trial providing there were no contraindications to performing MCP. Participants were allocated to either MCP or no MCP on an intention-to-treat (ITT) basis. However, active cycle of breathing techniques (ACBT) was used in both arms. Participants allocated to the intervention were guided to perform ACBT while the physiotherapist delivered MCP. Participants allocated to the control arm received instruction on ACBT only. The primary outcome was COPD-specific quality of life, measured using the St George's Respiratory Questionnaire (SGRQ) at 6 months post randomisation. The European Quality of Life-5 Dimensions (EQ-5D) questionnaire was used to calculate the quality-adjusted life-year (QALY) gain associated with MCP compared with no MCP. Secondary physiological outcome measures were also used. Of the 526 participants, 261 were allocated to MCP and 264 to control, with 186 participants evaluable in each arm. ITT analyses indicated no significant difference at 6 months post randomisation in total SGRQ score [adjusted effect size (no MCP - MCP) 0.03 (95% confidence interval, CI -0.14 to 0.19)], SGRQ symptom score [adjusted effect size 0.04 (95% CI -0.15 to 0.23)], SGRQ activity score [adjusted effect size -0.02 (95% CI -0.20 to 0.16)] or SGRQ impact score [adjusted effect size 0.02 (95% CI -0.15 to 0.18)]. The imputed ITT and per-protocol results were similar. No significant differences were observed in any of the outcome measures or subgroup analyses. Compared with no MCP, employing MCP was associated with a slight loss in quality of life (0.001 QALY loss) but lower health service costs (cost saving of 410.79 pounds). Based on these estimates, at a cost-effectiveness threshold of lambda = 20,000 pounds per QALY, MCP would constitute a cost-effective use of resources (net benefit = 376.14 pounds). There was, however, a high level of uncertainty associated with these results and it is possible that the lower health service costs could have been due to other factors. In terms of longer-term quality of life the use of MCP did not appear to affect outcome. However, this does not mean that MCP is of no therapeutic value to patients with COPD in specific circumstances. Although the cost-effectiveness analysis suggested that its use was cost-effective, much uncertainty was associated with this finding and it would be difficult to justify providing MCP therapy on the basis of cost-effectiveness alone. Future research should include evaluation of MCP for patients with COPD producing high volumes of sputum, and an evaluation of the effectiveness of ACBT in COPD exacerbation. Current Controlled Trials ISRCTN13825248.

A cost-effectiveness comparisons of adult spinal deformity surgery in the United States and Japan.

PubMed

Yagi, Mitsuru; Ames, Christopher P; Keefe, Malla; Hosogane, Naobumi; Smith, Justin S; Shaffrey, Christopher I; Schwab, Frank; Lafage, Virginie; Shay Bess, R; Matsumoto, Morio; Watanabe, Kota

2018-03-01

Information about the cost-effectiveness of surgical procedures for adult spinal deformity (ASD) is critical for providing appropriate treatments for these patients. The purposes of this study were to compare the direct cost and cost-effectiveness of surgery for ASD in the United States (US) and Japan (JP). Retrospective analysis of 76 US and 76 JP patients receiving surgery for ASD with ≥2-year follow-up was identified. Data analysis included preoperative and postoperative demographic, radiographic, health-related quality of life (HRQOL), and direct cost for surgery. An incremental cost-effectiveness ratio (ICER) was determined using cost/quality-adjusted life years (QALY). The cost/QALY was calculated from the 2-year cost and HRQOL data. JP exhibited worse baseline spinopelvic alignment than the US (pelvic incidence and lumbar lordosis: 35.4° vs 22.7°, p < 0.01). The US had more three-column osteotomies (50 vs 16%), and shorter hospital stay (7.9 vs 22.7 days) (p < 0.05). The US demonstrated worse postoperative ODI (41.3 vs. 33.9%) and greater revision surgery rate (40 vs 10%) (p < 0.05). Due to the high initial cost and revision frequency, the US had greater total cost ($92,133 vs. $49,647) and cost/QALY ($511,840 vs. $225,668) at 2-year follow-up (p < 0.05). Retrospective analysis comparing the direct costs and cost-effectiveness of ASD surgery in the US vs JP demonstrated that the total direct costs and cost/QALY were substantially higher in the US than JP. Variations in patient cohort, healthcare costs, revision frequencies, and HRQOL improvement influenced the cost/QALY differential between these countries.

An economic evaluation of the ketogenic diet versus care as usual in children and adolescents with intractable epilepsy: An interim analysis.

PubMed

de Kinderen, Reina J A; Lambrechts, Danielle A J E; Wijnen, Ben F M; Postulart, Debby; Aldenkamp, Albert P; Majoie, Marian H J M; Evers, Silvia M A A

2016-01-01

To gain insight into the cost-effectiveness of the ketogenic (KD) diet compared with care as usual (CAU) in children and adolescents with intractable epilepsy, we conducted an economic evaluation from a societal perspective, alongside a randomized controlled trial. Participants from a tertiary epilepsy center were randomized into KD (intervention) group or CAU (control) group. Seizure frequency, quality adjusted life years (QALYs), health care costs, production losses of parents and patient, and family costs were assessed at baseline and during a 4-month study period and compared between the intervention and control groups. The incremental cost-effectiveness ratios (ICERs) (i.e., cost per QALY and cost per responder), and cost-effectiveness acceptability curves (CEACs) were calculated and presented. In total, 48 children were included in the analyses of this study (26 KD group). At 4 months, 50% of the participants in the KD group had a seizure reduction ≥50% from baseline, compared with 18.2 of the participants in the CAU group. The mean costs per patient in the CAU group were €15,245 compared to €20,986 per patient in the KD group, resulting in an ICER of €18,044 per responder. We failed, however, to measure any benefits in terms of QALYs and therefore, the cost per QALY rise high above any acceptable ceiling ratio. It might be that the quality of life instruments used in this study were not sufficiently sensitive to detect changes, or it might be that being a clinical responder is not sufficient to improve a patient's quality of life. Univariate and multivariate sensitivity analyses and nonparametric bootstrapping were performed and demonstrated the robustness of our results. The results show that the KD reduces seizure frequency. The study did not find any improvements in quality of life and, therefore, unfavorable cost per QALY ratio's resulted. Wiley Periodicals, Inc. © 2015 International League Against Epilepsy.

Economic evaluations of eHealth technologies: A systematic review.

PubMed

Sanyal, Chiranjeev; Stolee, Paul; Juzwishin, Don; Husereau, Don

2018-01-01

Innovations in eHealth technologies have the potential to help older adults live independently, maintain their quality of life, and to reduce their health system dependency and health care expenditure. The objective of this study was to systematically review and appraise the quality of cost-effectiveness or utility studies assessing eHealth technologies in study populations involving older adults. We systematically searched multiple databases (MEDLINE, EMBASE, CINAHL, NHS EED, and PsycINFO) for peer-reviewed studies published in English from 2000 to 2016 that examined cost-effectiveness (or utility) of eHealth technologies. The reporting quality of included studies was appraised using the Consolidated Health Economic Evaluation Reporting Standards statement. Eleven full text articles met the inclusion criteria representing public and private health care systems. eHealth technologies evaluated by these studies includes computerized decision support system, a web-based physical activity intervention, internet-delivered cognitive behavioral therapy, telecare, and telehealth. Overall, the reporting quality of the studies included in the review was varied. Most studies demonstrated efficacy and cost-effectiveness of an intervention using a randomized control trial and statistical modeling, respectively. This review found limited information on the feasibility of adopting these technologies based on economic and organizational factors. This review identified few economic evaluations of eHealth technologies that included older adults. The quality of the current evidence is limited and further research is warranted to clearly demonstrate the long-term cost-effectiveness of eHealth technologies from the health care system and societal perspectives.

Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program.

PubMed

Morphew, Tricia; Scott, Lyne; Li, Marilyn; Galant, Stanley P; Wong, Webster; Garcia Lloret, Maria I; Jones, Felita; Bollinger, Mary Elizabeth; Jones, Craig A

2013-08-01

Underserved populations have limited access to care. Improved access to effective asthma care potentially improves quality of life and reduces costs associated with emergency department (ED) visits. The purpose of this study is to examine return on investment (ROI) for the Breathmobile Program in terms of improved patient quality-adjusted life years saved and reduced costs attributed to preventable ED visits for 2010, with extrapolation to previous years of operation. It also examines cost-benefit related to reduced morbidity (ED visits, hospitalizations, and school absenteeism) for new patients to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits). This is a retrospective analysis of data for 15,986 pediatric patients, covering 88,865 visits, participating in 4 Southern California Breathmobile Programs (November 16, 1995-December 31, 2010). The ROI calculation expressed the cost-benefit ratio as the net benefits (ED costs avoided+relative value of quality-adjusted life years saved) over the per annum program costs (∼$500,000 per mobile). The ROI across the 4 California programs in 2010 was $6.73 per dollar invested. Annual estimated emergency costs avoided in the 4 regions were $2,541,639. The relative value of quality-adjusted life years saved was $24,381,000. For patients new to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits), total annual morbidity costs avoided per patient were $1395. This study suggests that mobile health care is a cost-effective strategy to deliver medical care to underserved populations, consistent with the Triple Aims of Therapy.

Is There Evidence of Cost Benefits of Electronic Medical Records, Standards, or Interoperability in Hospital Information Systems? Overview of Systematic Reviews

PubMed Central

2017-01-01

Background Electronic health (eHealth) interventions may improve the quality of care by providing timely, accessible information about one patient or an entire population. Electronic patient care information forms the nucleus of computerized health information systems. However, interoperability among systems depends on the adoption of information standards. Additionally, investing in technology systems requires cost-effectiveness studies to ensure the sustainability of processes for stakeholders. Objective The objective of this study was to assess cost-effectiveness of the use of electronically available inpatient data systems, health information exchange, or standards to support interoperability among systems. Methods An overview of systematic reviews was conducted, assessing the MEDLINE, Cochrane Library, LILACS, and IEEE Library databases to identify relevant studies published through February 2016. The search was supplemented by citations from the selected papers. The primary outcome sought the cost-effectiveness, and the secondary outcome was the impact on quality of care. Independent reviewers selected studies, and disagreement was resolved by consensus. The quality of the included studies was evaluated using a measurement tool to assess systematic reviews (AMSTAR). Results The primary search identified 286 papers, and two papers were manually included. A total of 211 were systematic reviews. From the 20 studies that were selected after screening the title and abstract, 14 were deemed ineligible, and six met the inclusion criteria. The interventions did not show a measurable effect on cost-effectiveness. Despite the limited number of studies, the heterogeneity of electronic systems reported, and the types of intervention in hospital routines, it was possible to identify some preliminary benefits in quality of care. Hospital information systems, along with information sharing, had the potential to improve clinical practice by reducing staff errors or incidents, improving automated harm detection, monitoring infections more effectively, and enhancing the continuity of care during physician handoffs. Conclusions This review identified some benefits in the quality of care but did not provide evidence that the implementation of eHealth interventions had a measurable impact on cost-effectiveness in hospital settings. However, further evidence is needed to infer the impact of standards adoption or interoperability in cost benefits of health care; this in turn requires further research. PMID:28851681

Is There Evidence of Cost Benefits of Electronic Medical Records, Standards, or Interoperability in Hospital Information Systems? Overview of Systematic Reviews.

PubMed

Reis, Zilma Silveira Nogueira; Maia, Thais Abreu; Marcolino, Milena Soriano; Becerra-Posada, Francisco; Novillo-Ortiz, David; Ribeiro, Antonio Luiz Pinho

2017-08-29

Electronic health (eHealth) interventions may improve the quality of care by providing timely, accessible information about one patient or an entire population. Electronic patient care information forms the nucleus of computerized health information systems. However, interoperability among systems depends on the adoption of information standards. Additionally, investing in technology systems requires cost-effectiveness studies to ensure the sustainability of processes for stakeholders. The objective of this study was to assess cost-effectiveness of the use of electronically available inpatient data systems, health information exchange, or standards to support interoperability among systems. An overview of systematic reviews was conducted, assessing the MEDLINE, Cochrane Library, LILACS, and IEEE Library databases to identify relevant studies published through February 2016. The search was supplemented by citations from the selected papers. The primary outcome sought the cost-effectiveness, and the secondary outcome was the impact on quality of care. Independent reviewers selected studies, and disagreement was resolved by consensus. The quality of the included studies was evaluated using a measurement tool to assess systematic reviews (AMSTAR). The primary search identified 286 papers, and two papers were manually included. A total of 211 were systematic reviews. From the 20 studies that were selected after screening the title and abstract, 14 were deemed ineligible, and six met the inclusion criteria. The interventions did not show a measurable effect on cost-effectiveness. Despite the limited number of studies, the heterogeneity of electronic systems reported, and the types of intervention in hospital routines, it was possible to identify some preliminary benefits in quality of care. Hospital information systems, along with information sharing, had the potential to improve clinical practice by reducing staff errors or incidents, improving automated harm detection, monitoring infections more effectively, and enhancing the continuity of care during physician handoffs. This review identified some benefits in the quality of care but did not provide evidence that the implementation of eHealth interventions had a measurable impact on cost-effectiveness in hospital settings. However, further evidence is needed to infer the impact of standards adoption or interoperability in cost benefits of health care; this in turn requires further research. ©Zilma Silveira Nogueira Reis, Thais Abreu Maia, Milena Soriano Marcolino, Francisco Becerra-Posada, David Novillo-Ortiz, Antonio Luiz Pinho Ribeiro. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 29.08.2017.

TEAM-HF Cost-Effectiveness Model: A Web-Based Program Designed to Evaluate the Cost-Effectiveness of Disease Management Programs in Heart Failure

PubMed Central

Reed, Shelby D.; Neilson, Matthew P.; Gardner, Matthew; Li, Yanhong; Briggs, Andrew H.; Polsky, Daniel E.; Graham, Felicia L.; Bowers, Margaret T.; Paul, Sara C.; Granger, Bradi B.; Schulman, Kevin A.; Whellan, David J.; Riegel, Barbara; Levy, Wayne C.

2015-01-01

Background Heart failure disease management programs can influence medical resource use and quality-adjusted survival. Because projecting long-term costs and survival is challenging, a consistent and valid approach to extrapolating short-term outcomes would be valuable. Methods We developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Cost-Effectiveness Model, a Web-based simulation tool designed to integrate data on demographic, clinical, and laboratory characteristics, use of evidence-based medications, and costs to generate predicted outcomes. Survival projections are based on a modified Seattle Heart Failure Model (SHFM). Projections of resource use and quality of life are modeled using relationships with time-varying SHFM scores. The model can be used to evaluate parallel-group and single-cohort designs and hypothetical programs. Simulations consist of 10,000 pairs of virtual cohorts used to generate estimates of resource use, costs, survival, and incremental cost-effectiveness ratios from user inputs. Results The model demonstrated acceptable internal and external validity in replicating resource use, costs, and survival estimates from 3 clinical trials. Simulations to evaluate the cost-effectiveness of heart failure disease management programs across 3 scenarios demonstrate how the model can be used to design a program in which short-term improvements in functioning and use of evidence-based treatments are sufficient to demonstrate good long-term value to the health care system. Conclusion The TEAM-HF Cost-Effectiveness Model provides researchers and providers with a tool for conducting long-term cost-effectiveness analyses of disease management programs in heart failure. PMID:26542504

Cost-Effectiveness Analysis of Acupuncture, Counselling and Usual Care in Treating Patients with Depression: The Results of the ACUDep Trial

PubMed Central

Spackman, Eldon; Richmond, Stewart; Sculpher, Mark; Bland, Martin; Brealey, Stephen; Gabe, Rhian; Hopton, Ann; Keding, Ada; Lansdown, Harriet; Perren, Sara; Torgerson, David; Watt, Ian; MacPherson, Hugh

2014-01-01

Background New evidence on the clinical effectiveness of acupuncture plus usual care (acupuncture) and counselling plus usual care (counselling) for patients with depression suggests the need to investigate the health-related quality of life and costs of these treatments to understand whether they should be considered a good use of limited health resources. Methods and Findings The cost-effectiveness analyses are based on the Acupuncture, Counselling or Usual care for Depression (ACUDep) trial results. Statistical analyses demonstrate a difference in mean quality adjusted life years (QALYs) and suggest differences in mean costs which are mainly due to the price of the interventions. Probabilistic sensitivity analysis is used to express decision uncertainty. Acupuncture and counselling are found to have higher mean QALYs and costs than usual care. In the base case analysis acupuncture has an incremental cost-effectiveness ratio (ICER) of £4,560 per additional QALY and is cost-effective with a probability of 0.62 at a cost-effectiveness threshold of £20,000 per QALY. Counselling compared with acupuncture is more effective and more costly with an ICER of £71,757 and a probability of being cost-effective of 0.36. A scenario analysis of counselling versus usual care, excluding acupuncture as a comparator, results in an ICER of £7,935 and a probability of 0.91. Conclusions Acupuncture is cost-effective compared with counselling or usual care alone, although the ranking of counselling and acupuncture depends on the relative cost of delivering these interventions. For patients in whom acupuncture is unavailable or perhaps inappropriate, counselling has an ICER less than most cost-effectiveness thresholds. However, further research is needed to determine the most cost-effective treatment pathways for depressed patients when the full range of available interventions is considered. PMID:25426637

Can Families Eat Better Without Spending More? Improving Diet Quality Does Not Increase Diet Cost in a Randomized Clinical Trial among Youth with Type 1 Diabetes and Their Parents.

PubMed

Nansel, Tonja R; Lipsky, Leah M; Eisenberg, Miriam H; Liu, Aiyi; Mehta, Sanjeev N; Laffel, Lori M B

2016-11-01

Although cost is a frequently cited barrier to healthful eating, limited prospective data exist. To examine the association of diet cost with diet quality change. An 18-month randomized clinical trial evaluated a dietary intervention. Youth with type 1 diabetes duration ≥1 year, age 8.0 to 16.9 years, receiving care at an outpatient tertiary diabetes center in Boston, MA, participated along with a parent from 2010 to 2013 (N=136). Eighty-two percent of participants were from middle- to upper-income households. The family-based behavioral intervention targeted intake of whole plant foods. Diet quality as indicated by the Healthy Eating Index 2005 (HEI-2005) (which measures conformance to the 2005 Dietary Guidelines for Americans) and whole plant food density (cup or ounce equivalents per 1,000 kcal target food groups) were calculated from 3-day food records of youth and parent dietary intake at six and four time points, respectively. Food prices were obtained from two online supermarkets common to the study location. Daily diet cost was calculated by summing prices of reported foods. Random effects models estimated treatment group differences in time-varying diet cost. Separate models for youth and parent adjusted for covariates examined associations of time-varying change in diet quality with change in diet cost. There was no treatment effect on time-varying diet cost for either youth (β -.49, 95% CI -1.07 to 0.08; P=0.10) or parents (β .24, 95% CI -1.61 to 2.08; P=0.80). In addition, time-varying change in diet quality indicators was not associated with time-varying change in diet cost for youth. Among parents, a 1-cup or 1-oz equivalent increase in whole plant food density was associated with a $0.63/day lower diet cost (β -.63, 95% CI -1.20 to -0.05; P=0.03). Improved diet quality was not accompanied by greater cost for youth with type 1 diabetes and their parents participating in a randomized clinical trial. Findings challenge the prevailing assumption that improving diet quality necessitates greater cost. Copyright © 2016 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Can families eat better without spending more? Improving diet quality does not increase diet cost in a randomized clinical trial among youth with type 1 diabetes and their parents

PubMed Central

Lipsky, Leah M.; Eisenberg, Miriam H.; Liu, Aiyi; Mehta, Sanjeev N.; Laffel, Lori M.B.

2016-01-01

Background Although cost is a frequently cited barrier to healthful eating, limited prospective data exist. Objective This study examined the association of diet cost with diet quality change. Design An 18-month randomized clinical trial evaluated a dietary intervention. Participants/setting Youth with type 1 diabetes duration ≥1 year, age 8.0 to 16.9 years (N=136), receiving care at an outpatient tertiary diabetes center in Boston, Massachusetts participated along with a parent from 2010 to 2013. Eighty-two percent of participants were from middle to upper income households. Intervention The family-based behavioral intervention targeted intake of whole plant foods. Main outcome measures Diet quality as indicated by the Healthy Eating Index-2005 (HEI-2005, measures conformance to 2005 Dietary Guidelines for Americans) and whole plant food density (WPFD, cup/oz equivalents per 1000 kcal of target food groups) were calculated from three-day food records of youth and parent dietary intake at six and four time points, respectively. Food prices were obtained from two online supermarkets common to the study location; daily diet cost was calculated by summing prices of reported foods. Statistical analyses performed Random effects models estimated treatment group differences in time-varying diet cost. Separate models for youth and parent adjusted for covariates examined associations of time-varying change in diet quality with change in diet cost. Results There was no treatment effect on time-varying diet cost for either youth [β (95%CI) = −0.49 (−1.07, 0.08), p=.10] or parents [β=0.24 (−1.61, 2.08) p=.80]. Additionally, time-varying change in diet quality indicators was not associated with time-varying change in diet cost for youth. Among parents, a 1 cup/oz-equivalent increase in whole plant food density was associated with a $.63/day lower diet cost [β=−0.63 (−1.20, −0.05), p=0.03]. Conclusions Improved diet quality was not accompanied by greater cost for youth with type 1 diabetes and their parents participating in a randomized clinical trial. Findings challenge the prevailing assumption that improving diet quality necessitates greater cost. PMID:27597745

Cost-effectiveness of molecular testing for thyroid nodules with atypia of undetermined significance cytology.

PubMed

Lee, Lawrence; How, Jacques; Tabah, Roger J; Mitmaker, Elliot J

2014-08-01

Novel molecular diagnostics, such as the gene expression classifier (GEC) and gene mutation panel (GMP) testing, may improve the management for thyroid nodules with atypia of undetermined significance (AUS) cytology. The cost-effectiveness of an approach combining both tests in different practice settings in North America is unknown. The aim of the study was to determine the cost-effectiveness of two diagnostic molecular tests, singly or in combination, for AUS thyroid nodules. We constructed a microsimulation model to investigate cost-effectiveness from US (Medicare) and Canadian healthcare system perspectives. Low-risk patients with AUS thyroid nodules were simulated. We examined five management strategies: 1) routine GEC; 2) routine GEC + selective GMP; 3) routine GMP; 4) routine GMP + selective GEC; and 5) standard management. Lifetime costs and quality-adjusted life-years were measured. From the US perspective, the routine GEC + selective GMP strategy was the dominant strategy. From the Canadian perspective, routine GEC + selective GMP cost and additional CAN$24 030 per quality-adjusted life-year gained over standard management, and was dominant over the other strategies. Sensitivity analyses reported that the decisions from both perspectives were sensitive to variations in the probability of malignancy in the nodule and the costs of the GEC and GMP. The probability of cost-effectiveness for routine GEC + selective GMP was low. In the US setting, the most cost-effective strategy was routine GEC + selective GMP. In the Canadian setting, standard management was most likely to be cost effective. The cost of these molecular diagnostics will need to be reduced to increase their cost-effectiveness for practice settings outside the United States.

Cost-effectiveness of lung cancer screening and treatment methods: a systematic review of systematic reviews.

PubMed

Azar, Farbod Ebadifard; Azami-Aghdash, Saber; Pournaghi-Azar, Fatemeh; Mazdaki, Alireza; Rezapour, Aziz; Ebrahimi, Parvin; Yousefzadeh, Negar

2017-06-19

Due to extensive literature in the field of lung cancer and their heterogeneous results, the aim of this study was to systematically review of systematic reviews studies which reviewed the cost-effectiveness of various lung cancer screening and treatment methods. In this systematic review of systematic reviews study, required data were collected searching the following key words which selected from Mesh: "lung cancer", "lung oncology", "lung Carcinoma", "lung neoplasm", "lung tumors", "cost- effectiveness", "systematic review" and "Meta-analysis". The following databases were searched: PubMed, Cochrane Library electronic databases, Google Scholar, and Scopus. Two reviewers (RA and A-AS) evaluated the articles according to the checklist of "assessment of multiple systematic reviews" (AMSTAR) tool. Overall, information of 110 papers was discussed in eight systematic reviews. Authors focused on cost-effectiveness of lung cancer treatments in five systematic reviews. Targeted therapy options (bevacizumab, Erlotinib and Crizotinib) show an acceptable cost-effectiveness. Results of three studies failed to show cost-effectiveness of screening methods. None of the studies had used the meta-analysis method. The Quality of Health Economic Studies (QHES) tool and Drummond checklist were mostly used in assessing the quality of articles. Most perspective was related to the Payer (64 times) and the lowest was related to Social (11times). Most cases referred to Incremental analysis (82%) and also the lowest point of referral was related to Discounting (in 49% of the cases). The average quality score of included studies was calculated 9.2% from 11. Targeted therapy can be an option for the treatment of lung cancer. Evaluation of the cost-effectiveness of computerized tomographic colonography (CTC) in lung cancer screening is recommended. The perspective of the community should be more taken into consideration in studies of cost-effectiveness. Paying more attention to the topic of Discounting will be necessary in the studies.

Cost-effectiveness of vaccination against herpes zoster and postherpetic neuralgia: a critical review.

PubMed

Kawai, Kosuke; Preaud, Emmanuelle; Baron-Papillon, Florence; Largeron, Nathalie; Acosta, Camilo J

2014-03-26

The objective of this study was to systematically review cost-effectiveness studies of vaccination against herpes zoster (HZ) and postherpetic neuralgia (PHN). We searched MEDLINE and EMBASE databases for eligible studies published prior to November 2013. We extracted information regarding model structure, model input parameters, and study results. We compared the results across studies by projecting the health and economic impacts of vaccinating one million adults over their lifetimes. We identified 15 cost-effectiveness studies performed in North America and Europe. Results ranged from approximately US$10,000 to more than US$100,000 per quality-adjusted life years (QALY) gained. Most studies in Europe concluded that zoster vaccination is likely to be cost-effective. Differences in results among studies are largely due to differing assumptions regarding duration of vaccine protection and a loss in quality of life associated with HZ and to a larger extent, PHN. Moreover, vaccine efficacy against PHN, age at vaccination, and vaccine cost strongly influenced the results in sensitivity analyses. Most studies included in this review shows that vaccination against HZ is likely to be cost-effective. Future research addressing key model parameters and cost-effectiveness studies in other parts of the world are needed. Copyright © 2014 Elsevier Ltd. All rights reserved.

Reviewing the quality, health benefit and value for money of chemotherapy and targeted therapy for metastatic breast cancer.

PubMed

Pouwels, Xavier Ghislain Léon Victor; Ramaekers, Bram L T; Joore, Manuela A

2017-10-01

To provide an overview of model characteristics and outcomes of model-based economic evaluations concerning chemotherapy and targeted therapy (TT) for metastatic breast cancer (MBC); to assess the quality of the studies; to analyse the association between model characteristics and study quality and outcomes. PubMED and NHS EED were systematically searched. Inclusion criteria were as follows: English or Dutch language, model-based economic evaluation, chemotherapy or TT as intervention, population diagnosed with MBC, published between 2000 and 2014, reporting life years (LY) or quality-adjusted life-year (QALY) and an incremental cost-effectiveness ratio. General characteristics, model characteristics and outcomes of the studies were extracted. Quality of the studies was assessed through a checklist. 24 studies were included, considering 50 comparisons (20 concerning chemotherapy and 30 TT). Seven comparisons were represented in multiple studies. A health state-transition model including the following health states: stable/progression-free disease, progression and death was used in 18 studies. Studies fulfilled on average 14 out of the 26 items of the quality checklist, mostly due to a lack of transparency in reporting. Thirty-one per cent of the incremental net monetary benefit was positive. TT led to higher iQALY gained, and industry-sponsored studies reported more favourable cost-effectiveness outcomes. The development of a disease-specific reference model would improve the transparency and quality of model-based cost-effectiveness assessments for MBC treatments. Incremental health benefits increased over time, but were outweighed by the increased treatment costs. Consequently, increased health benefits led to lower value for money.

Improving cost-effectiveness of and outcomes from drug therapy in patients with atrial fibrillation in managed care: role of the pharmacist.

PubMed

Johnson, Samuel G

2009-08-01

The medical care costs for procedures, medications, and testing associated with atrial fibrillation (AF) in the United States are high and projected to increase markedly in the future as the number of Americans affected grows. The burden on patient quality of life, the health care system, and society are pharmacoeconomic considerations in managing AF. To identify key pharmacoeconomic considerations in managing AF and describe ways in which managed care pharmacists can improve the cost-effectiveness of and outcomes from drug therapy for AF. The high medical care costs of AF are largely the result of the high cost of hospitalization and inpatient procedures. Recurrence of AF dramatically increases costs, especially for hospital care. Managed care pharmacists have many opportunities to provide cost-effective care to and improve outcomes in patients with AF. Policy and process review, population management, and case management are key strategies for improving outcomes in patients with AF. Pharmacist input into policy and process review, including pharmacy benefits design, formulary management, and the use of information technology, can help ensure that the use of drug therapy for AF is cost-effective. Population management strategies, such as development of clinical pathways and patient registries, seek to improve the quality, consistency, and cost-effectiveness of care and the likelihood that desired therapeutic outcomes are achieved through targeted interventions. Case management strategies focus on longitudinal care for individuals in order to improve quality. Pharmacist-managed anticoagulation services and antiarrhythmic drug monitoring are the 2 most widely known case management strategies for patients with AF. Managed care pharmacists can screen patients with AF for the use of anticoagulation, which is needed to prevent embolic stroke but is under-used, even though recommended by evidence-based guidelines. The clinical efficacy and cost-effectiveness of pharmacist-managed anticoagulation services for patients with AF are well documented. Pharmacist-managed antiarrhythmic drug monitoring is a less well-known case management strategy that facilitates early detection and intervention to minimize toxicity. Managed care pharmacists can play an instrumental role in implementing strategies to improve the cost-effectiveness of and outcomes from drug therapy for AF.

Cost effectiveness of dipeptidyl peptidase-4 inhibitors for type 2 diabetes.

PubMed

Geng, Jinsong; Yu, Hao; Mao, Yiwei; Zhang, Peng; Chen, Yingyao

2015-06-01

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of antidiabetic drugs used for treating type 2 diabetes mellitus. While many studies have reported on the cost-effectiveness of DPP-4 inhibitors for treating type 2 diabetes, a systematic review of economic evaluations of DPP-4 inhibitors is currently lacking. The aim of this systematic review was to assess the cost effectiveness of DPP-4 inhibitors for patients with type 2 diabetes. MEDLINE, EMBASE, National Health Service Economic Evaluation Database (NHS EED), Web of Science, EconLit databases, and the Cochrane Library were searched in November 2013. Studies assessing the cost effectiveness of DPP-4 inhibitors for type 2 diabetes were eligible for analysis. DPP-4 inhibitor monotherapy or combinations with other antidiabetic agents were included in the review. The DPP-4 inhibitors were all marketed drugs. Two reviewers independently reviewed titles, abstracts, and articles sequentially to select studies for data abstraction based on the inclusion and exclusion criteria. Disagreements were resolved by consensus. The quality of included studies was assessed according to the 24-item checklist of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. The costs reported by the included studies were converted to US dollars via purchasing power parities (PPP) in the year 2013 using the CCEMG-EPPI-Center Cost Converter. A total of 11 published studies were selected for inclusion; all were cost-utility analyses. Nine studies were conducted from a payer perspective and one used a societal perspective; however, the perspective of the other study was unclear. Four studies were of good quality, six were of moderate quality, and one was of low quality. Of the seven studies comparing DPP-4 inhibitors plus metformin with sulfonylureas plus metformin, six concluded that DPP-4 inhibitors were cost effective in patients with type 2 diabetes who were no longer adequately controlled by metformin monotherapy. Five studies compared DPP-4 inhibitors with thiazolidinediones, and whether DPP-4 inhibitors were cost effective was uncertain. Only two economic evaluations provided data to compare DPP-4 inhibitors versus insulin, and the results favored the use of DPP-4 inhibitors as second-line therapy. Synthesis of the data was impossible because of heterogeneity in the methodology and data sources of the economic evaluations, and the inclusion criteria excluded conference abstracts. It was difficult to find reliable weightings for each of the items of the CHEERS checklist, and the ratings were dichotomous. This study provides the first systematic evaluation of DPP-4 inhibitors for patients with type 2 diabetes. It found that, in patients with type 2 diabetes who do not achieve glycemic targets with antidiabetic monotherapy, DPP-4 inhibitors as add-on treatment may represent a cost-effective option compared with sulfonylureas and insulin. However, high-quality cost-effectiveness analyses that utilize long-term follow-up data and have no conflicts of interest are still needed.

Levonorgestrel-Releasing Intrauterine System (52 mg) for Idiopathic Heavy Menstrual Bleeding: A Health Technology Assessment

PubMed Central

Schaink, Alexis; Chan, Brian; Higgins, Caroline

2016-01-01

Background Heavy menstrual bleeding affects as many as one in three women and has negative physical, economic, and psychosocial impacts including activity limitations and reduced quality of life. The goal of treatment is to make menstruation manageable, and options include medical therapy or surgery such as endometrial ablation or hysterectomy. This review examined the evidence of effectiveness and cost-effectiveness of the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) as a treatment alternative for idiopathic heavy menstrual bleeding. Methods We conducted a systematic review of the clinical and economic evidence comparing LNG-IUS with usual medical therapy, endometrial ablation, or hysterectomy. Medline, EMBASE, Cochrane, and the Centres for Reviews and Dissemination were searched from inception to August 2015. The quality of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also completed an economic evaluation to determine the cost-effectiveness and budget impact of the LNG-IUS compared with endometrial ablation and with hysterectomy. The economic evaluation was conducted from the perspective the Ontario Ministry of Health and Long-Term Care. Results Relevant systematic reviews (n = 18) returned from the literature search were used to identify eligible randomized controlled trials, and 16 trials were included. The LNG-IUS improved quality of life and reduced menstrual blood loss better than usual medical therapy. There was no evidence of a significant difference in these outcomes compared with the improvements offered by endometrial ablation or hysterectomy. Mild hormonal side effects were the most commonly reported. The quality of the evidence varied from very low to moderate across outcomes. Results from the economic evaluation showed the LNG-IUS was less costly (incremental saving of $372 per person) and more effective providing higher quality-adjusted life years (incremental value of 0.05) compared with endometrial ablation. Similarly, the LNG-IUS costs less (incremental saving of $3,138 per person) and yields higher quality-adjusted life-years (incremental value of 0.04) compared with hysterectomy. Publicly funding LNG-IUS as an alternative to endometrial ablation and hysterectomy would result in annual cost savings of $3 million to $9 million and $0.1 million to $23 million, respectively, over the first 5 years. Conclusions The 52-mg LNG-IUS is an effective and cost-effective treatment option for idiopathic heavy menstrual bleeding. It improves quality of life and menstrual blood loss, and is well tolerated compared with endometrial ablation, hysterectomy, or usual medical therapies. PMID:27990196

Controlling costs without compromising quality: paying hospitals for total knee replacement.

PubMed

Pine, Michael; Fry, Donald E; Jones, Barbara L; Meimban, Roger J; Pine, Gregory J

2010-10-01

Unit costs of health services are substantially higher in the United States than in any other developed country in the world, without a correspondingly healthier population. An alternative payment structure, especially for high volume, high cost episodes of care (eg, total knee replacement), is needed to reward high quality care and reduce costs. The National Inpatient Sample of administrative claims data was used to measure risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. Empirically identified inefficient and ineffective hospitals were then removed to create a reference group of high-performance hospitals. Predictive models for outcomes and costs were recalibrated to the reference hospitals and used to compute risk-adjusted outcomes and costs for all hospitals. Per case predicted costs were computed and compared with observed costs. Of the 688 hospitals with acceptable data, 62 failed to meet effectiveness criteria and 210 were identified as inefficient. The remaining 416 high-performance hospitals had 13.4% fewer risk-adjusted adverse outcomes (4.56%-3.95%; P < 0.001; χ) and 9.9% lower risk-adjusted total costs ($12,773-$11,512; P < 0.001; t test) than all study hospitals. Inefficiency accounted for 96% of excess costs. A payment system based on the demonstrated performance of effective, efficient hospitals can produce sizable cost savings without jeopardizing quality. In this study, 96% of total excess hospital costs resulted from higher routine costs at inefficient hospitals, whereas only 4% was associated with ineffective care.

Cost-effectiveness of adherence therapy versus health education for people with schizophrenia: randomised controlled trial in four European countries

PubMed Central

2013-01-01

Background Non-adherence to anti-psychotics is common, expensive and affects recovery. We therefore examine the cost-effectiveness of adherence therapy for people with schizophrenia by multi-centre randomised trial in Amsterdam, London, Leipzig and Verona. Methods Participants received 8 sessions of adherence therapy or health education. We measured lost productivity and use of health/social care, criminal justice system and informal care at baseline and one year to estimate and compare mean total costs from health/social care and societal perspectives. Outcomes were the Short Form 36 (SF-36) mental component score (MCS) and quality-adjusted life years (QALYs) gained (SF-36 and EuroQoL 5 dimension (EQ5D)). Cost-effectiveness was examined for all cost and outcome combinations using cost-effectiveness acceptability curves (CEACs). Results 409 participants were recruited. There were no cost or outcome differences between adherence therapy and health education. The probability of adherence therapy being cost-effective compared to health education was between 0.3 and 0.6 for the six cost-outcome combinations at the willingness to pay thresholds we examined. Conclusions Adherence therapy appears equivalent to health education. It is unclear whether it would have performed differently against a treatment as usual control, whether such an intervention can impact on quality of life in the short-term, or whether it is likely to be cost-effective in some sites but not others. Trial registration Trial registration: Current Controlled Trials ISRCTN01816159 PMID:23705862

Cost-effectiveness of a community-based physical activity programme for adults (Be Active) in the UK: an economic analysis within a natural experiment.

PubMed

Frew, Emma J; Bhatti, Mobeen; Win, Khine; Sitch, Alice; Lyon, Anna; Pallan, Miranda; Adab, Peymane

2014-02-01

To determine the cost-effectiveness of a physical activity programme (Be Active) aimed at city-dwelling adults living in Birmingham, UK. Very little is known about the cost-effectiveness of public health programmes to improve city-wide physical activity rates. This paper presents a cost-effectiveness analysis that compares a physical activity intervention (Be Active) with no intervention (usual care) using an economic model to quantify the reduction in disease risk over a lifetime. Metabolic equivalent minutes achieved per week, quality-adjusted life years (QALYs) gained and healthcare costs were all included as the main outcome measures in the model. A cost-benefit analysis was also conducted using 'willingness-to-pay' as a measure of value. Under base-case assumptions-that is, assuming that the benefits of increased physical activity are sustained over 5 years, participation in the Be Active programme increased quality-adjusted life expectancy by 0.06 years, at an expected discounted cost of £3552, and thus the cost-effectiveness of Be Active is £400 per QALY. When the start-up costs of the programme are removed from the economic model, the cost-effectiveness is further improved to £16 per QALY. The societal value placed on the Be Active programme was greater than the operation cost therefore the Be Active physical activity intervention results in a net benefit to society. Participation in Be Active appeared to be cost-effective and cost-beneficial. These results support the use of Be Active as part of a public health programme to improve physical activity levels within the Birmingham-wide population.

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth.

PubMed

Aas, Eline; Iversen, Tor; Holt, Tonje; Ormhaug, Silje M; Jensen, Tine K

2018-06-07

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10-18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.

Cost, Quality and Enrollment Demand at Liberal Arts Colleges

ERIC Educational Resources Information Center

Buss, Christian; Parker, Jeffrey; Rivenburg, Jon

2004-01-01

This paper examines the effects of cost, quality and macroeconomic factors on the demand for higher education (represented by the share of admitted freshmen choosing to enroll) at a group of selective liberal arts colleges over the period from 1988 to 1998. Students are segregated by their financial-aid status with different demand equations…

Economic evaluation of a web-based tailored lifestyle intervention for adults: findings regarding cost-effectiveness and cost-utility from a randomized controlled trial.

PubMed

Schulz, Daniela N; Smit, Eline S; Stanczyk, Nicola E; Kremers, Stef P J; de Vries, Hein; Evers, Silvia M A A

2014-03-20

Different studies have reported the effectiveness of Web-based computer-tailored lifestyle interventions, but economic evaluations of these interventions are scarce. The objective was to assess the cost-effectiveness and cost-utility of a sequential and a simultaneous Web-based computer-tailored lifestyle intervention for adults compared to a control group. The economic evaluation, conducted from a societal perspective, was part of a 2-year randomized controlled trial including 3 study groups. All groups received personalized health risk appraisals based on the guidelines for physical activity, fruit intake, vegetable intake, alcohol consumption, and smoking. Additionally, respondents in the sequential condition received personal advice about one lifestyle behavior in the first year and a second behavior in the second year; respondents in the simultaneous condition received personal advice about all unhealthy behaviors in both years. During a period of 24 months, health care use, medication use, absenteeism from work, and quality of life (EQ-5D-3L) were assessed every 3 months using Web-based questionnaires. Demographics were assessed at baseline, and lifestyle behaviors were assessed at both baseline and after 24 months. Cost-effectiveness and cost-utility analyses were performed based on the outcome measures lifestyle factor (the number of guidelines respondents adhered to) and quality of life, respectively. We accounted for uncertainty by using bootstrapping techniques and sensitivity analyses. A total of 1733 respondents were included in the analyses. From a willingness to pay of €4594 per additional guideline met, the sequential intervention (n=552) was likely to be the most cost-effective, whereas from a willingness to pay of €10,850, the simultaneous intervention (n=517) was likely to be most cost-effective. The control condition (n=664) appeared to be preferred with regard to quality of life. Both the sequential and the simultaneous lifestyle interventions were likely to be cost-effective when it concerned the lifestyle factor, whereas the control condition was when it concerned quality of life. However, there is no accepted cutoff point for the willingness to pay per gain in lifestyle behaviors, making it impossible to draw firm conclusions. Further economic evaluations of lifestyle interventions are needed. Dutch Trial Register NTR2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB).

Occupational therapy compared with social work assessment for older people. An economic evaluation alongside the CAMELOT randomised controlled trial.

PubMed

Flood, Chris; Mugford, Miranda; Stewart, Sandra; Harvey, Ian; Poland, Fiona; Lloyd-Smith, Walter

2005-01-01

To compare costs and outcome of occupational therapy-led assessment with social worker-led assessment of older people, in terms of their independence and quality of life. Cost-effectiveness analysis alongside a randomised controlled trial. The analysis took viewpoints of health services and patients. The primary outcome measure for cost-effectiveness was dependency using the Community Dependency Index (CDI). Secondary outcomes included utility scores based on the EuroQoL (EQ-5D). Resource use was measured for each patient, from clinical records and from patient carer interviews at 8 months. Unit costs of health and social care resources were derived from local sources and national datasets. Cost-effectiveness was analysed using cost-effectiveness acceptability curves. There were no differences between the two arms of the trial in terms of cost-effectiveness. There is an apparent increase in mean cost per case for the occupational therapy arm but this is not statistically significant (mean difference in cost per case 542 pounds, 95% CI 434-1,519 pounds). Mean total costs of care per participant were 4,379 pounds and 3,837 pounds for the occupational therapy and social work arms, respectively. At best the intervention would improve outcomes at a cost of 14,000 pounds per quality-adjusted life year (QALY). The probability of such an outcome was <50%. From a policy perspective, the lack of difference in clinical and cost-effectiveness means that either a social work or an occupational therapy service is successful in making care assessments that enable an older person to remain in their own home.

Cost-Effectiveness of New Direct-Acting Antivirals to Prevent Post-Liver Transplant Recurrent Hepatitis.

PubMed

Cortesi, P A; Mantovani, L G; Ciaccio, A; Rota, M; Mazzarelli, C; Cesana, G; Strazzabosco, M; Belli, L S

2015-07-01

Preliminary studies on HCV-cirrhotics listed for transplant suggest that sofosbuvir in combination with ribavirin is very effective in promoting viral clearance and preventing disease recurrence. Unfortunately, the high cost of such treatment (€46 500 per 12 weeks of treatment) makes its cost-effectiveness questionable. A semi-Markov model was developed to assess the cost-effectiveness of sofosbuvir/ribavirin treatment in cirrhotic patients without HCC (HCV-CIRRH) and with HCC (HCV-HCC) listed for transplant. In the base-case analysis, the incremental cost-effectiveness ratio for 24 weeks of sofosbuvir/ribavirin was €44 875 per quality-adjusted life-year gained in HCV-CIRRH and €60 380 in HCV-HCC patients. Both results were above the willingness to pay threshold of €37 000 per quality-adjusted life-year. Our data also show that in order to remain cost-effective (with a 24-week treatment), any novel interferon-free treatment endowed with ideal efficacy should cost less than €67 224 or €95 712 in HCV-cirrhotics with and without HCC, respectively. The results shows that sofosbuvir/ribavirin therapy, given to patients listed for transplant, is not cost-effective at current prices despite being very effective, and new, more effective treatments will have little economic margins to remain cost-effective. New interferon-free combinations have the potential to revolutionize the treatment and prognosis of HCV-positive patients listed for transplant; however, without sustainable prices, this revolution is unlikely to happen. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

Outcomes and costs of incorporating a multibiomarker disease activity test in the management of patients with rheumatoid arthritis.

PubMed

Michaud, Kaleb; Strand, Vibeke; Shadick, Nancy A; Degtiar, Irina; Ford, Kerri; Michalopoulos, Steven N; Hornberger, John

2015-09-01

The multibiomarker disease activity (MBDA) blood test has been clinically validated as a measure of disease activity in patients with RA. We aimed to estimate the effect of the MBDA test on physical function for patients with RA (based on HAQ), quality-adjusted life years and costs over 10 years. A decision analysis was conducted to quantify the effect of using the MBDA test on RA-related outcomes and costs to private payers and employers. Results of a clinical management study reporting changes to anti-rheumatic drug recommendations after use of the MBDA test informed clinical utility. The effect of treatment changes on HAQ was derived from 5 tight-control and 13 treatment-switch trials. Baseline HAQ scores and the HAQ score relationship with medical costs and quality of life were derived from published National Data Bank for Rheumatic Diseases data. Use of the MBDA test is projected to improve HAQ scores by 0.09 units in year 1, declining to 0.02 units after 10 years. Over the 10 year time horizon, quality-adjusted life years increased by 0.08 years and costs decreased by US$457 (cost savings in disability-related medical costs, US$659; in productivity costs, US$2137). The most influential variable in the analysis was the effect of the MBDA test on clinician treatment recommendations and subsequent HAQ changes. The MBDA test aids in the assessment of disease activity in patients with RA by changing treatment decisions, improving the functional status of patients and cost savings. Further validation is ongoing and future longitudinal studies are warranted. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology.

Cost effectiveness of bisphosphonates in the management of breast cancer patients with bone metastases.

PubMed

Botteman, M; Barghout, V; Stephens, J; Hay, J; Brandman, J; Aapro, M

2006-07-01

Bisphosphonates are recommended to prevent skeletal related events (SREs) in patients with breast cancer and bone metastases (BCBM). However, their clinical and economic profiles vary from one agent to the other. Using modeling techniques, we simulated from the perspective of the UK's National Health Service (NHS) the cost and quality adjusted survival (QALY) associated with five commonly-used bisphosphonates or no therapy in this patient population. The simulation followed patients into several health states (i.e. alive or dead, experiencing an SRE or no SRE, and receiving first or second line therapy). Drugs costs, infusion costs, SREs costs, and utility values were estimated from published sources. Utilities were applied to time with and without SREs to capture the impact on quality of life. Compared to no therapy, all bisphosphonates are either cost saving or highly cost-effective (with a cost per QALY < or = 6126 pounds sterlings). Within this evaluation, zoledronic acid was more effective and less expensive than all other options. Based on our model, the use of bisphosphonates in breast cancer patients with bone metastases should lead to improved patient outcomes and cost savings to the NHS and possibly other similar entities.

Cost-Effectiveness Analysis of Stereotactic Body Radiation Therapy Compared With Radiofrequency Ablation for Inoperable Colorectal Liver Metastases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, Hayeon, E-mail: kimh2@upmc.edu; Gill, Beant; Beriwal, Sushil

Purpose: To conduct a cost-effectiveness analysis to determine whether stereotactic body radiation therapy (SBRT) is a cost-effective therapy compared with radiofrequency ablation (RFA) for patients with unresectable colorectal cancer (CRC) liver metastases. Methods and Materials: A cost-effectiveness analysis was conducted using a Markov model and 1-month cycle over a lifetime horizon. Transition probabilities, quality of life utilities, and costs associated with SBRT and RFA were captured in the model on the basis of a comprehensive literature review and Medicare reimbursements in 2014. Strategies were compared using the incremental cost-effectiveness ratio, with effectiveness measured in quality-adjusted life years (QALYs). To account formore » model uncertainty, 1-way and probabilistic sensitivity analyses were performed. Strategies were evaluated with a willingness-to-pay threshold of $100,000 per QALY gained. Results: In base case analysis, treatment costs for 3 fractions of SBRT and 1 RFA procedure were $13,000 and $4397, respectively. Median survival was assumed the same for both strategies (25 months). The SBRT costs $8202 more than RFA while gaining 0.05 QALYs, resulting in an incremental cost-effectiveness ratio of $164,660 per QALY gained. In 1-way sensitivity analyses, results were most sensitive to variation of median survival from both treatments. Stereotactic body radiation therapy was economically reasonable if better survival was presumed (>1 month gain) or if used for large tumors (>4 cm). Conclusions: If equal survival is assumed, SBRT is not cost-effective compared with RFA for inoperable colorectal liver metastases. However, if better local control leads to small survival gains with SBRT, this strategy becomes cost-effective. Ideally, these results should be confirmed with prospective comparative data.« less

Treatment for ADHD: Is More Complex Treatment Cost-Effective for More Complex Cases?

PubMed Central

Foster, E Michael; Jensen, Peter S; Schlander, Michael; Pelham, William E; Hechtman, Lily; Arnold, L Eugene; Swanson, James M; Wigal, Timothy

2007-01-01

Objective To determine the cost-effectiveness of three alternative high-quality treatments for attention deficit hyperactivity disorder (ADHD) relative to community care (CC) and to determine whether cost-effectiveness varies with the presence of comorbid disorders. Data Sources/Collection The study included 579 children ages 7–9.9 with diagnosed ADHD at six sites. Data for the study were distilled from administrative data and from interviews with parents, including estimates of the child's functional impairment. These analyses focus on changes in functional impairment over 14 months. Study Design The study involved a large clinical trial that randomized participants to one of four arms: routine CC, intensive medication management (MedMgt), multicomponent behavioral treatment, and a combination of behavioral treatment and medication. Principal Findings We assessed the cost-effectiveness of the alternatives using costs measured from a payer perspective. The preferred cost-effective treatment varies as a function of the child's comorbidity and of the policy maker's willingness to pay. For pure (no comorbidity) ADHD, high-quality MedMgt appears likely to be cost-effective at all levels of willingness to pay. In contrast, for some comorbid conditions, willingness to pay is critical: the policy maker with low willingness to pay likely will judge MedMgt most cost-effective. On the other hand, a policy maker willing to pay more now in expectation of future costs savings (involving, for example, juvenile justice), will recognize that the most cost-effective choice for comorbid conditions likely involves behavior therapy, with or without medication. Conclusions Analyses of costs and effectiveness of treatment for ADHD must consider the role of comorbidities. PMID:17355587

Cost-effectiveness of on-site versus off-site collaborative care for depression in rural FQHCs.

PubMed

Pyne, Jeffrey M; Fortney, John C; Mouden, Sip; Lu, Liya; Hudson, Teresa J; Mittal, Dinesh

2015-05-01

Collaborative care for depression in primary care settings is effective and cost-effective. However, there is minimal evidence to support the choice of on-site versus off-site models. This study examined the cost-effectiveness of on-site practice-based collaborative care (PBCC) versus off-site telemedicine-based collaborative care (TBCC) for depression in federally qualified health centers (FQHCs). In a multisite, randomized, pragmatic comparative cost-effectiveness trial, 19,285 patients were screened for depression, 2,863 (14.8%) screened positive, and 364 were enrolled. Telephone interview data were collected at baseline and at six, 12, and 18 months. Base case analysis used Arkansas FQHC health care costs, and secondary analysis used national cost estimates. Effectiveness measures were depression-free days and quality-adjusted life years (QALYs) derived from depression-free days, the 12-Item Short-Form Survey, and the Quality of Well-Being (QWB) Scale. Nonparametric bootstrap with replacement methods were used to generate an empirical joint distribution of incremental costs and QALYs and acceptability curves. The TBCC intervention resulted in more depression-free days and QALYs but at a greater cost than the PBCC intervention. The disease-specific (depression-free day) and generic (QALY) incremental cost-effectiveness ratios (ICERs) were below their respective ICER thresholds for implementation, suggesting that the TBCC intervention was more cost effective than the PBCC intervention. These results support the cost-effectiveness of TBCC in medically underserved primary care settings. Information about whether to insource (make) or outsource (buy) depression care management is important, given the current interest in patient-centered medical homes, value-based purchasing, and bundled payments for depression care.

Strategies for Sustainable Cancer Care.

PubMed

Kerr, David J; Jani, Anant; Gray, Sir Muir

2016-01-01

There is an increasing focus on the relative cost-effectiveness and sustainability of delivering high-quality cancer care, with most emphasis, debatably, given to cost control of innovative treatments. It is difficult to calculate all the direct and indirect contributors to the total cost of cancer treatment, but it is estimated that cancer drugs constitute 10% to 30% of the total cost of cancer care. A 2007 study in France showed the contribution of drug costs was less than 20%, with approximately 70% of the total expenditure on cancer accounted for by health care resource use, such as hospitalization. The U.K. government established the National Institute for Health and Care Excellence (NICE)-the dominant function of which is technology appraisal-to assess the clinical and cost-effectiveness of new pharmaceutical and biopharmaceutical products. This is to ensure that all National Health Service (NHS) patients have equitable access to the most clinically effective and cost-effective treatments that are viable. NICE has developed a transparent, public process to judge incremental cost-effectiveness using the quality-adjusted life year (QALY), which allows comparisons of cost-effectiveness across medical specialties. NICE has been both lauded and criticized-especially when it passes judgment on marginally effective but expensive anticancer drugs-but it provides a route to "rational rationing" and, therefore, may contribute to sustainable cancer care by highlighting the issue of affordable medicine. This implies a challenge to the wider oncology community as to how we might cooperate to introduce the concept of value-driven cancer care.

Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial.

PubMed

Coombes, Brooke K; Connelly, Luke; Bisset, Leanne; Vicenzino, Bill

2016-11-01

To determine the cost-effectiveness of corticosteroid injection, physiotherapy and a combination of these interventions, compared to a reference group receiving a blinded placebo injection. 165 adults with unilateral lateral epicondylalgia of longer than 6 weeks duration from Brisbane, Australia, were randomised for concealed allocation to saline injection (placebo), corticosteroid injection, saline injection plus physiotherapy (eight sessions of elbow manipulation and exercise) or corticosteroid injection plus physiotherapy. Costs to society and health-related quality of life (estimated by EuroQol-5D) over the 1 year follow-up were used to generate incremental cost per quality-adjusted life year (QALY) ratios for each intervention relative to placebo. Intention-to-treat analysis was possible for 154 (93%) of trial participants. Physiotherapy was more costly, but was the only intervention that produced a statistically significant improvement in quality of life relative to placebo (MD, 95% CI 0.035, 0.003 to 0.068). Similar cost/QALY ratios were found for physiotherapy ($A29 343; GBP18 962) and corticosteroid injection ($A31 750; GBP20 518); however, the probability of being more cost-effective than placebo at values above $A50 000 per quality-adjusted life year was 81% for physiotherapy and 53% for corticosteroid injection. Cost/QALY was far greater for a combination of corticosteroid injection and physiotherapy ($A228 000; GBP147 340). Physiotherapy was a cost-effective treatment for lateral epicondylalgia. Corticosteroid injection was associated with greater variability, and a lower probability of being cost-effective if a willingness to pay threshold of $A50 000 is assumed. A combination of corticosteroid injection and physiotherapy was ineffective and cost-ineffective. Physiotherapy, not corticosteroid injection, should be considered as a first-line intervention for lateral epicondylalgia. anzctr.org Trial identifier: ACTRN12609000051246. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations

PubMed Central

Herman, Patricia M; Poindexter, Beth L; Witt, Claudia M; Eisenberg, David M

2012-01-01

Objective A comprehensive systematic review of economic evaluations of complementary and integrative medicine (CIM) to establish the value of these therapies to health reform efforts. Data sources PubMed, CINAHL, AMED, PsychInfo, Web of Science and EMBASE were searched from inception through 2010. In addition, bibliographies of found articles and reviews were searched, and key researchers were contacted. Eligibility criteria for selecting studies Studies of CIM were identified using criteria based on those of the Cochrane complementary and alternative medicine group. All studies of CIM reporting economic outcomes were included. Study appraisal methods All recent (and likely most cost-relevant) full economic evaluations published 2001–2010 were subjected to several measures of quality. Detailed results of higher-quality studies are reported. Results A total of 338 economic evaluations of CIM were identified, of which 204, covering a wide variety of CIM for different populations, were published 2001–2010. A total of 114 of these were full economic evaluations. And 90% of these articles covered studies of single CIM therapies and only one compared usual care to usual care plus access to multiple licensed CIM practitioners. Of the recent full evaluations, 31 (27%) met five study-quality criteria, and 22 of these also met the minimum criterion for study transferability (‘generalisability’). Of the 56 comparisons made in the higher-quality studies, 16 (29%) show a health improvement with cost savings for the CIM therapy versus usual care. Study quality of the cost-utility analyses (CUAs) of CIM was generally comparable to that seen in CUAs across all medicine according to several measures, and the quality of the cost-saving studies was slightly, but not significantly, lower than those showing cost increases (85% vs 88%, p=0.460). Conclusions This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. Recommendations are made for future studies. PMID:22945962

Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial.

PubMed

Oestergaard, Lisa G; Christensen, Finn B; Nielsen, Claus V; Bünger, Cody E; Fruensgaard, Soeren; Sogaard, Rikke

2013-11-01

Economic evaluation conducted alongside a randomized controlled trial with 1-year follow-up. To examine the cost-effectiveness of initiating rehabilitation 6 weeks after surgery as opposed to 12 weeks after surgery. In a previously reported randomized controlled trial, we assessed the impact of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, it seems relevant to address the societal perspective including return to work, quality of life, and costs. A cost-effectiveness analysis and a cost-utility analysis were conducted. Eighty-two patients undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomized to an identical protocol of 4 sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in euros. Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI). The fast-track strategy tended to be costlier by €6869 (95% CI, -4640 to 18,378) while at the same time leading to significantly poorer outcomes of functional disability by -9 points (95% CI, -18 to -3) and a tendency for a reduced gain in quality-adjusted life years by -0.04 (95% CI, -0.13 to 0.01). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness. Initiating rehabilitation at 6 weeks as opposed to 12 weeks after surgery is on average more costly and less effective. The uncertainty of this result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation strategies have reason to reconsider their choice. .

Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma.

PubMed

Cucchetti, Alessandro; Piscaglia, Fabio; Cescon, Matteo; Colecchia, Antonio; Ercolani, Giorgio; Bolondi, Luigi; Pinna, Antonio D

2013-08-01

Both hepatic resection and radiofrequency ablation (RFA) are considered curative treatments for hepatocellular carcinoma (HCC), but their economic impact still remains not determined. Aim of the present study was to analyze the cost-effectiveness (CE) of these two strategies in early stage HCC (Milan criteria). As first step, a meta-analysis of the pertinent literature of the last decade was performed. Seventeen studies fulfilled the inclusion criteria: 3996 patients underwent resection and 4424 underwent RFA for early HCC. Data obtained from the meta-analysis were used to construct a Markov model. Costs were assessed from the health care provider perspective. A Monte Carlo probabilistic sensitivity analysis was used to estimate outcomes with distribution samples of 1000 patients for each treatment arm. In a 10-year perspective, for very early HCC (single nodule <2 cm) in Child-Pugh class A patients, RFA provided similar life-expectancy and quality-adjusted life-expectancy at a lower cost than resection and was the most cost-effective therapeutic strategy. For single HCCs of 3-5 cm, resection provided better life-expectancy and was more cost-effective than RFA, at a willingness-to-pay above €4200 per quality-adjusted life-year. In the presence of two or three nodules ≤3 cm, life-expectancy and quality-adjusted life-expectancy were very similar between the two treatments, but cost-effectiveness was again in favour of RFA. For very early HCC and in the presence of two or three nodules ≤3 cm, RFA is more cost-effective than resection; for single larger early stage HCCs, surgical resection remains the best strategy to adopt as a result of better survival rates at an acceptable increase in cost. Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Blood salvage produces higher total blood product costs in single-level lumbar spine surgery.

PubMed

Canan, Chelsea E; Myers, John A; Owens, Roger Kirk; Crawford, Charles H; Djurasovic, Mladen; Burke, Lauren O; Bratcher, Kelly R; McCarthy, Kathryn J; Carreon, Leah Y

2013-04-15

Retrospective review. To determine the incremental cost-effectiveness of cell saver for single-level posterior lumbar decompression and fusion (PLDF). Intraoperative cell salvage is used during surgery to reduce the need for perioperative allogeneic blood transfusion. Although the use of cell saver may be beneficial in certain circumstances, its utility has not been clearly established for the common procedure of an adult single-level PLDF. Randomly selected adult patients treated with a single-level PLDF between July 2010 and June 2011 at a single institution were identified. Patients who had a combined anterior and posterior approach were excluded. The final study sample for analysis consisted of 180 patients. Hospital records were reviewed to determine whether: (1) cell saver was available during surgery, (2) recovered autologous blood was infused, and (3) the patient received intra- or postoperative allogeneic transfusions. Estimated blood loss, levels fused, volume(s) transfused, and all related complications were recorded. Costs included the cost of allogeneic blood transfusion, setting up the cell saver recovery system, and infusing autologous blood from cell saver, whereas effectiveness measures were allogeneic blood transfusions averted and quality adjusted life years. The incremental cost-effectiveness ratio was $55,538 per allogeneic transfusion averted, with a decrease in the transfusion rate from 40.0% to 38.7% associated with the cell saver approach. This translated into an incremental cost-effectiveness ratio of $5,555,380 per quality adjusted life years gained, which is well above the threshold for an intervention to be considered cost-effective ($100,000 per quality adjusted life years gained). The use of cell saver during a single-level PLDF does not significantly reduce the need for allogeneic blood transfusion and is not cost-effective. The high cost of cell saver in combination with the low complication rate of allogeneic blood transfusion, suggest that cell saver should not be used for single-level PLDF. Further studies are needed to evaluate the necessity for cell saver among other types of spinal surgery.

Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.

PubMed

Turino, Cecilia; de Batlle, Jordi; Woehrle, Holger; Mayoral, Ana; Castro-Grattoni, Anabel Lourdes; Gómez, Sílvia; Dalmases, Mireia; Sánchez-de-la-Torre, Manuel; Barbé, Ferran

2017-02-01

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnoea (OSA), but treatment compliance is often unsatisfactory. This study investigated the efficacy and cost-effectiveness of telemonitoring for improving CPAP compliance.100 newly diagnosed OSA patients requiring CPAP (apnoea-hypopnoea index >15 events·h -1 ) were randomised to standard management or a telemonitoring programme that collected daily information about compliance, air leaks and residual respiratory events, and initiated patient contact to resolve issues. Clinical/anthropometric variables, daytime sleepiness and quality of life were recorded at baseline and after 3 months. Patient satisfaction, additional visits/calls, side-effects and total costs were assessed.There were no significant differences between the standard and telemedicine groups in terms of CPAP compliance (4.9±2.2 versus 5.1±2.1 h·night -1 ), symptoms, clinical variables, quality of life and unwanted effects. Telemedicine was less expensive than standard management (EUR123.65 versus EUR170.97; p=0.022) and was cost-effective (incremental cost-effectiveness ratio EUR17 358.65 per quality-adjusted life-year gained). Overall patient satisfaction was high, but significantly more patients rated satisfaction as high/very high in the standard management versus telemedicine group (96% versus 74%; p=0.034).Telemonitoring did not improve CPAP treatment compliance and was associated with lower patient satisfaction. However, it was more cost-effective than traditional follow-up. Copyright ©ERS 2017.

Cost Models for MMC Manufacturing Processes

NASA Technical Reports Server (NTRS)

Elzey, Dana M.; Wadley, Haydn N. G.

1996-01-01

The quality cost modeling (QCM) tool is intended to be a relatively simple-to-use device for obtaining a first-order assessment of the quality-cost relationship for a given process-material combination. The QCM curve is a plot of cost versus quality (an index indicating microstructural quality), which is unique for a given process-material combination. The QCM curve indicates the tradeoff between cost and performance, thus enabling one to evaluate affordability. Additionally, the effect of changes in process design, raw materials, and process conditions on the cost-quality relationship can be evaluated. Such results might indicate the most efficient means to obtain improved quality at reduced cost by process design refinements, the implementation of sensors and models for closed loop process control, or improvement in the properties of raw materials being fed into the process. QCM also allows alternative processes for producing the same or similar material to be compared in terms of their potential for producing competitively priced, high quality material. Aside from demonstrating the usefulness of the QCM concept, this is one of the main foci of the present research program, namely to compare processes for making continuous fiber reinforced, metal matrix composites (MMC's). Two processes, low pressure plasma spray deposition and tape casting are considered for QCM development. This document consists of a detailed look at the design of the QCM approach, followed by discussion of the application of QCM to each of the selected MMC manufacturing processes along with results, comparison of processes, and finally, a summary of findings and recommendations.

Cost-effectiveness analysis of cochlear dose reduction by proton beam therapy for medulloblastoma in childhood.

PubMed

Hirano, Emi; Fuji, Hiroshi; Onoe, Tsuyoshi; Kumar, Vinay; Shirato, Hiroki; Kawabuchi, Koichi

2014-03-01

The aim of this study is to evaluate the cost-effectiveness of proton beam therapy with cochlear dose reduction compared with conventional X-ray radiotherapy for medulloblastoma in childhood. We developed a Markov model to describe health states of 6-year-old children with medulloblastoma after treatment with proton or X-ray radiotherapy. The risks of hearing loss were calculated on cochlear dose for each treatment. Three types of health-related quality of life (HRQOL) of EQ-5D, HUI3 and SF-6D were used for estimation of quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for proton beam therapy compared with X-ray radiotherapy was calculated for each HRQOL. Sensitivity analyses were performed to model uncertainty in these parameters. The ICER for EQ-5D, HUI3 and SF-6D were $21 716/QALY, $11 773/QALY, and $20 150/QALY, respectively. One-way sensitivity analyses found that the results were sensitive to discount rate, the risk of hearing loss after proton therapy, and costs of proton irradiation. Cost-effectiveness acceptability curve analysis revealed a 99% probability of proton therapy being cost effective at a societal willingness-to-pay value. Proton beam therapy with cochlear dose reduction improves health outcomes at a cost that is within the acceptable cost-effectiveness range from the payer's standpoint.

Cost-effectiveness of chronic hepatitis C treatment with thymosin alpha-1.

PubMed

García-Contreras, Fernando; Nevárez-Sida, Armando; Constantino-Casas, Patricia; Abud-Bastida, Fernando; Garduño-Espinosa, Juan

2006-07-01

More than one million individuals in Mexico are infected with hepatitis C virus (HCV), and 80% are at risk for developing a chronic infection that could lead to hepatic cirrhosis and other complications that impact quality of life and institutional costs. The objective of the study was to determine the most cost-effective treatment against HCV among the following: peginterferon, peginterferon plus ribavirin, peginterferon plus ribavirin plus thymosin, and no treatment. We carried out cost-effectiveness analysis using the institutional perspective, including a 45-year time frame and a 3% discount rate for costs and effectiveness. We employed a Bayesian-focused decision tree and a Markov model. One- and two-way sensitivity analyses were performed, as well as threshold-oriented and probabilistic analyses, and we obtained acceptability curves and net health benefits. Triple therapy (peginterferon plus ribavirin plus thymosin alpha-1) was dominant with lower cost and higher utility in relationship with peginterferon + ribavirin option, peginterferon alone and no-treatment option. In triple therapy the cost per unit of success was of 1,908 [USD/quality-adjusted life years (QALY)] compared with peginterferon plus ribavirin 2,277/QALY, peginterferon alone 2,929/QALY, and no treatment 4,204/QALY. Sensitivity analyses confirmed the robustness of the base case. Peginterferon plus ribavirin plus thymosin alpha-1 option was dominant (lowest cost and highest effectiveness). Using no drug was the most expensive and least effective option.

An economic evaluation of contingency management for completion of hepatitis B vaccination in those on treatment for opiate dependence.

PubMed

Rafia, Rachid; Dodd, Peter J; Brennan, Alan; Meier, Petra S; Hope, Vivian D; Ncube, Fortune; Byford, Sarah; Tie, Hiong; Metrebian, Nicola; Hellier, Jennifer; Weaver, Tim; Strang, John

2016-09-01

To determine whether the provision of contingency management using financial incentives to improve hepatitis B vaccine completion in people who inject drugs entering community treatment represents a cost-effective use of health-care resources. A probabilistic cost-effectiveness analysis was conducted, using a decision-tree to estimate the short-term clinical and health-care cost impact of the vaccination strategies, followed by a Markov process to evaluate the long-term clinical consequences and costs associated with hepatitis B infection. Data on attendance to vaccination from a UK cluster randomized trial. Two contingency management options were examined in the trial: fixed versus escalating schedule financial incentives. Life-time health-care costs and quality-adjusted life years discounted at 3.5% annually; incremental cost-effectiveness ratios. The resulting estimate for the incremental life-time health-care cost of the contingency management strategy versus usual care was £21.86 [95% confidence interval (CI) = -£12.20 to 39.86] per person offered the incentive. For 1000 people offered the incentive, the incremental reduction in numbers of hepatitis B infections avoided over their lifetime was estimated at 19 (95% CI = 8-30). The probabilistic incremental cost per quality adjusted life-year gained of the contingency management programme was estimated to be £6738 (95% CI = £6297-7172), with an 89% probability of being considered cost-effective at a threshold of £20 000 per quality-adjusted life years gained (97.60% at £30 000). Using financial incentives to increase hepatitis B vaccination completion in people who inject drugs could be a cost-effective use of health-care resources in the UK as long as the incidence remains above 1.2%. © 2016 Society for the Study of Addiction.

The cost-utility of photodynamic therapy in eyes with neovascular macular degeneration--a value-based reappraisal with 5-year data.

PubMed

Brown, Gary C; Brown, Melissa M; Campanella, Joseph; Beauchamp, George R

2005-10-01

To assess the value conferred by photodynamic therapy (PDT) and the cost-utility of PDT for the treatment of classic, subfoveal choroidal neovascularization associated with age-related macular degeneration (ARMD). Average cost-utility analysis utilizing clinical trial data, patient-based time tradeoff utility preferences, and a third party insurer cost perspective. Five-year visual acuity data from the TAP (Treatment of Age-related Macular Degeneration With Photodynamic Therapy) Investigation were modeled into a 12-year, value-based, reference case, cost-utility model utilizing year 2004 Medicare costs and an outcome of dollar/QALY (dollars/quality-adjusted life-year). Discounting of outcomes and costs using net present value analysis with a 3% annual rate was performed as recommended by the Panel for Cost-Effectiveness in Health and Medicine. PDT with verteporfin (Visudyne) dye for classic subfoveal choroidal neovascularization confers an 8.1% quality of life (value) improvement over the 12-year life expectancy of the reference case, while during the last 8 years the value improvement is 9.5%. The average cost-utility of the intervention is dollar 31,103/QALY (quality-adjusted life-year). Extensive one-way sensitivity analysis values range from dollar 20,736/QALY if treatment efficacy is increased by 50% to dollar 62,207 if treatment efficacy is decreased by 50%, indicating robustness of the model. PDT using verteporfin dye to treat classic subfoveal choroidal neovascularization is a very cost-effective treatment by conventional standards. The marked improvement in cost-effectiveness compared with a previous report results from the facts that the treatment benefit increasingly accrues during 5 years of follow-up while the number of yearly treatments diminishes markedly during that time.

The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review.

PubMed

Bryant-Lukosius, Denise; Carter, Nancy; Reid, Kim; Donald, Faith; Martin-Misener, Ruth; Kilpatrick, Kelley; Harbman, Patricia; Kaasalainen, Sharon; Marshall, Deborah; Charbonneau-Smith, Renee; DiCenso, Alba

2015-10-01

Clinical nurse specialists (CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care. We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We pooled data for similar outcomes. Thirteen RCTs of CNS transitional care were identified (n = 2463 participants). The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs. There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed. © 2015 John Wiley & Sons, Ltd.

Economic evaluation of multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: A randomized controlled trial.

PubMed

Vos-Vromans, Desirée; Evers, Silvia; Huijnen, Ivan; Köke, Albère; Hitters, Minou; Rijnders, Nieke; Pont, Menno; Knottnerus, André; Smeets, Rob

2017-01-01

A multi-centre RCT has shown that multidisciplinary rehabilitation treatment (MRT) is more effective in reducing fatigue over the long-term in comparison with cognitive behavioural therapy (CBT) for patients with chronic fatigue syndrome (CFS), but evidence on its cost-effectiveness is lacking. To compare the cost-effectiveness of MRT versus CBT for patients with CFS from a societal perspective. A multi-centre randomized controlled trial comparing MRT with CBT was conducted among 122 patients with CFS diagnosed using the 1994 criteria of the Centers for Disease Control and Prevention and aged between 18 and 60 years. The societal costs (healthcare costs, patient and family costs, and costs for loss of productivity), fatigue severity, quality of life, quality-adjusted life-year (QALY), and cost-effectiveness ratios (ICERs) were measured over a follow-up period of one year. The main outcome of the cost-effectiveness analysis was fatigue measured by the Checklist Individual Strength (CIS). The main outcome of the cost-utility analysis was the QALY based on the EuroQol-5D-3L utilities. Sensitivity analyses were performed, and uncertainty was calculated using the cost-effectiveness acceptability curves and cost-effectiveness planes. The data of 109 patients (57 MRT and 52 CBT) were analyzed. MRT was significantly more effective in reducing fatigue at 52 weeks. The mean difference in QALY between the treatments was not significant (0.09, 95% CI: -0.02 to 0.19). The total societal costs were significantly higher for patients allocated to MRT (a difference of €5,389, 95% CI: 2,488 to 8,091). MRT has a high probability of being the most cost effective, using fatigue as the primary outcome. The ICER is €856 per unit of the CIS fatigue subscale. The results of the cost-utility analysis, using the QALY, indicate that the CBT had a higher likelihood of being more cost-effective. The probability of being more cost-effective is higher for MRT when using fatigue as primary outcome variable. Using QALY as the primary outcome, CBT has the highest probability of being more cost-effective. ISRCTN77567702.

Clinical effectiveness and cost-effectiveness of different models of managing long-term oral anticoagulation therapy: a systematic review and economic modelling.

PubMed

Connock, M; Stevens, C; Fry-Smith, A; Jowett, S; Fitzmaurice, D; Moore, D; Song, F

2007-10-01

To examine the clinical effectiveness and cost-effectiveness of self-testing and self-management of oral anticoagulation treatment compared with clinic-based monitoring. Major electronic databases were searched up to September 2005. A systematic review was undertaken of relevant data from selected studies. Results about complication events and deaths were pooled in meta-analyses using risk difference (RD) as the outcome statistic. Heterogeneity across trials and possible publication bias were statistically measured. Subgroup analyses (post hoc) were conducted to compare results of self-testing versus self-management, low versus high trial quality, trials conducted in the UK versus trials in other countries and industry versus other sponsors. A Markov-type, state-transition model was developed. Stochastic simulations using the model were conducted to investigate uncertainty in estimated model parameters. In the 16 randomised and eight non-randomised trials selected, patient self-monitoring of oral anticoagulation therapy was found to be more effective than poor-quality usual care provided by family doctors and as effective as good-quality specialised anticoagulation clinics in maintaining the quality of anticoagulation therapy. There was no significant RD of major bleeding events between patient self-monitoring and usual care controls and pooled analyses found that compared with primary care or anticoagulation control (AC) clinics, self-monitoring was statistically significantly associated with fewer thromboembolic events. However, the reduction in complication events and deaths was not consistently associated with the improvement of AC; in some trials this may be due to alternative explanations, including patient education and patient empowerment. Also, the improved AC and the reduction of major complications and deaths by patient self-monitoring were mainly observed in trials conducted outside the UK. According to UK-specific data, for every 100 eligible patients, 24% would agree to conduct self-monitoring, 17 of the 24 patients (70%) could be successfully trained and able to carry out self-monitoring and only 14 of these (80%) would conduct long-term self-monitoring. Seven cost-effectiveness studies were identified and the study that provided the most relevant UK data found that patient self-management was more expensive than current routine care (417 pounds versus 122 pounds per patient-year) and concluded that using a cost-effectiveness threshold of 30,000 pounds per quality-adjusted life-year (QALY) gained, patient self-management does not appear to be cost-effective. De novo modelling for this report found that the incremental cost per QALY gained by patient self-monitoring is 122,365 pounds over 5 years and 63,655 pounds over 10 years. The estimated probability that patient self-monitoring is cost-effective (up to 30,000 pounds/QALY) is 44% over a 10-year period. Wide adoption of patient self-monitoring of anticoagulation therapy would cost the NHS an estimated additional 8-14 million pounds per year. For selected and successfully trained patients, self-monitoring is effective and safe for long-term oral anticoagulation therapy. In general, patient self-management (PSM) is unlikely to be more cost-effective than the current specialised anticoagulation clinics in the UK; self-monitoring may enhance the quality of life for some patients who are frequently away from home, who are in employment or education, or those who find it difficult to travel to clinics. Further research is needed into alternative dosing regimes, the clinical effectiveness and cost-effectiveness of patient education and training in long-term oral anticoagulation therapy, UK-relevant cost-effectiveness, the effectiveness of PSM in children, and the potential future developments of near-patient testing devices.

Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life: clinical article.

PubMed

Parker, Scott L; Godil, Saniya S; Mendenhall, Stephen K; Zuckerman, Scott L; Shau, David N; McGirt, Matthew J

2014-08-01

Current health care reform calls for a reduction of procedures and treatments that are less effective, more costly, and of little value (high cost/low quality). The authors assessed the 2-year cost and effectiveness of comprehensive medical management for lumbar spondylolisthesis, stenosis, and herniation by utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting. Analysis was performed on a prospective longitudinal quality of life spine registry. Patients with lumbar spondylolisthesis (n = 50), stenosis (n = 50), and disc herniation (n = 50) who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were entered into a prospective registry after deciding on nonsurgical treatment. In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, antiinflammatory medication, and narcotic oral agents. Two-year patient-reported outcomes, back-related medical resource utilization, and occupational work-day losses were prospectively collected and used to calculate Medicare fee-based direct and indirect costs from the payer and societal perspectives. The maximum health gain associated with medical management was defined as the improvement in pain, disability, and quality of life experienced after 2 years of medical treatment or at the time a patient decided to cross over to surgery. The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis. Eighteen patients (36%) with spondylolisthesis, 11 (22%) with stenosis, and 17 (34%) with disc herniation eventually required surgical management due to lack of improvement. The 2-year improvement did not achieve a minimum clinically important difference in any outcome measure. The mean 2-year total cost (direct plus indirect) of medical management was $6606 for spondylolisthesis, $7747 for stenosis, and $7097 for herniation. In an institution-wide, prospective, longitudinal quality of life registry that measures cost and effectiveness of all spine care provided, comprehensive medical management did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation. From both the societal and payer perspective, continued medical management of patients with these lumbar pathologies in whom 6 weeks of conservative therapy failed was of minimal value given its lack of health utility and effectiveness and its health care costs. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of nonoperative care in surgically eligible patient populations.

A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types.

PubMed

Tricco, Andrea C; Cogo, Elise; Isaranuwatchai, Wanrudee; Khan, Paul A; Sanmugalingham, Geetha; Antony, Jesmin; Hoch, Jeffrey S; Straus, Sharon E

2015-04-22

Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base. We searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013. Overall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types. Our results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings. Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5.

Air quality co-benefits and costs under state, regional, or national cooperation to regulate CO2 from existing power plants

NASA Astrophysics Data System (ADS)

Saari, R.; Selin, N. E.

2015-12-01

We examine the effect of state, regional, and national cooperation on the costs and air quality co-benefits of a policy to limit the carbon intensity of existing electricity generation. Electricity generation is a significant source of both greenhouse gases and air pollutant emissions that harm human health. Previous studies have shown that air quality co-benefits can be substantial compared to the costs of limiting carbon emissions in the energy system. The EPA's proposed Clean Power Plan seeks to impose carbon intensity limits for each state, but allows states to cooperate in order to meet combined limits. We explore how such cooperation might produce trade-offs between lower costs, widespread pollution reductions, and local reductions. We employ a new state-level model of the US energy system and economy to examine the costs and emissions as states reduce demand or deploy cleaner generation. We use an advanced air quality impacts modeling system, including SMOKE, CAMx, and BenMAP, to estimate health-related air quality co-benefits and compare these to costs under different levels of cooperation. We draw conclusions about the potential impacts of cooperation on economic welfare at various scales.

Research of Influence Modification of Natural Concentrate on Quality Metal

NASA Astrophysics Data System (ADS)

Fedoseev, S. N.; Gizatulin, R. A.; Korotkova, E. A.

2016-08-01

Questions of increase of mechanical, technological and service properties of metal at minimum cost to produce it are relevant for the metallurgical enterprises. Modification of complex steel alloys containing reactive elements is one of the effective ways to improve the quality of steel. At the same time the direct costs for the use of modifiers are 0.2-0.3%, which little effect on the cost of production. The paper presents the results of the application of natural concentrates as a modifier steel. The effects on the metal quality changes due to the impact of the modification concentrates demonstrate the effectiveness of their application. As a result of modification decreased the content of nonmetallic inclusions and grain size. Reduction of impurity modified metal of was the cause more high plastic properties, especially, impact strength at ordinary and low temperatures of tests. Based on the experimental data evaluated hardening mechanisms that lead to a significant improvement of physic-mechanical properties of the metal workpiece after administration modifier.

The cost-effectiveness of routine postoperative radiotherapy after sector resection and axillary dissection for breast cancer stage I. Results from a randomized trial.

PubMed

Liljegren, G; Karlsson, G; Bergh, J; Holmberg, L

1997-08-01

Cost-effectiveness of routine postoperative radiotherapy after breast-conserving surgery has not been prospectively evaluated earlier. In times of rationing of medical resources, valid assessments of cost-effectiveness are important for rational allocation of resources. Cost and cost-effectiveness of routine postoperative radiotherapy was calculated in a prospective randomized trial comparing sector resection plus axillary dissection with (XRT group) or without (non-XRT group) postoperative radiotherapy in breast cancer stage I. Three hundred eighty-one patients were included. After a median follow-up of five years 43 local recurrences, six of them in the XRT-group occurred (P < 0.0001). No difference in regional and distant recurrence (P = 0.23) or survival (P = 0.44) was observed. Direct medical costs as well as indirect costs in terms of production lost during the treatment period and travel expenses were estimated from data in the medical records and the national insurance registry of each patient. Average costs of different treatment activities and measures were estimated for the XRT-group and the non-XRT group respectively. From these estimates differences in costs and effectiveness between the groups were calculated and marginal cost-effectiveness ratios were estimated. For the construction of QALYs each life-year was quality-adjusted by a utility value depending on which health state the patient was considered to perceive. Taking into account the cost of primary treatment, the cost of follow-up, the cost of treatment of a local recurrence, travel expenses and indirect costs (production lost) excluding costs for treatment of regional and distant recurrence the cost per avoided local recurrence at five years was SEK 337,727 ($44,438, Pounds 27,018). Adjustment for quality of life showed a cost for every gained QALY to be SEK approximately 1.6 million, ($210,526, Pounds 128,000), range SEK 0.2-3.9 million ($26,315-513,158, Pounds 16,000-312,000). The cost of routine postoperative radiotherapy after sector resection and axillary dissection in breast cancer stage I per avoided local recurrence and gained QALY is high. The cost per gained QALY show great variation depending on utility value, which in this study was derived from external observers and not from the patients themselves. These results stress the importance of identifying risk factors for local recurrence, better understanding of impact on quality of life of a local recurrence and adding cost evaluations to clinical trials in early breast cancer.

Modeling green infrastructure land use changes on future air quality in Kansas City

EPA Science Inventory

Green infrastructure can be a cost-effective approach for reducing stormwater runoff and improving water quality as a result, but it could also bring co-benefits for air quality: less impervious surfaces and more vegetation can decrease the urban heat island effect, and also resu...

Cost Effective Prototyping

NASA Technical Reports Server (NTRS)

Wickman, Jerry L.; Kundu, Nikhil K.

1996-01-01

This laboratory exercise seeks to develop a cost effective prototype development. The exercise has the potential of linking part design, CAD, mold development, quality control, metrology, mold flow, materials testing, fixture design, automation, limited parts production and other issues as related to plastics manufacturing.

Cost-Effectiveness of a Community Pharmacist-Led Sleep Apnea Screening Program - A Markov Model.

PubMed

Perraudin, Clémence; Le Vaillant, Marc; Pelletier-Fleury, Nathalie

2013-01-01

Despite the high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. In many developed countries, because community pharmacists (CP) are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other healthcare providers (general practitioners (GPs), nurses, etc.). Alternative strategies for primary care screening programs for OSAS involving the CP are discussed. To estimate the quality of life, costs, and cost-effectiveness of three screening strategies among patients who are at risk of having moderate to severe OSAS in primary care. Markov decision model. Published data. Hypothetical cohort of 50-year-old male patients with symptoms highly evocative of OSAS. The 5 years after initial evaluation for OSAS. Societal. Screening strategy with CP (CP-GP collaboration), screening strategy without CP (GP alone) and no screening. Quality of life, survival and costs for each screening strategy. Under almost all modeled conditions, the involvement of CPs in OSAS screening was cost effective. The maximal incremental cost for "screening strategy with CP" was about 455€ per QALY gained. Our results were robust but primarily sensitive to the treatment costs by continuous positive airway pressure, and the costs of untreated OSAS. The probabilistic sensitivity analysis showed that the "screening strategy with CP" was dominant in 80% of cases. It was more effective and less costly in 47% of cases, and within the cost-effective range (maximum incremental cost effectiveness ratio at €6186.67/QALY) in 33% of cases. CP involvement in OSAS screening is a cost-effective strategy. This proposal is consistent with the trend in Europe and the United States to extend the practices and responsibilities of the pharmacist in primary care.

The clinical impact and cost-effectiveness of essential oils and aromatherapy for the treatment of acne vulgaris: a protocol for a randomized controlled trial.

PubMed

Agnew, Tamara; Leach, Matthew; Segal, Leonie

2014-05-01

Acne is a prevalent, chronic, and sometimes severe skin disorder affecting an estimated 85% of adolescents and 50% of adults older than age 20 years. The psychosocial implications of acne can be considerable, often continuing long after physical symptoms resolve. Although effective acne medications are available, most exhibit adverse-effect profiles that can leave the patient with few effective treatment options. Emerging evidence indicates that plant-derived essential oils may be a biologically plausible treatment for acne, although high-quality evidence of effectiveness and safety is lacking. To examine the clinical effectiveness and cost-effectiveness of essential oils and aromatherapy for the treatment of acne. This randomized, wait-list controlled trial will have three parallel groups; 192 participants with acne vulgaris, aged 16-45 years, will be recruited primarily through eight Technical and Further Education campuses across Adelaide, South Australia. Participants will be randomly assigned to standard essential oil blend, customized aromatherapy treatment, or wait-list control. Changes in the physical and psychosocial symptoms of acne will be assessed at baseline and 6 and 12 weeks by using the Leeds Acne Grading System, Assessment of Quality of Life-8 Dimension instrument, and Acne-Specific Quality of Life instrument. Costs of treatment will be measured on the basis of resource inputs and unit costs and will be limited to acne treatment. The clinical effectiveness and cost-effectiveness will be compared between each intervention and against usual care, using standard health economic techniques. The provision of high-quality evidence of the effectiveness of essential oils and aromatherapy in the treatment of acne may help consumers make better-informed choices about acne management. Insights gained from this research will also contribute to the academic field of complementary medicine, specifically aromatherapy, for which the evidence base is extremely limited.

Optimizing Chronic Disease Management Mega-Analysis

PubMed Central

PATH-THETA Collaboration

2013-01-01

Background As Ontario’s population ages, chronic diseases are becoming increasingly common. There is growing interest in services and care models designed to optimize the management of chronic disease. Objective To evaluate the cost-effectiveness and expected budget impact of interventions in chronic disease cohorts evaluated as part of the Optimizing Chronic Disease Management mega-analysis. Data Sources Sector-specific costs, disease incidence, and mortality were calculated for each condition using administrative databases from the Institute for Clinical Evaluative Sciences. Intervention outcomes were based on literature identified in the evidence-based analyses. Quality-of-life and disease prevalence data were obtained from the literature. Methods Analyses were restricted to interventions that showed significant benefit for resource use or mortality from the evidence-based analyses. An Ontario cohort of patients with each chronic disease was constructed and followed over 5 years (2006–2011). A phase-based approach was used to estimate costs across all sectors of the health care system. Utility values identified in the literature and effect estimates for resource use and mortality obtained from the evidence-based analyses were applied to calculate incremental costs and quality-adjusted life-years (QALYs). Given uncertainty about how many patients would benefit from each intervention, a system-wide budget impact was not determined. Instead, the difference in lifetime cost between an individual-administered intervention and no intervention was presented. Results Of 70 potential cost-effectiveness analyses, 8 met our inclusion criteria. All were found to result in QALY gains and cost savings compared with usual care. The models were robust to the majority of sensitivity analyses undertaken, but due to structural limitations and time constraints, few sensitivity analyses were conducted. Incremental cost savings per patient who received intervention ranged between $15 per diabetic patient with specialized nursing to $10,665 per patient wth congestive heart failure receiving in-home care. Limitations Evidence used to inform estimates of effect was often limited to a single trial with limited generalizability across populations, interventions, and health care systems. Because of the low clinical fidelity of health administrative data sets, intermediate clinical outcomes could not be included. Cohort costs included an average of all health care costs and were not restricted to costs associated with the disease. Intervention costs were based on resource use specified in clinical trials. Conclusions Applying estimates of effect from the evidence-based analyses to real-world resource use resulted in cost savings for all interventions. On the basis of quality-of-life data identified in the literature, all interventions were found to result in a greater QALY gain than usual care would. Implementation of all interventions could offer significant cost reductions. However, this analysis was subject to important limitations. Plain Language Summary Chronic diseases are the leading cause of death and disability in Ontario. They account for a third of direct health care costs across the province. This study aims to evaluate the cost-effectiveness of health care interventions that might improve the management of chronic diseases. The evaluated interventions led to lower costs and better quality of life than usual care. Offering these options could reduce costs per patient. However, the studies used in this analysis were of medium to very low quality, and the methods had many limitations. PMID:24228076

Information quality-control model

NASA Technical Reports Server (NTRS)

Vincent, D. A.

1971-01-01

Model serves as graphic tool for estimating complete product objectives from limited input information, and is applied to cost estimations, product-quality evaluations, and effectiveness measurements for manpower resources allocation. Six product quality levels are defined.

Clinical effectiveness, tolerability and cost-effectiveness of newer drugs for epilepsy in adults: a systematic review and economic evaluation.

PubMed

Wilby, J; Kainth, A; Hawkins, N; Epstein, D; McIntosh, H; McDaid, C; Mason, A; Golder, S; O'Meara, S; Sculpher, M; Drummond, M; Forbes, C

2005-04-01

To examine the clinical effectiveness, tolerability and cost-effectiveness of gabapentin (GBP), lamotrigine (LTG), levetiracetam (LEV), oxcarbazepine (OXC), tiagabine (TGB), topiramate (TPM) and vigabatrin (VGB) for epilepsy in adults. Electronic databases. Internet resources. Pharmaceutical company submissions. Selected studies were screened and quality assessed. Separate analyses assessed clinical effectiveness, serious, rare and long-term adverse events and cost-effectiveness. An integrated economic analysis incorporating information on costs and effects of newer and older antiepileptic drugs (AEDs) was performed to give direct comparisons of long-term costs and benefits. A total of 212 studies were included in the review. All included systematic reviews were Cochrane reviews and of good quality. The quality of randomised controlled trials (RCTs) was variable. Assessment was hampered by poor reporting of methods of randomisation, allocation concealment and blinding. Few of the non-randomised studies were of good quality. The main weakness of the economic evaluations was inappropriate use of the cost-minimisation design. The included systematic reviews reported that newer AEDs were effective as adjunctive therapy compared to placebo. For newer versus older drugs, data were available for all three monotherapy AEDs, although data for OXC and TPM were limited. There was limited, poor-quality evidence of a significant improvement in cognitive function with LTG and OXC compared with older AEDs. However, there were no consistent statistically significant differences in other clinical outcomes, including proportion of seizure-free patients. No studies assessed effectiveness of AEDs in people with intellectual disabilities or in pregnant women. There was very little evidence to assess the effectiveness of AEDs in the elderly; no significant differences were found between LTG and carbamazepine monotherapy. Sixty-seven RCTs compared adjunctive therapy with placebo, older AEDs or other newer AEDs. For newer AEDs versus placebo, a trend was observed in favour of newer drugs, and there was evidence of statistically significant differences in proportion of responders favouring newer drugs. However, it was not possible to assess long-term effectiveness. Most trials were conducted in patients with partial seizures. For newer AEDs versus older drugs, there was no evidence to assess the effectiveness of LEV, LTG or OXC, and evidence for other newer drugs was limited to single studies. Trials only included patients with partial seizures and follow-up was relatively short. There was no evidence to assess effectiveness of adjunctive LEV, OXC or TPM versus other newer drugs, and there were no time to event or cognitive data. No studies assessed the effectiveness of adjunctive AEDs in the elderly or pregnant women. There was some evidence from one study (GBP versus LTG) that both drugs have some beneficial effect on behaviour in people with learning disabilities. Eighty RCTs reported the incidence of adverse events. There was no consistent or convincing evidence to draw any conclusions concerning relative safety and tolerability of newer AEDs compared with each other, older AEDs or placebo. The integrated economic analysis for monotherapy for newly diagnosed patients with partial seizures showed that older AEDs were more likely to be cost-effective, although there was considerable uncertainty in these results. The integrated analysis suggested that newer AEDs used as adjunctive therapy for refractory patients with partial seizures were more effective and more costly than continuing with existing treatment alone. Combination therapy, involving new AEDs, may be cost-effective at a threshold willingness to pay per quality-adjusted life year (QALY) greater than 20,000 pounds, depending on patients' previous treatment history. There was, again, considerable uncertainty in these results. There were few data available to determine effectiveness of treatments for patients with generalised seizures. LTG and VPA showed similar health benefits when used as monotherapy. VPA was less costly and was likely to be cost-effective. The analysis indicated that TPM might be cost-effective when used as an adjunctive therapy, with an estimated incremental cost-effectiveness ratio of 34,500 pounds compared with continuing current treatment alone. There was little good-quality evidence from clinical trials to support the use of newer monotherapy or adjunctive therapy AEDs over older drugs, or to support the use of one newer AED in preference to another. In general, data relating to clinical effectiveness, safety and tolerability failed to demonstrate consistent and statistically significant differences between the drugs. The exception was comparisons between newer adjunctive AEDs and placebo, where significant differences favoured newer AEDs. However, trials often had relatively short-term treatment durations and often failed to limit recruitment to either partial or generalised onset seizures, thus limiting the applicability of the data. Newer AEDs, used as monotherapy, may be cost-effective for the treatment of patients who have experienced adverse events with older AEDs, who have failed to respond to the older drugs, or where such drugs are contraindicated. The integrated economic analysis also suggested that newer AEDs used as adjunctive therapy may be cost-effective compared with the continuing current treatment alone given a QALY of about 20,000 pounds. There is a need for more direct comparisons of the different AEDs within clinical trials, considering different treatment sequences within both monotherapy and adjunctive therapy. Length of follow-up also needs to be considered. Trials are needed that recruit patients with either partial or generalised seizures; that investigate effectiveness and cost-effectiveness in patients with generalised onset seizures and that investigate effectiveness in specific populations of epilepsy patients, as well as studies evaluating cognitive outcomes to use more stringent testing protocols and to adopt a more consistent approach in assessing outcomes. Further research is also required to assess the quality of life within trials of epilepsy therapy using preference-based measures of outcomes that generate cost-effectiveness data. Future RCTs should use CONSORT guidelines; and observational data to provide information on the use of AEDs in actual practice, including details of treatment sequences and doses.

Visual screening for malignant melanoma: a cost-effectiveness analysis.

PubMed

Losina, Elena; Walensky, Rochelle P; Geller, Alan; Beddingfield, Frederick C; Wolf, Lindsey L; Gilchrest, Barbara A; Freedberg, Kenneth A

2007-01-01

To evaluate the cost-effectiveness of various melanoma screening strategies proposed in the United States. We developed a computer simulation Markov model to evaluate alternative melanoma screening strategies. Hypothetical cohort of the general population and siblings of patients with melanoma. Intervention We considered the following 4 strategies: background screening only, and screening 1 time, every 2 years, and annually, all beginning at age 50 years. Prevalence, incidence, and mortality data were taken from the Surveillance, Epidemiology, and End Results Program. Sibling risk, recurrence rates, and treatment costs were taken from the literature. Outcomes included life expectancy, quality-adjusted life expectancy, and lifetime costs. Cost-effectiveness ratios were in dollars per quality-adjusted life year (US dollars/QALY) gained. In the general population, screening 1 time, every 2 years, and annually saved 1.6, 4.4, and 5.2 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 10,100/QALY, US dollars 80,700/QALY, and US dollars 586,800/QALY, respectively. In siblings of patients with melanoma (relative risk, 2.24 compared with the general population), 1-time, every-2-years, and annual screenings saved 3.6, 9.8, and 11.4 QALYs per 1000 persons screened, with incremental cost-effectiveness ratios of US dollars 4000/QALY, US dollars 35,500/QALY, and US dollars 257,800/QALY, respectively. In higher risk siblings of patients with melanoma (relative risk, 5.56), screening was more cost-effective. Results were most sensitive to screening cost, melanoma progression rate, and specificity of visual screening. One-time melanoma screening of the general population older than 50 years is very cost-effective compared with other cancer screening programs in the United States. Screening every 2 years in siblings of patients with melanoma is also cost-effective.

Cost-utility analyses of drug therapies in breast cancer: a systematic review.

PubMed

Nerich, Virginie; Saing, Sopany; Gamper, Eva Maria; Kemmler, Georg; Daval, Franck; Pivot, Xavier; Holzner, Bernhard

2016-10-01

The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.

Quality of Life and Cost-Effectiveness Assessment of Radioiodine Ablation Strategies in Patients With Thyroid Cancer: Results From the Randomized Phase III ESTIMABL Trial.

PubMed

Borget, Isabelle; Bonastre, Julia; Catargi, Bogdan; Déandréis, Désirée; Zerdoud, Slimane; Rusu, Daniela; Bardet, Stéphane; Leenhardt, Laurence; Bastie, Delphine; Schvartz, Claire; Vera, Pierre; Morel, Olivier; Benisvy, Daniele; Bournaud, Claire; Bonichon, Francoise; Kelly, Antony; Toubert, Marie-Elisabeth; Leboulleux, Sophie; Journeau, Florence; Benhamou, Ellen; Schlumberger, Martin

2015-09-10

In the ESTIMABL phase III trial, the thyroid ablation rate was equivalent for the two thyroid-stimulating hormone (TSH) stimulation methods (thyroid hormone withdrawal [THW] and recombinant human TSH [rhTSH]) and the two iodine-131 ((131)I) activities (1.1 or 3.7 GBq). The objectives of this article were to present health-related quality-of-life (HRQoL) results and a cost-effectiveness evaluation performed alongside this trial. HRQoL and utility were longitudinally assessed, from random assignment to the follow-up visit at 8 ± 2 months for the 752 patients with thyroid cancer, using the Short Form-36 and the EuroQoL-5D questionnaires, respectively. A cost-effectiveness analysis was performed from the societal perspective in the French context. Resource use (hospitalization for (131)I administration, rhTSH, sick leaves, and transportation) was collected prospectively. We used the net monetary benefit approach and computed cost-effectiveness acceptability curves for both TSH stimulation methods and (131)I activities. Sensitivity analyses of the costs of rhTSH were performed. At (131)I administration, THW caused a clinically significant deterioration of HRQoL, whereas HRQoL remained stable with rhTSH. This deterioration was transient with no difference 3 months later. rhTSH was more effective than THW in terms of quality-adjusted life-years (QALYs; +0.013 QALY/patient) but more expensive (+€474/patient). The probability that rhTSH would be cost effective at a €50,000/QALY threshold was 47% in France. The use of 1.1 GBq of (131)I instead of 3.7 GBq reduced per-patient costs by €955 (US$1,018) but with slightly decreased efficacy (-0.007 QALY/patient). rhTSH avoids the transient THW-induced deterioration of HRQoL but is unlikely to be cost effective at its current price. © 2015 by American Society of Clinical Oncology.

Mobile App for Treatment of Stress Urinary Incontinence: A Cost-Effectiveness Analysis.

PubMed

Sjöström, Malin; Lindholm, Lars; Samuelsson, Eva

2017-05-08

Mobile apps can increase access to care, facilitate self-management, and improve adherence to treatment. Stress urinary incontinence (SUI) affects 10-35% of women and, currently, an app with instructions for pelvic floor muscle training (PFMT) is available as first-line treatment. A previous randomized controlled study demonstrated that the app benefitted symptom severity and quality of life (QoL); in this study we investigate the cost-effectiveness of the app. The objective of this study was to evaluate the health economy of the app for treating SUI. This deterministic cost-utility analysis, with a 1-year societal perspective, compared the app treatment with no treatment. Health economic data were collected alongside a randomized controlled trial performed in Sweden from March 2013 to October 2014. This study included 123 community-dwelling women participants of 18 years and above, with stress urinary incontinence ≥1 time per week. Participants were self-assessed with validated questionnaires and 2-day leakage diaries, and then randomized to 3 months of treatment (app group, n=62) or no treatment (controls, n=61). The app focused on pelvic floor muscle training, prescribed 3 times daily. We continuously registered treatment delivery costs. Data were collected on each participant's training time, incontinence aids, and laundry at baseline and at a 3-month follow-up. We measured quality of life with the International Consultation on Incontinence Modular Questionnaire on Lower Urinary Tract Symptoms and Quality of Life, and calculated the quality-adjusted life years (QALYs) gained. Data from the 3-month follow-up were extrapolated to 1 year for the calculations. Our main outcome was the incremental cost-effectiveness ratios compared between app and control groups. One-way and multiway sensitivity analyses were performed. The mean age of participants was 44.7 years (SD 9.4). Annual costs were €547.0 for the app group and €482.4 for the control group. Annual gains in quality-adjusted life years for app and control groups were 0.0101 and 0.0016, respectively. Compared with controls, the extra cost per quality-adjusted life year for the app group ranged from -€2425.7 to €14,870.6, which indicated greater gains in quality-adjusted life years at similar or slightly higher cost. The app for treating stress urinary incontinence is a new, cost-effective, first-line treatment with potential for increasing access to care in a sustainable way for this patient group. ©Malin Sjöström, Lars Lindholm, Eva Samuelsson. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.05.2017.

Is procalcitonin-guided antimicrobial use cost-effective in adult patients with suspected bacterial infection and sepsis?

PubMed

Harrison, Michelle; Collins, Curtis D

2015-03-01

Procalcitonin has emerged as a promising biomarker of bacterial infection. Published literature demonstrates that use of procalcitonin testing and an associated treatment pathway reduces duration of antibiotic therapy without impacting mortality. The objective of this study was to determine the financial impact of utilizing a procalcitonin-guided treatment algorithm in hospitalized patients with sepsis. Cost-minimization and cost-utility analysis. Hypothetical cohort of adult ICU patients with suspected bacterial infection and sepsis. Utilizing published clinical and economic data, a decision analytic model was developed from the U.S. hospital perspective. Effectiveness and utility measures were defined using cost-per-clinical episode and cost per quality-adjusted life years (QALYs). Upper and lower sensitivity ranges were determined for all inputs. Univariate and probabilistic sensitivity analyses assessed the robustness of our model and variables. Incremental cost-effectiveness ratios (ICERs) were calculated and compared to predetermined willingness-to-pay thresholds. Base-case results predicted the use of a procalcitonin-guided treatment algorithm dominated standard care with improved quality (0.0002 QALYs) and decreased overall treatment costs ($65). The model was sensitive to a number of key variables that had the potential to impact results, including algorithm adherence (<42.3%), number and cost of procalcitonin tests ordered (≥9 and >$46), days of antimicrobial reduction (<1.6 d), incidence of nephrotoxicity and rate of nephrotoxicity reduction. The combination of procalcitonin testing with an evidence-based treatment algorithm may improve patients' quality of life while decreasing costs in ICU patients with suspected bacterial infection and sepsis; however, results were highly dependent on a number of variables and assumptions.

Cost-effectiveness of human papilloma virus vaccination in Iceland.

PubMed

Oddsson, Kristjan; Johannsson, Jakob; Asgeirsdottir, Tinna Laufey; Gudnason, Thorolfur

2009-01-01

To evaluate the likely cost-effectiveness of introducing routine HPV vaccination in Iceland. Prospective cost-effectiveness analysis of human papilloma virus (HPV) vaccination. Population of 12-year-old girls in the Icelandic population. A model was developed, comparing a cohort of all 12-year-old girls alive in year 2006, with or without vaccination. The model was based on the epidemiology of cervical cancer in Iceland and its premalignant stages as well as the costs involved in the treatment of each stage, assuming that the vaccines only prevent infections caused by HPV 16/18 at an efficacy of 95% and participation rate of 90%, no catch-up vaccination, no vaccination of boys and no booster dose needed. All costs were calculated on the basis of the price level of mid-year 2006 with a 3% discount rate. Incremental cost-effectiveness ratio calculations were performed and sensitivity analysis was carried out on factors most relevant for cost-effectiveness. Vaccination costs in excess of savings would be about euro313.000/year. Vaccination would reduce the number of women diagnosed with cervical cancer by almost 9, prevent the death of 1.7 women and result in 16.9 quality-adjusted life years gained annually. The incremental cost-effectiveness ratio was calculated to be about euro18.500/quality-adjusted life year saved. HPV vaccination seems to be cost-effective in Iceland, but this was sensitive to various parameters in the model, mainly the discount rate, the price of the vaccines and the need for a booster dose.

The cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer.

PubMed

Lao, Chunhuan; Edlin, Richard; Rouse, Paul; Brown, Charis; Holmes, Michael; Gilling, Peter; Lawrenson, Ross

2017-08-08

Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy. This study aims to evaluate the cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy. Markov models were constructed to estimate the life-time cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer patients aged 45-70 years, using national datasets in New Zealand and published studies including the SPCG-4 study. This study was from the perspective of the Ministry of Health in New Zealand. Radical prostatectomy is less costly than active surveillance in men aged 45-55 years with low risk localised prostate cancer, but more costly for men aged 60-70 years. Scenario analyses demonstrated significant uncertainty as to the most cost-effective option in all age groups because of the unavailability of good quality of life data for men under active surveillance. Uncertainties around the likelihood of having radical prostatectomy when managed with active surveillance also affect the cost-effectiveness of active surveillance against radical prostatectomy. Active surveillance is less likely to be cost-effective compared to radical prostatectomy for younger men diagnosed with low risk localised prostate cancer. The cost-effectiveness of active surveillance compared to radical prostatectomy is critically dependent on the 'trigger' for radical prostatectomy and the quality of life in men on active surveillance. Research on the latter would be beneficial.

Economic Analysis of Apixaban Therapy for Patients With Atrial Fibrillation From a US Perspective: Results From the ARISTOTLE Randomized Clinical Trial.

PubMed

Cowper, Patricia A; Sheng, Shubin; Lopes, Renato D; Anstrom, Kevin J; Stafford, Judith A; Davidson-Ray, Linda; Al-Khatib, Sana M; Ansell, Jack; Dorian, Paul; Husted, Steen; McMurray, John J V; Steg, P Gabriel; Alexander, John H; Wallentin, Lars; Granger, Christopher B; Mark, Daniel B

2017-05-01

The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial reported that apixaban therapy was superior to warfarin therapy in preventing stroke and all-cause death while causing significantly fewer major bleeds. To establish the value proposition of substituting apixiban therapy for warfarin therapy in patients with atrial fibrillation, we performed a cost-effectiveness analysis using patient-level data from the ARISTOTLE trial. To assess the cost and cost-effectiveness of apixaban therapy compared with warfarin therapy in patients with atrial fibrillation from the perspective of the US health care system. This economic analysis uses patient-level resource use and clinical data collected in the ARISTOTLE trial, a multinational randomized clinical trial that observed 18 201 patients (3417 US patients) for a median of 1.8 years between 2006 and 2011. Apixaban therapy vs warfarin therapy. Within-trial resource use and cost were compared between treatments, using externally derived US cost weights. Life expectancies for US patients were estimated according to their baseline risk and treatment using time-based and age-based survival models developed using the overall ARISTOTLE population. Quality-of-life adjustment factors were obtained from external sources. Cost-effectiveness (incremental cost per quality-adjusted life-year gained) was evaluated from a US perspective, and extensive sensitivity analyses were performed. Of the 3417 US patients enrolled in ARISTOTLE, the mean (SD) age was 71 (10) years; 2329 (68.2%) were male and 3264 (95.5%) were white. After 2 years of anticoagulation therapy, health care costs (excluding the study drug) of patients treated with apixaban therapy and warfarin therapy were not statistically different (difference, -$60; 95% CI, -$2728 to $2608). Life expectancy, modeled from ARISTOTLE outcomes, was significantly longer with apixaban therapy vs warfarin therapy (7.94 vs 7.54 quality-adjusted life years). The incremental cost, including cost of anticoagulant and monitoring, of achieving these benefits was within accepted US norms ($53 925 per quality-adjusted life year, with 98% likelihood of meeting a $100 000 willingness-to-pay threshold). Results were generally consistent when model assumptions were varied, with lifetime cost-effectiveness most affected by the price of apixaban and the time horizon. Apixaban therapy for ARISTOTLE-eligible patients with atrial fibrillation provides clinical benefits at an incremental cost that represents reasonable value for money judged using US benchmarks for cost-effectiveness. clinicaltrials.gov Identifier: NCT00412984.

Economic Analysis of Apixaban Therapy for Patients With Atrial Fibrillation From a US Perspective

PubMed Central

Sheng, Shubin; Lopes, Renato D.; Anstrom, Kevin J.; Stafford, Judith A.; Davidson-Ray, Linda; Al-Khatib, Sana M.; Ansell, Jack; Dorian, Paul; Husted, Steen; McMurray, John J. V.; Steg, P. Gabriel; Alexander, John H.; Wallentin, Lars; Granger, Christopher B.; Mark, Daniel B.

2017-01-01

Importance The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial reported that apixaban therapy was superior to warfarin therapy in preventing stroke and all-cause death while causing significantly fewer major bleeds. To establish the value proposition of substituting apixiban therapy for warfarin therapy in patients with atrial fibrillation, we performed a cost-effectiveness analysis using patient-level data from the ARISTOTLE trial. Objective To assess the cost and cost-effectiveness of apixaban therapy compared with warfarin therapy in patients with atrial fibrillation from the perspective of the US health care system. Design, Setting, and Participants This economic analysis uses patient-level resource use and clinical data collected in the ARISTOTLE trial, a multinational randomized clinical trial that observed 18 201 patients (3417 US patients) for a median of 1.8 years between 2006 and 2011. Interventions Apixaban therapy vs warfarin therapy. Main Outcomes and Measures Within-trial resource use and cost were compared between treatments, using externally derived US cost weights. Life expectancies for US patients were estimated according to their baseline risk and treatment using time-based and age-based survival models developed using the overall ARISTOTLE population. Quality-of-life adjustment factors were obtained from external sources. Cost-effectiveness (incremental cost per quality-adjusted life-year gained) was evaluated from a US perspective, and extensive sensitivity analyses were performed. Results Of the 3417 US patients enrolled in ARISTOTLE, the mean (SD) age was 71 (10) years; 2329 (68.2%) were male and 3264 (95.5%) were white. After 2 years of anticoagulation therapy, health care costs (excluding the study drug) of patients treated with apixaban therapy and warfarin therapy were not statistically different (difference, −$60; 95% CI, −$2728 to $2608). Life expectancy, modeled from ARISTOTLE outcomes, was significantly longer with apixaban therapy vs warfarin therapy (7.94 vs 7.54 quality-adjusted life years). The incremental cost, including cost of anticoagulant and monitoring, of achieving these benefits was within accepted US norms ($53 925 per quality-adjusted life year, with 98% likelihood of meeting a $100 000 willingness-to-pay threshold). Results were generally consistent when model assumptions were varied, with lifetime cost-effectiveness most affected by the price of apixaban and the time horizon. Conclusions and Relevance Apixaban therapy for ARISTOTLE-eligible patients with atrial fibrillation provides clinical benefits at an incremental cost that represents reasonable value for money judged using US benchmarks for cost-effectiveness. Trial Registration clinicaltrials.gov Identifier: NCT00412984 PMID:28355434

Cost-effectiveness of disease-modifying therapy for multiple sclerosis

PubMed Central

Bajorska, A.; Chappel, A.; Schwid, S.R.; Mehta, L.R.; Weinstock-Guttman, B.; Holloway, R.G.; Dick, A.W.

2011-01-01

Objective: To evaluate the cost-effectiveness of disease-modifying therapies (DMTs) in the United States compared to basic supportive therapy without DMT for patients with relapsing multiple sclerosis (MS). Methods: Using data from a longitudinal MS survey, we generated 10-year disease progression paths for an MS cohort. We used first-order annual Markov models to estimate transitional probabilities. Costs associated with losses of employment were obtained from the Bureau of Labor Statistics. Medical costs were estimated using the Centers for Medicare and Medicaid Services reimbursement rates and other sources. Outcomes were measured as gains in quality-adjusted life-years (QALY) and relapse-free years. Monte Carlo simulations, resampling methods, and sensitivity analyses were conducted to evaluate model uncertainty. Results: Using DMT for 10 years resulted in modest health gains for all DMTs compared to treatment without DMT (0.082 QALY or <1 quality-adjusted month gain for glatiramer acetate, and 0.126–0.192 QALY gain for interferons). The cost-effectiveness of all DMTs far exceeded $800,000/QALY. Reducing the cost of DMTs had by far the greatest impact on the cost-effectiveness of these treatments (e.g., cost reduction by 67% would improve the probability of Avonex being cost-effective at $164,000/QALY to 50%). Compared to treating patients with all levels of disease, starting DMT earlier was associated with a lower (more favorable) incremental cost-effectiveness ratio compared to initiating treatment at any disease state. Conclusion: Use of DMT in MS results in health gains that come at a very high cost. PMID:21775734

Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis.

PubMed

Padula, William V; Mishra, Manish K; Makic, Mary Beth F; Sullivan, Patrick W

2011-04-01

In October 2008, Centers for Medicare and Medicaid Services discontinued reimbursement for hospital-acquired pressure ulcers (HAPUs), thus placing stress on hospitals to prevent incidence of this costly condition. To evaluate whether prevention methods are cost-effective compared with standard care in the management of HAPUs. A semi-Markov model simulated the admission of patients to an acute care hospital from the time of admission through 1 year using the societal perspective. The model simulated health states that could potentially lead to an HAPU through either the practice of "prevention" or "standard care." Univariate sensitivity analyses, threshold analyses, and Bayesian multivariate probabilistic sensitivity analysis using 10,000 Monte Carlo simulations were conducted. Cost per quality-adjusted life-years (QALYs) gained for the prevention of HAPUs. Prevention was cost saving and resulted in greater expected effectiveness compared with the standard care approach per hospitalization. The expected cost of prevention was $7276.35, and the expected effectiveness was 11.241 QALYs. The expected cost for standard care was $10,053.95, and the expected effectiveness was 9.342 QALYs. The multivariate probabilistic sensitivity analysis showed that prevention resulted in cost savings in 99.99% of the simulations. The threshold cost of prevention was $821.53 per day per person, whereas the cost of prevention was estimated to be $54.66 per day per person. This study suggests that it is more cost effective to pay for prevention of HAPUs compared with standard care. Continuous preventive care of HAPUs in acutely ill patients could potentially reduce incidence and prevalence, as well as lead to lower expenditures.

Does litigation increase or decrease health care quality?: a national study of negligence claims against nursing homes.

PubMed

Stevenson, David G; Spittal, Matthew J; Studdert, David M

2013-05-01

The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic. To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes. We linked information on 6471 negligence claims brought against 1514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from 2 US national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homes' litigation experience in the preceding 12-18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥ 1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects. Nearly all combinations of the 3 litigation exposure measures and 9 quality measures--27 models in all--showed an inverse relationship between litigation costs and quality. However, only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates. Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly.

Does litigation increase or decrease health care quality? A national study of negligence claims against nursing homes

PubMed Central

Stevenson, David G.; Spittal, Matthew J.; Studdert, David M.

2016-01-01

Background The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic. Objective To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes. Research Design, Subjects, Measures We linked information on 6,471 negligence claims brought against 1,514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from two U.S. national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homes’ litigation experience in the preceding 12–18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects. Results Nearly all combinations of the 3 litigation exposure measures and 9 quality measures—27 models in all—showed an inverse relationship between litigation costs and quality. However only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates. Conclusions Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly. PMID:23552438

Cost-effectiveness of external cephalic version for term breech presentation

PubMed Central

2010-01-01

Background External cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation. Methods A computer-based decision model (TreeAge Pro 2008, Tree Age Software, Inc.) was developed for a hypothetical base case parturient presenting with a term singleton breech fetus with no contraindications for vaginal delivery. The model incorporated actual hospital costs (e.g., $8,023 for cesarean and $5,581 for vaginal delivery), utilities to quantify health-related quality of life, and probabilities based on analysis of published literature of successful ECV trial, spontaneous reversion, mode of delivery, and need for unanticipated emergency cesarean delivery. The primary endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted year of life gained. A threshold of $50,000 per quality-adjusted life-years (QALY) was used to determine cost-effectiveness. Results The incremental cost-effectiveness of ECV, assuming a baseline 58% success rate, equaled $7,900/QALY. If the estimated probability of successful ECV is less than 32%, then ECV costs more to society and has poorer QALYs for the patient. However, as the probability of successful ECV was between 32% and 63%, ECV cost more than cesarean delivery but with greater associated QALY such that the cost-effectiveness ratio was less than $50,000/QALY. If the probability of successful ECV was greater than 63%, the computer modeling indicated that a trial of ECV is less costly and with better QALYs than a scheduled cesarean. The cost-effectiveness of a trial of ECV is most sensitive to its probability of success, and not to the probabilities of a cesarean after ECV, spontaneous reversion to breech, successful second ECV trial, or adverse outcome from emergency cesarean. Conclusions From society's perspective, ECV trial is cost-effective when compared to a scheduled cesarean for breech presentation provided the probability of successful ECV is > 32%. Improved algorithms are needed to more precisely estimate the likelihood that a patient will have a successful ECV. PMID:20092630

Benefits and Costs of Pulp and Paper Effluent Controls Under the Clean Water Act

NASA Astrophysics Data System (ADS)

Luken, Ralph A.; Johnson, F. Reed; Kibler, Virginia

1992-03-01

This study quantifies local improvements in environmental quality from controlling effluents in the pulp and paper industry. Although it is confined to a single industry, this study is the first effort to assess the actual net benefits of the Clean Water Act pollution control program. An assessment of water quality benefits requires linking regulatory policy, technical effects, and behavioral responses. Regulatory policies mandate specific controls that influence the quantity and nature of effluent discharges. We identify a subset of stream segments suitable for analysis, describe water quality simulations and control cost calculations under alternative regulatory scenarios, assign feasible water uses to each segment based on water quality, and determine probable upper bounds for the willingness of beneficiaries to pay. Because the act imposes uniform regulations that do not account for differences in compliance costs, existing stream quality, contributions of other effluent sources, and recreation potential, the relation between water quality benefits and costs varies widely across sites. This variation suggests that significant positive net benefits have probably been achieved in some cases, but we conclude that the costs of the Clean Water Act as a whole exceed likely benefits by a significant margin.

Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis.

PubMed

Thoma, Achilleas; Veltri, Karen; Khuthaila, Dana; Rockwell, Gloria; Duku, Eric

2004-05-01

This study compared the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap in postmastectomy reconstruction using a cost-effectiveness analysis. A decision analytic model was used. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits for 2002. Hospital costs were obtained from St. Joseph's Healthcare, a university teaching hospital in Hamilton, Ontario, Canada. The utilities of clinically important health states related to breast reconstruction were obtained from 32 "experts" across Canada and converted into quality-adjusted life years. The probabilities of these various clinically important health states being associated with the DIEP and free TRAM flaps were obtained after a thorough review of the literature. The DIEP flap was more costly than the free TRAM flap ($7026.47 versus $6508.29), but it provided more quality-adjusted life years than the free TRAM flap (28.88 years versus 28.53 years). The baseline incremental cost-utility ratio was $1464.30 per quality-adjusted life year, favoring adoption of the DIEP flap. Sensitivity analyses were performed by assuming that the probabilities of occurrence of hernia, abdominal bulging, total flap loss, operating room time, and hospital stay were identical with the DIEP and free TRAM techniques. By assuming that the probability of postoperative hernia for the DIEP flap increased from 0.008 to 0.054 (same as for TRAM flap), the incremental cost-utility ratio changed to $1435.00 per quality-adjusted life year. A sensitivity analysis was performed for the complication of hernia because the DIEP flap allegedly diminishes this complication. Increasing the probability of abdominal bulge from 0.041 to 0.103 for the DIEP flap changed the ratio to $2731.78 per quality-adjusted life year. When the probability of total flap failure was increased from 0.014 to 0.016, the ratio changed to $1384.01 per quality-adjusted life year. When the time in the operating room was assumed to be the same for both flaps, the ratio changed to $4026.57 per quality-adjusted life year. If the hospital stay was assumed to be the same for both flaps, the ratio changed to $1944.30 per quality-adjusted life year. On the basis of the baseline calculation and sensitivity analyses, the DIEP flap remained a cost-effective procedure. Thus, adoption of this new technique for postmastectomy reconstruction is warranted in the Canadian health care system.

Economic Analysis of Physical Activity Interventions

PubMed Central

Wu, Shinyi; Cohen, Deborah; Shi, Yuyan; Pearson, Marjorie; Sturm, Roland

2011-01-01

Background Numerous interventions have been shown to increase physical activity, but have not been ranked by effectiveness or cost. Purpose This study provides a systematic review of physical activity interventions and calculates their cost-effectiveness ratios. Methods A systematic literature review was conducted (5,579 articles) and 91 effective interventions promoting physical activity were identified with enough information to translate effects into MET-hours gained. Cost-effectiveness ratios were then calculated as cost per MET-hour gained per day per individual reached. Physical activity benefits were compared to U.S. guideline–recommended levels (1.5 MET-hours per day for adults and 3.0 MET-hours per day for children, equivalent to walking 30 and 60 minutes respectively). Results The most cost-effective strategies were for point-of-decision prompts (e.g., signs to prompt stair use), with a median cost of $0.07/MET-hour/day/person; these had tiny effects, adding only 0.2% of minimum recommended physical activity levels. School-based physical activity interventions targeting children and adolescents ranked well with a median of $0.42/MET-hour/day/person, generating an average of 16% of recommended physical activity. Although there were few interventions in the categories of “creation or enhanced access to places for physical activity” and “community campaigns”, several were cost effective. The least cost-effective categories were the high-intensity “individually-adapted behavior change” and “social support” programs; with median CE ratios of $0.84/ and $1.16/MET-hour/day/person. However, they also had the largest effect sizes, adding 35%–43% of recommended physical activity, respectively. Study quality was variable, with many relying on self-reported outcomes. Conclusions The cost-effectiveness, effect size, and study quality should all be considered when choosing physical activity interventions. PMID:21238863

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada.

PubMed

Enns, Eva A; Zaric, Gregory S; Strike, Carol J; Jairam, Jennifer A; Kolla, Gillian; Bayoumi, Ahmed M

2016-03-01

Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. Toronto and Ottawa, Canada. Simulated population of each city. Zero to five supervised injection facilities. Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada. © 2015 Society for the Study of Addiction.

Economic Evaluations of Pathology Tests, 2010-2015: A Scoping Review.

PubMed

Watts, Rory D; Li, Ian W; Geelhoed, Elizabeth A; Sanfilippo, Frank M; St John, Andrew

2017-09-01

Concerns about pathology testing such as the value provided by new tests and the potential for inappropriate utilization have led to a greater need to assess costs and benefits. Economic evaluations are a formal method of analyzing costs and benefits, yet for pathology tests, questions remain about the scope and quality of the economic evidence. To describe the extent and quality of published evidence provided by economic evaluations of pathology tests from 2010 to 2015. Economic evaluations relating to pathology tests from 2010 to 2015 were reviewed. Eight databases were searched for published studies, and details recorded for the country, clinical focus, type of testing, and consideration of sensitivity, specificity, and false test results. The reporting quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist and cost-effectiveness ratios were analyzed for publication bias. We found 356 economic evaluations of pathology tests, most of which regarded developed countries. The most common economic evaluations were cost-utility analyses and the most common clinical focus was infectious diseases. More than half of the studies considered sensitivity and specificity, but few studies considered the impact of false test results. The average Consolidated Health Economic Evaluation Reporting Standards checklist score was 17 out of 24. Cost-utility ratios were commonly less than $10,000/quality-adjusted life-year or more than $200,000/quality-adjusted life-year. The number of economic evaluations of pathology tests has increased in recent years, but the rate of increase has plateaued. Furthermore, the quality of studies in the past 5 years was highly variable, and there is some question of publication bias in reporting cost-effectiveness ratios. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

The Cost-Effectiveness of Ranibizumab for the Treatment of Diabetic Macular Edema.

PubMed

Brown, Gary C; Brown, Melissa M; Turpcu, Adam; Rajput, Yamina

2015-07-01

To assess the incremental, comparative effectiveness (patient value gain) and cost effectiveness (financial value gain) associated with 0.3-mg intravitreal ranibizumab injection therapy versus sham therapy for diabetic macular edema (DME). Value-Based Medicine (Center for Value-Based Medicine, Flourtown, PA) 14-year, cost-utility analysis using patient preferences and 2012 United States real dollars. Published data from the identical Ranibizumab Injection in Subjects with Clinically Significant Macular Edema with Center Involvement Secondary to Diabetes Mellitus (RISE and RIDE) clinical trials. An incremental cost-utility analysis was performed using societal and third-party insurer cost perspectives. Costs and outcomes were discounted with net present value analysis at 3% per annum. The incremental comparative effectiveness was measured in: (1) quality-adjusted life year (QALY) gain and (2) percent patient value (quality-of-life) gain. Cost effectiveness was quantified with the cost-utility ratio (CUR) measured as $/QALY. The 14-year, incremental patient value gain conferred by intravitreal ranibizumab therapy for diabetic maculopathy was 0.9981 QALY, equating to an 11.6% improvement in quality of life. The direct, ophthalmic medical cost for ranibizumab therapy in 1 eye was $30 116, whereas for 2 eyes it was $56 336. The direct, nonophthalmic, medical costs saved from decreased depression, injury, skilled nursing facility admissions, nursing home admissions, and other vision-associated costs totaled $51 758, resulting in an overall direct medical cost of $4578. The net mean societal cost for bilateral ranibizumab therapy was -$30 807. Of this total, decreased caregiver costs accrued a $31 406 savings against the direct medical costs, whereas decreased wage losses accrued a $3978 savings. The third-party insurer CUR for bilateral ranibizumab therapy was $4587/QALY. The societal cost perspective for bilateral therapy was -$30 807/QALY, indicating that ranibizumab therapy dominated sham therapy because it conferred both a positive QALY gain of 0.9981 and a financial value gain (positive financial return on investment) of $30 807 referent to the direct ophthalmic medical costs expended. Intravitreal ranibizumab therapy for the treatment of DME confers considerable patient (human) value gain. It also accrues financial value to patients, public and private insurers, and society. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

The development of funding recommendations for health technologies at the state level: A South Australian case study.

PubMed

Lambert, Robyn; Carter, Drew; Burgess, Naomi; Haji Ali Afzali, Hossein

2018-04-20

State governments often face capped budgets that can restrict expenditure on health technologies and their evaluation, yet many technologies are introduced to practice through state-funded institutions such as hospitals, rather than through national evaluation mechanisms. This research aimed to identify the criteria, evidence, and standards used by South Australian committee members to recommend funding for high-cost health technologies. We undertook 8 semi-structured interviews and 2 meeting observations with members of state-wide committees that have a mandate to consider the safety, effectiveness, and cost-effectiveness of high-cost health technologies. Safety and effectiveness were fundamental criteria for decision makers, who were also concerned with increasing consistency in care and equitable access to technologies. Committee members often consider evidence that is limited in quantity and quality; however, they perceive evaluations to be rigorous and sufficient for decision making. Precise standards for safety, effective, and cost-effectiveness could not be identified. Consideration of new technologies at the state level is grounded in the desire to improve health outcomes and equity of access for patients. High quality evidence is often limited. The impact funding decisions have on population health is unclear due to limited use of cost-effectiveness analysis and unclear cost-effectiveness standards. Copyright © 2018 John Wiley & Sons, Ltd.

Electrical Stimulation for Pressure Injuries: A Health Technology Assessment

PubMed Central

Lambrinos, Anna; Falk, Lindsey; Ali, Arshia; Holubowich, Corinne; Walter, Melissa

2017-01-01

Background Pressure injuries (bedsores) are common and reduce quality of life. They are also costly and difficult to treat. This health technology assessment evaluates the effectiveness, cost-effectiveness, budget impact, and lived experience of adding electrical stimulation to standard wound care for pressure injuries. Methods We conducted a systematic search for studies published to December 7, 2016, limited to randomized and non–randomized controlled trials examining the effectiveness of electrical stimulation plus standard wound care versus standard wound care alone for patients with pressure injuries. We assessed the quality of evidence through Grading of Recommendations Assessment, Development, and Evaluation (GRADE). In addition, we conducted an economic literature review and a budget impact analysis to assess the cost-effectiveness and affordability of electrical stimulation for treatment of pressure ulcers in Ontario. Given uncertainties in clinical evidence and resource use, we did not conduct a primary economic evaluation. Finally, we conducted qualitative interviews with patients and caregivers about their experiences with pressure injuries, currently available treatments, and (if applicable) electrical stimulation. Results Nine randomized controlled trials and two non–randomized controlled trials were found from the systematic search. There was no significant difference in complete pressure injury healing between adjunct electrical stimulation and standard wound care. There was a significant difference in wound surface area reduction favouring electrical stimulation compared with standard wound care. The only study on cost-effectiveness of electrical stimulation was partially applicable to the patient population of interest. Therefore, the cost-effectiveness of electrical stimulation cannot be determined. We estimate that the cost of publicly funding electrical stimulation for pressure injuries would be $0.77 to $3.85 million yearly for the next 5 years. Patients and caregivers reported that pressure injuries were burdensome and reduced their quality of life. Patients and caregivers also noted that electrical stimulation seemed to reduce the time it took the wounds to heal. Conclusions While electrical stimulation is safe to use (GRADE quality of evidence: high) there is uncertainty about whether it improves wound healing (GRADE quality of evidence: low). In Ontario, publicly funding electrical stimulation for pressure injuries could result in extra costs of $0.77 to $3.85 million yearly for the next 5 years. PMID:29201261

Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment.

PubMed

Donohue, Julie M; Pincus, Harold Alan

2007-01-01

Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the 'business case' for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment. We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression. There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic. Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of 2519 US dollars to a high of 49,500 US dollars. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.

Cost-effectiveness of pediatric bilateral cochlear implantation in Spain.

PubMed

Pérez-Martín, Jorge; Artaso, Miguel A; Díez, Francisco J

2017-12-01

To determine the incremental cost-effectiveness of bilateral versus unilateral cochlear implantation for 1-year-old children suffering from bilateral sensorineural severe to profound hearing loss from the perspective of the Spanish public health system. Cost-utility analysis. We conducted a general-population survey to estimate the quality-of-life increase contributed by the second implant. We built a Markov influence diagram and evaluated it for a life-long time horizon with a 3% discount rate in the base case. The incremental cost-effectiveness ratio of simultaneous bilateral implantation with respect to unilateral implantation for 1-year-old children with severe to profound deafness is €10,323 per quality-adjusted life year (QALY). For sequential bilateral implantation, it rises to €11,733/QALY. Both options are cost-effective for the Spanish health system, whose willingness to pay is estimated at around €30,000/QALY. The probabilistic sensitivity analysis shows that the probability of bilateral implantation being cost-effective reaches 100% for that cost-effectiveness threshold. Bilateral implantation is clearly cost-effective for the population considered. If possible, it should be done simultaneously (i.e., in one surgical operation), because it is as safe and effective as sequential implantation, and saves costs for the system and for users and their families. Sequential implantation is also cost-effective for children who have received the first implant recently, but it is difficult to determine when it ceases to be so because of the lack of detailed data. These results are specific for Spain, but the model can easily be adapted to other countries. 2C. Laryngoscope, 127:2866-2872, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results from PROTECT AF vs. PREVAIL

PubMed Central

Freeman, James V.; Hutton, David W.; Barnes, Geoffrey D.; Zhu, Ruo P.; Owens, Douglas K.; Garber, Alan M.; Go, Alan S.; Hlatky, Mark A.; Heidenreich, Paul A.; Wang, Paul J.; Al-Ahmad, Amin; Turakhia, Mintu P.

2016-01-01

Background Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost-effectiveness compared to anticoagulation has not been evaluated using all available contemporary trial data. Methods and Results We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost-effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of PROTECT AF and PREVAIL randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios (ICER) compared to warfarin and dabigatran were $20,486 and $23,422 per quality adjusted life year (QALY), respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 QALYs, respectively) and more costly. At a willingness-to-pay-threshold of $50,000 per QALY, LAA closure was cost-effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation. Conclusions Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost-effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer term trial results and post-marketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice. PMID:27307517

75 FR 8338 - EPA Science Advisory Board Staff Office Notification of a Meeting of the Ecological Effects...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-24

... the Second Section 812 Benefit-Cost Analysis of the Clean Air Act. The assessment of ecological... Analysis of the benefits and costs of the Clean Air Act. DATES: The EES augmented with additional experts... ecological effects of modeled air quality scenarios developed to support the Second Section 812 Benefit-Cost...

A cost-effectiveness study of ICT training among the visually impaired in the Netherlands.

PubMed

Patty, Nathalie J S; Koopmanschap, Marc; Holtzer-Goor, Kim

2018-04-17

Due to the ageing population, the number of visually impaired people in the Netherlands will increase. To ensure the future availability of services in rehabilitative eye care, we aim to assess the cost-effectiveness of information and communication technology (ICT) training among visually impaired adults from a societal perspective, using primary data from two large rehabilitative eye care providers in the Netherlands. Participants were asked to fill in a questionnaire, which used six different instruments at three different time points: pre training, post training and three months post training. We investigated whether the participants' quality of life and well-being improved after the training and whether this improvement persisted three months post training. Economic evaluation was conducted by comparing costs and outcomes before and after training. Quality of life and well-being were derived from the EQ-5D and ICECAP-O, respectively. Costs for productivity losses and medical consumption were obtained from the questionnaires. Information regarding the costs of training sessions was provided by the providers. Thirty-eight participants filled in all three questionnaires. The mean age at baseline was 63 years (SD = 16). The effect of ICT training on ICT skills and participants' well-being was positive and persisted three months after the last training session. Assuming these effects remain constant for 10 years, this would result in an incremental cost-effectiveness ratio (ICER) of € 11,000 per quality-adjusted life-year (QALY) and € 8000 per year of well-being gained, when only the costs of ICT training are considered. When the total costs of medical consumption are included, the ICER increases to € 17,000 per QALY gained and € 12,000 per year of well-being gained. Furthermore, when the willingness-to-pay threshold is € 20,000 per year of well-being, the probability that ICT training will be cost-effective is 75% (91% when including only the costs of ICT training). Our study suggests that ICT training among the visually impaired is cost-effective when the effects of ICT training on well-being persist for several years. However, further research involving a larger sample and incorporating long-term effects should be conducted.

How often do sensitivity analyses for economic parameters change cost-utility analysis conclusions?

PubMed

Schackman, Bruce R; Gold, Heather Taffet; Stone, Patricia W; Neumann, Peter J

2004-01-01

There is limited evidence about the extent to which sensitivity analysis has been used in the cost-effectiveness literature. Sensitivity analyses for health-related QOL (HR-QOL), cost and discount rate economic parameters are of particular interest because they measure the effects of methodological and estimation uncertainties. To investigate the use of sensitivity analyses in the pharmaceutical cost-utility literature in order to test whether a change in economic parameters could result in a different conclusion regarding the cost effectiveness of the intervention analysed. Cost-utility analyses of pharmaceuticals identified in a prior comprehensive audit (70 articles) were reviewed and further audited. For each base case for which sensitivity analyses were reported (n = 122), up to two sensitivity analyses for HR-QOL (n = 133), cost (n = 99), and discount rate (n = 128) were examined. Article mentions of thresholds for acceptable cost-utility ratios were recorded (total 36). Cost-utility ratios were denominated in US dollars for the year reported in each of the original articles in order to determine whether a different conclusion would have been indicated at the time the article was published. Quality ratings from the original audit for articles where sensitivity analysis results crossed the cost-utility ratio threshold above the base-case result were compared with those that did not. The most frequently mentioned cost-utility thresholds were $US20,000/QALY, $US50,000/QALY, and $US100,000/QALY. The proportions of sensitivity analyses reporting quantitative results that crossed the threshold above the base-case results (or where the sensitivity analysis result was dominated) were 31% for HR-QOL sensitivity analyses, 20% for cost-sensitivity analyses, and 15% for discount-rate sensitivity analyses. Almost half of the discount-rate sensitivity analyses did not report quantitative results. Articles that reported sensitivity analyses where results crossed the cost-utility threshold above the base-case results (n = 25) were of somewhat higher quality, and were more likely to justify their sensitivity analysis parameters, than those that did not (n = 45), but the overall quality rating was only moderate. Sensitivity analyses for economic parameters are widely reported and often identify whether choosing different assumptions leads to a different conclusion regarding cost effectiveness. Changes in HR-QOL and cost parameters should be used to test alternative guideline recommendations when there is uncertainty regarding these parameters. Changes in discount rates less frequently produce results that would change the conclusion about cost effectiveness. Improving the overall quality of published studies and describing the justifications for parameter ranges would allow more meaningful conclusions to be drawn from sensitivity analyses.

The cost-effectiveness of mandatory 20 mph zones for the prevention of injuries.

PubMed

Peters, Jaime L; Anderson, Rob

2013-03-01

Traffic calming and speed limits are major public health strategies for further reducing road injuries, especially for vulnerable pedestrians such as children and the elderly. We conducted a cost-benefit analysis (CBA-favoured by transport economists) alongside a cost-utility analysis (CUA-favoured by health economists) of mandatory 20 mph zones, providing a unique opportunity to compare assumptions and results. A CUA from the public sector perspective and a CBA from a broader societal perspective. One-way, threshold and probabilistic sensitivity analyses were undertaken. In low casualty areas the intervention was not cost-effective regardless of approach (CUA: cost per QALY = £429 800; CBA: net present value = -£25 500). In high casualty areas, the intervention was cost-effective from the CBA (a saving of £90 600), but not from the CUA [cost per quality-adjusted life year (QALY) = £86 500; assuming National Institute for Health and Clinical Excellence's benchmark for approving health technologies]. Mandatory 20 mph zones may be cost-effective in high casualty areas when a CBA from a societal perspective is considered. Although CBA may appear, in principle, more appropriate, the quality, age or absence of reliable data for many parameters means that there is a great deal of uncertainty and the results should be interpreted with caution.

The cost of nurse-sensitive adverse events.

PubMed

Pappas, Sharon Holcombe

2008-05-01

The aim of this study was to describe the methodology for nursing leaders to determine the cost of adverse events and effective levels of nurse staffing. The growing transparency of quality and cost outcomes motivates healthcare leaders to optimize the effectiveness of nurse staffing. Most hospitals have robust cost accounting systems that provide actual patient-level direct costs. These systems allow an analysis of the cost consumed by patients during a hospital stay. By knowing the cost of complications, leaders have the ability to justify the cost of improved staffing when quality evidence shows that higher nurse staffing improves quality. An analysis was performed on financial and clinical data from hospital databases of 3,200 inpatients. The purpose was to establish a methodology to determine actual cost per case. Three diagnosis-related groups were the focus of the analysis. Five adverse events were analyzed along with the costs. A regression analysis reported that the actual direct cost of an adverse event was dollars 1,029 per case in the congestive heart failure cases and dollars 903 in the surgical cases. There was a significant increase in the cost per case in medical patients with urinary tract infection and pressure ulcers and in surgical patients with urinary tract infection and pneumonia. The odds of pneumonia occurring in surgical patients decreased with additional registered nurse hours per patient day. Hospital cost accounting systems are useful in determining the cost of adverse events and can aid in decision making about nurse staffing. Adverse events add costs to patient care and should be measured at the unit level to adjust staffing to reduce adverse events and avoid costs.

Systematic review of the cost effectiveness of prophylactic treatments in the prevention of gastropathy in patients with rheumatoid arthritis or osteoarthritis taking non-steroidal anti-inflammatory drugs

PubMed Central

van Dieten, H. E M; Bos, I.; van Tulder, M. W; Lems, W.; Dijkmans, B.; Boers, M.

2000-01-01

A systematic review on the cost effectiveness of prophylactic treatments of non-steroidal anti-inflammatory drug (NSAID) induced gastropathy in patients with osteoarthritis or rheumatoid arthritis was conducted. Two reviewers conducted the literature search and the review. Both full and partial economic evaluations published in English, Dutch, or German were included. The criteria list published in the textbook of Drummond was used to determine the quality of the economic evaluations. The methodological quality of three randomised controlled trials (RCTs) in which the economic evaluations obtained probability estimates of NSAID induced gastropathy and adverse events was assessed by a list of internal validity criteria. The conclusions were based on a rating system consisting of four levels of evidence.
  Ten economic evaluations were included; three were based on RCTs. All evaluations studied misoprostol as prophylactic treatment: in one evaluation misoprostol was studied as a fixed component in a combination with diclofenac (Arthrotec). All economic evaluations comprised analytical studies containing a decision tree. The three trials were of high methodological quality. Nine economic evaluations were considered high quality and one economic evaluation was considered of low methodological quality. There is strong evidence (level "A") that the use of misoprostol for the prevention of NSAID induced gastropathy is cost effective, and limited evidence (level "C") that the use of Arthrotec is cost effective. Although the levels of evidence used in this review are arbitrary, it is believed that a qualitative analysis is useful: quantitative analyses in this field are hampered by the heterogeneity of economic evaluations. Existing criteria to evaluate the methodological quality of economic evaluations may need refinement for use in systematic reviews.

 PMID:11005773

Systematic review of the cost effectiveness of prophylactic treatments in the prevention of gastropathy in patients with rheumatoid arthritis or osteoarthritis taking non-steroidal anti-inflammatory drugs.

PubMed

van Dieten, H E; Korthals-de Bos, I B; van Tulder, M W; Lems, W F; Dijkmans, B A; Boers, M

2000-10-01

A systematic review on the cost effectiveness of prophylactic treatments of non-steroidal anti-inflammatory drug (NSAID) induced gastropathy in patients with osteoarthritis or rheumatoid arthritis was conducted. Two reviewers conducted the literature search and the review. Both full and partial economic evaluations published in English, Dutch, or German were included. The criteria list published in the textbook of Drummond was used to determine the quality of the economic evaluations. The methodological quality of three randomised controlled trials (RCTs) in which the economic evaluations obtained probability estimates of NSAID induced gastropathy and adverse events was assessed by a list of internal validity criteria. The conclusions were based on a rating system consisting of four levels of evidence. Ten economic evaluations were included; three were based on RCTs. All evaluations studied misoprostol as prophylactic treatment: in one evaluation misoprostol was studied as a fixed component in a combination with diclofenac (Arthrotec). All economic evaluations comprised analytical studies containing a decision tree. The three trials were of high methodological quality. Nine economic evaluations were considered high quality and one economic evaluation was considered of low methodological quality. There is strong evidence (level "A") that the use of misoprostol for the prevention of NSAID induced gastropathy is cost effective, and limited evidence (level "C") that the use of Arthrotec is cost effective. Although the levels of evidence used in this review are arbitrary, it is believed that a qualitative analysis is useful: quantitative analyses in this field are hampered by the heterogeneity of economic evaluations. Existing criteria to evaluate the methodological quality of economic evaluations may need refinement for use in systematic reviews.

Beyond Participation: Do the Cost and Quality of Higher Education Shape the Enrollment Composition? The Case of Italy

ERIC Educational Resources Information Center

Pigini, Claudia; Staffolani, Stefano

2016-01-01

We analyze the effects of costs, geographical accessibility, and quality of higher education institutions on participation and on the composition of enrolled students, in terms of their educational and socioeconomic backgrounds. We develop a theoretical framework for higher education choices of secondary school graduates where differently talented…

A systematic review of the cost and cost-effectiveness of electronic discharge communications

PubMed Central

Sevick, Laura K; Esmail, Rosmin; Tang, Karen; Lorenzetti, Diane L; Ronksley, Paul; James, Matthew; Santana, Maria; Ghali, William A; Clement, Fiona

2017-01-01

Background The transition between acute care and community care can be a vulnerable period in a patients’ treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. Objective To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. Methods We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. Results One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. Discussion Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care. PMID:28674136

Quality and safety in pediatric anesthesia.

PubMed

Varughese, Anna M; Rampersad, Sally E; Whitney, Gina M; Flick, Randall P; Anton, Blair; Heitmiller, Eugenie S

2013-12-01

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Prenatal nutrition services: a cost analysis.

PubMed

Splett, P L; Caldwell, H M; Holey, E S; Alton, I R

1987-02-01

The scarcity of information about program costs in relation to quality care prompted a cost analysis of prenatal nutrition services in two urban settings. This study examined prenatal nutrition services in terms of total costs, per client costs, per visit costs, and cost per successful outcome. Standard cost-accounting principles were used. Outcome measures, based on written quality assurance criteria, were audited using standard procedures. In the studied programs, nutrition services were delivered for a per client cost of $72 in a health department setting and $121 in a hospital-based prenatal care program. Further analysis illustrates that total and per client costs can be misleading and that costs related to successful outcomes are much higher. The three levels of cost analysis reported provide baseline data for quantifying the costs of providing prenatal nutrition services to healthy pregnant women. Cost information from these cost analysis procedures can be used to guide adjustments in service delivery to assure successful outcomes of nutrition care. Accurate cost and outcome data are necessary prerequisites to cost-effectiveness and cost-benefit studies.

What Are the Strength of Recommendations and Methodologic Reporting in Health Economic Studies in Orthopaedic Surgery?

PubMed

Makhni, Eric C; Steinhaus, Michael E; Swart, Eric; Bozic, Kevin J

2015-10-01

Cost-effectiveness research is an increasingly used tool in evaluating treatments in orthopaedic surgery. Without high-quality primary-source data, the results of a cost-effectiveness study are either unreliable or heavily dependent on sensitivity analyses of the findings from the source studies. However, to our knowledge, the strength of recommendations provided by these studies in orthopaedics has not been studied. We asked: (1) What are the strengths of recommendations in recent orthopaedic cost-effectiveness studies? (2) What are the reasons authors cite for weak recommendations? (3) What are the methodologic reporting practices used by these studies? The titles of all articles published in six different orthopaedic journals from January 1, 2004, through April 1, 2014, were scanned for original health economics studies comparing two different types of treatment or intervention. The full texts of included studies were reviewed to determine the strength of recommendations determined subjectively by our study team, with studies providing equivocal conclusions stemming from a lack or uncertainty surrounding key primary data classified as weak and those with definitive conclusions not lacking in high-quality primary data classified as strong. The reasons underlying a weak designation were noted, and methodologic practices reported in each of the studies were examined using a validated instrument. A total of 79 articles met our prespecified inclusion criteria and were evaluated in depth. Of the articles included, 50 (63%) provided strong recommendations, whereas 29 (37%) provided weak recommendations. Of the 29 studies, clinical outcomes data were cited in 26 references as being insufficient to provide definitive conclusions, whereas cost and utility data were cited in 13 and seven articles, respectively. Methodologic reporting practices varied greatly, with mixed adherence to framing, costs, and results reporting. The framing variables included clearly defined intervention, adequate description of a comparator, study perspective clearly stated, and reported discount rate for future costs and quality-adjusted life years. Reporting costs variables included economic data collected alongside a clinical trial or another primary source and clear statement of the year of monetary units. Finally, results reporting included whether a sensitivity analysis was performed. Given that a considerable portion of orthopaedic cost-effectiveness studies provide weak recommendations and that methodologic reporting practices varied greatly among strong and weak studies, we believe that clinicians should exercise great caution when considering the conclusions of cost-effectiveness studies. Future research could assess the effect of such cost-effectiveness studies in clinical practice, and whether the strength of recommendations of a study's conclusions has any effect on practice patterns. Given the increasing use of cost-effectiveness studies in orthopaedic surgery, understanding the quality of these studies and the reasons that limit the ability of studies to provide more definitive recommendations is critical. Highlighting the heterogeneity of methodologic reporting practices will aid clinicians in interpreting the conclusions of cost-effectiveness studies and improve future research efforts.

Is prostate cancer screening cost-effective? A microsimulation model of prostate-specific antigen-based screening for British Columbia, Canada

PubMed Central

Pataky, Reka; Gulati, Roman; Etzioni, Ruth; Black, Peter; Chi, Kim N.; Coldman, Andrew J.; Pickles, Tom; Tyldesley, Scott; Peacock, Stuart

2015-01-01

Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs considerable risk of overdiagnosis and potential harm to quality of life. Our objective was to evaluate the cost-effectiveness of PSA screening, with and without adjustment for quality of life, for the British Columbia (BC) population. We adapted an existing natural history model using BC incidence, treatment, cost and mortality patterns. The modeled mortality benefit of screening derives from a stage-shift mechanism, assuming mortality reduction consistent with the European Study of Randomized Screening for Prostate Cancer. The model projected outcomes for 40 year-old men under 14 combinations of screening ages and frequencies. Cost and utility estimates were explored with deterministic sensitivity analysis. The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55-69, to $588,300/LYG, for screening every two years from ages 40-74. The marginal benefits of increasing screening frequency to two years or starting screening at age 40 were small and came at significant cost. After utility adjustment, all screening strategies resulted in a loss of QALYs; however, this result was very sensitive to utility estimates. Plausible outcomes under a range of screening strategies inform discussion of prostate cancer screening policy in BC and similar jurisdictions. Screening may be cost-effective but the sensitivity of results to utility values suggests individual preferences for quality versus quantity of life should be a key consideration. PMID:24443367

Cost-effective handling of digital medical images in the telemedicine environment.

PubMed

Choong, Miew Keen; Logeswaran, Rajasvaran; Bister, Michel

2007-09-01

This paper concentrates on strategies for less costly handling of medical images. Aspects of digitization using conventional digital cameras, lossy compression with good diagnostic quality, and visualization through less costly monitors are discussed. For digitization of film-based media, subjective evaluation of the suitability of digital cameras as an alternative to the digitizer was undertaken. To save on storage, bandwidth and transmission time, the acceptable degree of compression with diagnostically no loss of important data was studied through randomized double-blind tests of the subjective image quality when compression noise was kept lower than the inherent noise. A diagnostic experiment was undertaken to evaluate normal low cost computer monitors as viable viewing displays for clinicians. The results show that conventional digital camera images of X-ray images were diagnostically similar to the expensive digitizer. Lossy compression, when used moderately with the imaging noise to compression noise ratio (ICR) greater than four, can bring about image improvement with better diagnostic quality than the original image. Statistical analysis shows that there is no diagnostic difference between expensive high quality monitors and conventional computer monitors. The results presented show good potential in implementing the proposed strategies to promote widespread cost-effective telemedicine and digital medical environments. 2006 Elsevier Ireland Ltd

Cost-effectiveness of a herpes zoster vaccination program among the French elderly people.

PubMed

Belchior, Emmanuel; Lévy-Bruhl, Daniel; Le Strat, Yann; Herida, Magid

2016-09-01

A vaccine against herpes zoster (HZ) and its complications has already proven safe and effective against infection and pain and against the related deterioration of quality of life in the elderly. In order to inform the vaccination decision-making process regarding inclusion of this vaccine in the French immunization schedule, we assessed the cost-effectiveness of several vaccination scenarios, compared to no vaccination. We chose to use a previously published Markov model. Starting vaccination in elderly individuals aged 65, 70 and 75 y old appears more cost-effective than vaccination for those aged 60 y old, with a cost-effectiveness ratio between 30,000 and 35,000 euros per quality-adjusted-life year (QALY) gained for the first 3 age groups versus 54,500 €; for the latter group. These results largely contributed to the recommendation to include the HZ vaccination in the French immunization schedule for people aged between 65 and 74 y old in France.

Cost-effectiveness of hospital pay-for-performance incentives.

PubMed

Nahra, Tammie A; Reiter, Kristin L; Hirth, Richard A; Shermer, Janet E; Wheeler, John R C

2006-02-01

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costsfor the payer were dollar 22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between dollar 12,967 and dollar 30,081, a level well under consensus measures of the value of a QALY.

Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review.

PubMed

Fiani, Brian; Quadri, Syed A; Farooqui, Mudassir; Cathel, Alessandra; Berman, Blake; Noel, Jerry; Siddiqi, Javed

2018-04-03

Whenever any new technology is introduced into the healthcare system, it should satisfy all three pillars of the iron triangle of health care, which are quality, cost-effectiveness, and accessibility. There has been quite advancement in the field of spine surgery in the last two decades with introduction of new technological modalities such as CAN and surgical robotic devices. MAZOR SpineAssist/Renaissance was the first robotic system to be approved for the use in spine surgeries in the USA in 2004. In this review, the authors sought to determine if the current literature supports this technology to be cost-effective, accessible, and improve the quality of care for individuals and populations by increasing the likelihood of desired health outcomes. Robotic-assisted surgery seems to provide perfection in surgical ergonomics and surgical dexterity, consequently improving patient outcomes. A lot of data is present on the accuracy, effectiveness, and safety of the robotic-guided technology which reflects remarkable improvements in quality of care, making its utility convincingly undisputable. The technology has been claimed to be cost-effective but there seems to be lack of data in the literature on this topic to validate this claim. Apart from just the outcome parameters, there is an immense need of studies on real-time cost-efficacy, patient perspective, surgeon and resident learning curve, and their experience with this new technology. Furthermore, new studies looking into increased utilities of this technology, such as brain and spine tumor resection, deep brain stimulation procedures, and osteotomies in deformity surgery, might authenticate the cost of the equipment.

Economic evaluation of chronic disease self-management for people with diabetes: a systematic review.

PubMed

Teljeur, C; Moran, P S; Walshe, S; Smith, S M; Cianci, F; Murphy, L; Harrington, P; Ryan, M

2017-08-01

To systematically review the evidence on the costs and cost-effectiveness of self-management support interventions for people with diabetes. Self-management support is the provision of education and supportive interventions to increase patients' skills and confidence in managing their health problems, potentially leading to improvements in HbA 1c levels in people with diabetes. Randomized controlled trials, observational studies or economic modelling studies were eligible for inclusion in the review. The target population was adults with diabetes. Interventions had to have a substantial component of self-management support and be compared with routine care. Study quality was evaluated using the Consensus on Health Economic Criteria and International Society of Pharmacoeconomic Outcomes Research questionnaires. A narrative review approach was used. A total of 16 costing and 21 cost-effectiveness studies of a range of self-management support interventions were identified. There was reasonably consistent evidence across 22 studies evaluating education self-management support programmes suggesting these interventions are cost-effective or superior to usual care. Telemedicine-type interventions were more expensive than usual care and potentially not cost-effective. There was insufficient evidence regarding the other types of self-management interventions, including pharmacist-led and behavioural interventions. The identified studies were predominantly of poor quality, with outcomes based on short-term follow-up data and study designs at high risk of bias. Self-management support education programmes may be cost-effective. There was limited evidence regarding other formats of self-management support interventions. The poor quality of many of the studies undermines the evidence base regarding the economic efficiency of self-management support interventions for people with diabetes. © 2016 Diabetes UK.

A simulation model of building intervention impacts on indoor environmental quality, pediatric asthma, and costs.

PubMed

Fabian, Maria Patricia; Adamkiewicz, Gary; Stout, Natasha Kay; Sandel, Megan; Levy, Jonathan Ian

2014-01-01

Although indoor environmental conditions can affect pediatric asthmatic patients, few studies have characterized the effect of building interventions on asthma-related outcomes. Simulation models can evaluate such complex systems but have not been applied in this context. We sought to evaluate the impact of building interventions on indoor environmental quality and pediatric asthma health care use, and to conduct cost comparisons between intervention and health care costs and energy savings. We applied our previously developed discrete event simulation model (DEM) to simulate the effect of environmental factors, medication compliance, seasonality, and medical history on (1) pollutant concentrations indoors and (2) asthma outcomes in low-income multifamily housing. We estimated health care use and costs at baseline and subsequent to interventions, and then compared health care costs with energy savings and intervention costs. Interventions, such as integrated pest management and repairing kitchen exhaust fans, led to 7% to 12% reductions in serious asthma events with 1- to 3-year payback periods. Weatherization efforts targeted solely toward tightening a building envelope led to 20% more serious asthma events, but bundling with repairing kitchen exhaust fans and eliminating indoor sources (eg, gas stoves or smokers) mitigated this effect. Our pediatric asthma model provides a tool to prioritize individual and bundled building interventions based on their effects on health and costs, highlighting the tradeoffs between weatherization, indoor air quality, and health. Our work bridges the gap between clinical and environmental health sciences by increasing physicians' understanding of the effect that home environmental changes can have on their patients' asthma. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.

Adding Specialized Clinics for Remote-Dwellers with Chronic Kidney Disease: A Cost-Utility Analysis

PubMed Central

Wiebe, Natasha; Klarenbach, Scott W.; Chui, Betty; Ayyalasomayajula, Bharati; Hemmelgarn, Brenda R.; Jindal, Kailash; Manns, Braden; Tonelli, Marcello

2012-01-01

Summary Background and objectives This study aimed to determine whether opening a new clinic in a remote region would be a cost-effective means of improving care for remote-dwellers with CKD. Design, setting, participants, & measurements This study is a cost-utility analysis from a public payer’s perspective over a lifetime horizon, using administrative data from a large cohort of adults with stage 3b-4 CKD in Alberta, Canada. The association between the distance from each simulated patient’s residence and the practice location of the closest nephrologist and clinical outcomes (quality of care, hospitalization, dialysis, and death) were examined. A Markov 6-month cycle economic decision model was analyzed; estimates of the effect of a new clinic were based on the association between residence location, resource use, and outcomes. Costs are reported in 2009 Canadian dollars. Results The costs for equipping and operating a clinic for 321 remote-dwelling patients were estimated at $25,000 and $250,000/yr, respectively. The incremental cost-utility ratios (ICURs) ranged from $4000 to $8000/quality-adjusted life-year under most scenarios. However, if reducing distance to nephrologist care does not alter mortality or hospitalization among remote-dwellers, the cost-effectiveness becomes less attractive. All other one-way sensitivity analyses had negligible effects on the ICUR. Conclusions Given the low costs of equipping and operating new clinics, and the very attractive ICUR relative to other currently funded interventions, establishing new clinics for remote-dwellers could play an important role in efficiently improving outcomes for patients with CKD. High-quality controlled studies are required to confirm this hypothesis. PMID:22076876

Cost-effectiveness analysis of oral fentanyl formulations for breakthrough cancer pain treatment

PubMed Central

Cortesi, Paolo Angelo; D’Angiolella, Lucia Sara; Vellucci, Renato; Allegri, Massimo; Casale, Giuseppe; Favaretti, Carlo; Kheiraoui, Flavia; Cesana, Giancarlo; Mantovani, Lorenzo Giovanni

2017-01-01

Breakthrough cancer Pain (BTcP) has a high prevalence in cancer population. Patients with BTcP reported relevant health care costs and poor quality of life. The study assessed the cost-effectiveness of the available Oral Fentanyl Formulations (OFFs) for BTcP in Italy. A decision-analytical model was developed to estimate costs and benefits associated with treatments, from the Italian NHS perspective. Expected reductions in pain intensity per BTcP episodes were translated into, percentage of BTcP reduction, resource use and Quality-Adjusted-Life-Years (QALYs). Relative efficacy, resources used and unit costs data were derived from the literature and validated by clinical experts. Probabilistic and deterministic sensitivity analyses were performed. At base-case analysis, Sublingual Fentanyl Citrate (FCSL) compared to other oral formulations reported a lower patient’s cost (€1,960.8) and a higher efficacy (18.7% of BTcP avoided and 0.0507 QALYs gained). The sensitivity analyses confirmed the main results in all tested scenarios, with the highest impact reported by BTcP duration and health care resources consumption parameters. Between OFFs, FCSL is the cost-effective option due to faster reduction of pain intensity. However, new research is needed to better understand the economic and epidemiologic impact of BTcP, and to collect more robust data on economic and quality of life impact of the different fentanyl formulations. Different fentanyl formulations are available to manage BTcP in cancer population. The study is the first that assesses the different impact in terms of cost and effectiveness of OFFs, providing new information to better allocate the resources available to treat BTcP and highlighting the need of better data. PMID:28654672

Cost-effectiveness of indwelling pleural catheter compared with talc in malignant pleural effusion.

PubMed

Olfert, Jordan A P; Penz, Erika D; Manns, Braden J; Mishra, Eleanor K; Davies, Helen E; Miller, Robert F; Luengo-Fernandez, Ramon; Gao, Song; Rahman, Najib M

2017-05-01

Malignant pleural effusion is associated with morbidity and mortality. A randomized controlled trial previously compared clinical outcomes and resource use with indwelling pleural catheter (IPC) and talc pleurodesis in this population. Using unpublished quality of life data, we estimate the cost-effectiveness of IPC compared with talc pleurodesis. Healthcare utilization and costs were captured during the trial. Utility weights produced by the EuroQol Group five-dimensional three-level questionnaire and survival were used to determine quality-adjusted life-years (QALYs) gained. The incremental cost-effectiveness ratio (ICER) was calculated over the 1-year trial period. Sensitivity analysis used patient survival data and modelled additional nursing time required per week for catheter drainage. Utility scores, cost and QALYs gained did not differ significantly between groups. The ICER for IPC compared with talc was favorable at $US10 870 per QALY gained. IPC was less costly with a probability exceeding 95% of being cost-effective when survival was <14 weeks, and was more costly when 2-h nursing time per week was assumed for catheter drainage. IPC is cost-effective when compared with talc, although substantial uncertainty exists around this estimate. IPC appears most cost-effective in patients with limited survival. If significant nursing time is required for catheter drainage, IPC becomes less likely to be cost-effective. Either therapy may be considered as a first-line option in treating malignant pleural effusion in patients without history of prior pleurodesis, with consideration for patient survival, support and preferences. © 2016 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.

Cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in Taiwan.

PubMed

Tseng, Chih-Chieh; Lai, Ming-Tang; Wu, Chia-Che; Yuan, Sheng-Po; Ding, Yi-Fang

2018-03-01

Health care systems and physicians need to conform to budgets and streamline resources to provide cost-effective quality care. Although endoscopic tympanoplasty (ET) has been performed for decades, no studies on the cost-effectiveness of ET and microscopic tympanoplasty (MT) for treating chronic otitis media have been published. The present study aimed to compare the cost-effectiveness of ET and MT for treating chronic otitis media. This study was performed using a Cohort-style Markov decision-tree economic model with a 30-year time horizon. The economic perspective was that of a third-party payer (Taiwan National Health Insurance System). Two treatment strategies were compared, namely ET and MT. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Probabilities were obtained from meta-analyses. Costs were obtained from the published literature and Taiwan National Health Insurance System database. Multiple sensitivity analyses were performed to account for data uncertainty. The reference case revealed that the total cost of ET was $NT 20,901 for 17.08 QALY per patient. By contrast, the total cost of MT was $NT 21,171 for 17.15 QALY per patient. The incremental cost effectiveness ratio for ET versus that of MT was $NT 3703 per QALY. The cost-effectiveness acceptability curve indicated that ET was comparable to MT at a willingness-to-pay threshold of larger than $NT 35,000 per QALY. This cost-effectiveness analysis indicates that ET is comparable to MT for treating chronic otitis media in Taiwan. This result provides the latest information for physicians, the government, and third-party payers to select proper clinical practice. Copyright © 2017. Published by Elsevier Taiwan LLC.

Cost-effectiveness of treating normal tension glaucoma.

PubMed

Li, Emmy Y; Tham, Clement C; Chi, Stanley C; Lam, Dennis S

2013-05-13

To assess the long-term cost-effectiveness of treating normal tension glaucoma (NTG). A Markov decision-analytic health model was developed to determine the cost-effectiveness of treating NTG with IOP lowering therapy to prevent progressive visual field loss. Transitional probabilities were derived from the Collaborative Normal Tension Glaucoma Study and cost data obtained from the literature and the Medicare fee schedule. Incremental cost-effectiveness ratios (ICER) of treating all patients with NTG and treating selected individuals with risk factors for disease progression were determined using Monte Carlo simulation. Sensitivity analyses were performed by varying the cost of consultations, medications, laser/surgery, and adjusting utility loss from progressed states. The ICER of treating all patients with NTG over a 10-year period was United States (US) $34,225 per quality-adjusted life year (QALY). The ICER would be reduced when treatment was offered selectively to those with risk factors for disease progression. The ICER for treating NTG patients with disc hemorrhage, migraine, and those who were female were US $24,350, US $25,533, and US $27,000 per QALY, respectively. The cost-effectiveness of treating all NTG patients in this model was sensitive to cost fluctuation of medications, choice of utility score associated with disease progression, and insensitive to cost of consultations and laser/surgery. It is cost-effective, in the long-term, to offer IOP lowering therapy, aiming for a 30% reduction from the baseline, to all NTG patients. The incremental cost-effectiveness ratio of treating all patients with normal tension glaucoma over a 10-year period was $34,225 per quality-adjusted life year and should be offered to individuals in need.

Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model: A Web-based program designed to evaluate the cost-effectiveness of disease management programs in heart failure.

PubMed

Reed, Shelby D; Neilson, Matthew P; Gardner, Matthew; Li, Yanhong; Briggs, Andrew H; Polsky, Daniel E; Graham, Felicia L; Bowers, Margaret T; Paul, Sara C; Granger, Bradi B; Schulman, Kevin A; Whellan, David J; Riegel, Barbara; Levy, Wayne C

2015-11-01

Heart failure disease management programs can influence medical resource use and quality-adjusted survival. Because projecting long-term costs and survival is challenging, a consistent and valid approach to extrapolating short-term outcomes would be valuable. We developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, a Web-based simulation tool designed to integrate data on demographic, clinical, and laboratory characteristics; use of evidence-based medications; and costs to generate predicted outcomes. Survival projections are based on a modified Seattle Heart Failure Model. Projections of resource use and quality of life are modeled using relationships with time-varying Seattle Heart Failure Model scores. The model can be used to evaluate parallel-group and single-cohort study designs and hypothetical programs. Simulations consist of 10,000 pairs of virtual cohorts used to generate estimates of resource use, costs, survival, and incremental cost-effectiveness ratios from user inputs. The model demonstrated acceptable internal and external validity in replicating resource use, costs, and survival estimates from 3 clinical trials. Simulations to evaluate the cost-effectiveness of heart failure disease management programs across 3 scenarios demonstrate how the model can be used to design a program in which short-term improvements in functioning and use of evidence-based treatments are sufficient to demonstrate good long-term value to the health care system. The Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model provides researchers and providers with a tool for conducting long-term cost-effectiveness analyses of disease management programs in heart failure. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of comprehensive cardiac telerehabilitation on one-year cardiovascular rehospitalization rate, medical costs and quality of life: A cost-effectiveness analysis.

PubMed

Frederix, Ines; Hansen, Dominique; Coninx, Karin; Vandervoort, Pieter; Vandijck, Dominique; Hens, Niel; Van Craenenbroeck, Emeline; Van Driessche, Niels; Dendale, Paul

2016-05-01

Notwithstanding the cardiovascular disease epidemic, current budgetary constraints do not allow for budget expansion of conventional cardiac rehabilitation programmes. Consequently, there is an increasing need for cost-effectiveness studies of alternative strategies such as telerehabilitation. The present study evaluated the cost-effectiveness of a comprehensive cardiac telerehabilitation programme. This multi-centre randomized controlled trial comprised 140 cardiac rehabilitation patients, randomized (1:1) to a 24-week telerehabilitation programme in addition to conventional cardiac rehabilitation (intervention group) or to conventional cardiac rehabilitation alone (control group). The incremental cost-effectiveness ratio was calculated based on intervention and health care costs (incremental cost), and the differential incremental quality adjusted life years (QALYs) gained. The total average cost per patient was significantly lower in the intervention group (€2156 ± €126) than in the control group (€2720 ± €276) (p = 0.01) with an overall incremental cost of €-564.40. Dividing this incremental cost by the baseline adjusted differential incremental QALYs (0.026 QALYs) yielded an incremental cost-effectiveness ratio of €-21,707/QALY. The number of days lost due to cardiovascular rehospitalizations in the intervention group (0.33 ± 0.15) was significantly lower than in the control group (0.79 ± 0.20) (p = 0.037). This paper shows the addition of cardiac telerehabilitation to conventional centre-based cardiac rehabilitation to be more effective and efficient than centre-based cardiac rehabilitation alone. These results are useful for policy makers charged with deciding how limited health care resources should best be allocated in the era of exploding need. © The European Society of Cardiology 2015.

Economic evaluation of fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection in Australia.

PubMed

Merlo, Gregory; Graves, Nicholas; Brain, David; Connelly, Luke B

2016-12-01

Clostridium difficile is the most common cause of hospital-acquired diarrhea in Australia. In 2013, a randomized controlled trial demonstrated the effectiveness of fecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). The aim of this study is to evaluate the cost-effectiveness of fecal microbiota transplantation-via either nasoduodenal or colorectal delivery-compared with vancomycin for the treatment of recurrent CDI in Australia. A Markov model was developed to compare the cost-effectiveness of fecal microbiota transplantation compared with standard antibiotic therapy. A literature review of clinical evidence informed the structure of the model and the choice of parameter values. Clinical effectiveness was measured in terms of quality-adjusted life years. Uncertainty in the model was explored using probabilistic sensitivity analysis. Both nasoduodenal and colorectal FMT resulted in improved quality of life and reduced cost compared with vancomycin. The incremental effectiveness of either FMT delivery compared with vancomycin was 1.2 (95% CI: 0.1, 2.3) quality-adjusted life years, or 1.4 (95% CI: 0.4, 2.4) life years saved. Treatment with vancomycin resulted in an increased cost of AU$4094 (95% CI: AU$26, AU$8161) compared with nasoduodenal delivery of FMT and AU$4045 (95% CI: -AU$33, AU$8124) compared with colorectal delivery. The mean difference in cost between colorectal and nasoduodenal FMT was not significant. If FMT, rather than vancomycin, became standard care for recurrent CDI in Australia, the estimated national healthcare savings would be over AU$4000 per treated person, with a substantial increase in quality of life. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Economic evaluation of emergency obstetric care training: a systematic review.

PubMed

Banke-Thomas, Aduragbemi; Wilson-Jones, Megan; Madaj, Barbara; van den Broek, Nynke

2017-12-04

Training healthcare providers in Emergency Obstetric Care (EmOC) has been shown to be effective in improving their capacity to provide this critical care package for mothers and babies. However, little is known about the costs and cost-effectiveness of such training. Understanding costs and cost-effectiveness is essential in guaranteeing value-for-money in healthcare spending. This study systematically reviewed the available literature on cost and cost-effectiveness of EmOC trainings. Peer-reviewed and grey literature was searched for relevant papers published after 1990. Studies were included if they described an economic evaluation of EmOC training and the training cost data were available. Two reviewers independently searched, screened, and selected studies that met the inclusion criteria, with disagreements resolved by a third reviewer. Quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. For comparability, all costs in local currency were converted to International dollar (I$) equivalents using purchasing power parity conversion factors. The cost per training per participant was calculated. Narrative synthesis was used to summarise the available evidence on cost effectiveness. Fourteen studies (five full and nine partial economic evaluations) met the inclusion criteria. All five and two of the nine partial economic evaluations were of high quality. The majority of studies (13/14) were from low- and middle-income countries. Training equipment, per diems and resource person allowance were the most expensive components. Cost of training per person per day ranged from I$33 to I$90 when accommodation was required and from I$5 to I$21 when training was facility-based. Cost-effectiveness of training was assessed in 5 studies with differing measures of effectiveness (knowledge, skills, procedure cost and lives saved) making comparison difficult. Economic evaluations of EmOC training are limited. There is a need to scale-up and standardise processes that capture both cost and effectiveness of training and to agree on suitable economic evaluation models that allow for comparability across settings. PROSPERO_CRD42016041911 .

Model-based evaluation of cost-effectiveness of nerve growth factor inhibitors in knee osteoarthritis: impact of drug cost, toxicity, and means of administration.

PubMed

Losina, E; Michl, G; Collins, J E; Hunter, D J; Jordan, J M; Yelin, E; Paltiel, A D; Katz, J N

2016-05-01

Studies suggest nerve growth factor inhibitors (NGFi) relieve pain but may accelerate disease progression in some patients with osteoarthritis (OA). We sought cost and toxicity thresholds that would make NGFi a cost-effective treatment for moderate-to-severe knee OA. We used the Osteoarthritis Policy (OAPol) model to estimate the cost-effectiveness of NGFi compared to standard of care (SOC) in OA, using Tanezumab as an example. Efficacy and rates of accelerated OA progression were based on published studies. We varied the price/dose from $200 to $1000. We considered self-administered subcutaneous (SC) injections (no administration cost) vs provider-administered intravenous (IV) infusion ($69-$433/dose). Strategies were defined as cost-effective if their incremental cost-effectiveness ratio (ICER) was less than $100,000/quality-adjusted life year (QALY). In sensitivity analyses we varied efficacy, toxicity, and costs. SOC in patients with high levels of pain led to an average discounted quality-adjusted life expectancy of 11.15 QALYs, a lifetime risk of total knee replacement surgery (TKR) of 74%, and cumulative discounted direct medical costs of $148,700. Adding Tanezumab increased QALYs to 11.42, reduced primary TKR utilization to 63%, and increased costs to between $155,400 and $199,500. In the base-case analysis, Tanezumab at $600/dose was cost-effective when delivered outside of a hospital. At $1000/dose, Tanezumab was not cost-effective in all but the most optimistic scenario. Only at rates of accelerated OA progression of 10% or more (10-fold higher than reported values) did Tanezumab decrease QALYs and fail to represent a viable option. At $100,000/QALY, Tanezumab would be cost effective if priced ≤$400/dose in all settings except IV hospital delivery. Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Analyzing the cost effectiveness of Santiago, Chile's policy of using urban forests to improve air quality.

PubMed

Escobedo, Francisco J; Wagner, John E; Nowak, David J; De la Maza, Carmen Luz; Rodriguez, Manuel; Crane, Daniel E

2008-01-01

Santiago, Chile has the distinction of having among the worst urban air pollution problems in Latin America. As part of an atmospheric pollution reduction plan, the Santiago Regional Metropolitan government defined an environmental policy goal of using urban forests to remove particulate matter less than 10 microm (PM(10)) in the Gran Santiago area. We used cost effectiveness, or the process of establishing costs and selecting least cost alternatives for obtaining a defined policy goal of PM(10) removal, to analyze this policy goal. For this study, we quantified PM(10) removal by Santiago's urban forests based on socioeconomic strata and using field and real-time pollution and climate data via a dry deposition urban forest effects model. Municipal urban forest management costs were estimated using management cost surveys and Chilean Ministry of Planning and Cooperation documents. Results indicate that managing municipal urban forests (trees, shrubs, and grass whose management is under the jurisdiction of Santiago's 36 municipalities) to remove PM(10) was a cost-effective policy for abating PM(10) based on criteria set by the World Bank. In addition, we compared the cost effectiveness of managing municipal urban forests and street trees to other control policies (e.g. alternative fuels) to abate PM(10) in Santiago and determined that municipal urban forest management efficiency was similar to these other air quality improvement measures.

Cost-effectiveness analysis of early point-of-care lactate testing in the emergency department.

PubMed

Ward, Michael J; Self, Wesley H; Singer, Adam; Lazar, Danielle; Pines, Jesse M

2016-12-01

To determine the cost-effectiveness of implementing a point-of-care (POC) Lactate Program in the emergency department (ED) for patients with suspected sepsis to identify patients who can benefit from early resuscitation. We constructed a cost-effectiveness model to examine an ED with 30 000 patients annually. We evaluated a POC lactate program screening patients with suspected sepsis for an elevated lactate ≥4 mmol/L. Those with elevated lactate levels are resuscitated and their lactate clearance is evaluated by serial POC lactate measurements. The POC Lactate Program was compared with a Usual Care Strategy in which all patients with sepsis and an elevated lactate are admitted to the intensive care unit. Costs were estimated from the 2014 Medicare Inpatient and National Physician Fee schedules, and hospital and industry estimates. In the base-case, the POC Lactate Program cost $39.53/patient whereas the Usual Care Strategy cost $33.20/patient. The screened patients in the POC arm resulted in 1.07 quality-adjusted life years for an incremental cost-effectiveness ratio of $31 590 per quality-adjusted life year gained, well below accepted willingness-to-pay-thresholds. Implementing a POC Lactate Program for screening ED patients with suspected sepsis is a cost-effective intervention to identify patients responsive to early resuscitation. Copyright © 2016 Elsevier Inc. All rights reserved.

Intensive Care Nurses’ Belief Systems Regarding the Health Economics: A Focused Ethnography

PubMed Central

Heydari, Abbas; Vafaee-Najar, Ali; Bakhshi, Mahmoud

2016-01-01

Background: Health care beliefs can have an effect on the efficiency and effectiveness of nursing practices. Nevertheless, how belief systems impact on the economic performance of intensive care unit (ICU) nurses is not known. This study aimed to explore the ICU nurses’ beliefs and their effect on nurse’s: practices and behavior patterns regarding the health economics. Methods: In this study, a focused ethnography method was used. Twenty-four informants from ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations were used for data collection. Data analysis was performed using the methods described by Miles and Huberman (1994). Findings: Eight beliefs were found that gave meaning to ICU nurse’s practices regarding the health economics. 1. The registration of medications and supplies disrupt the nursing care; 2. Monitoring and auditing improve consumption; 3. There is a fear of possible shortage in the future; 4. Supply and replacement of equipment is difficult; 5. Higher prices lead to more accurate consumption; 6. The quality of care precedes the costs; 7. Clinical Guidelines are abundant but useful; and 8. Patient economy has priority over hospital economy. Maintaining the quality of patient care with least attention to hospital costs was the main focus of the beliefs formed up in the ICU regarding the health economics. Conclusions: ICU nurses’ belief systems have significantly shaped in relation to providing a high-quality care. Although high quality of care can lead to a rise in the effectiveness of nursing care, cost control perspective should also be considered in planning for improve the quality of care. Therefore, it is necessary to involve the ICU nurses in decision-making about unit cost management. They must become familiar with the principles of heath care economics and productivity by applying an effective cost management program. It may be optimal to implement the reforms in various aspects, such as the hospital’s strategic plan and supply chain management system. PMID:27157164

Intensive Care Nurses' Belief Systems Regarding the Health Economics: A Focused Ethnography.

PubMed

Heydari, Abbas; Vafaee-Najar, Ali; Bakhshi, Mahmoud

2016-09-01

Health care beliefs can have an effect on the efficiency and effectiveness of nursing practices. Nevertheless, how belief systems impact on the economic performance of intensive care unit (ICU) nurses is not known. This study aimed to explore the ICU nurses' beliefs and their effect on nurse's practices and behavior patterns regarding the health economics. In this study, a focused ethnography method was used. Twenty-four informants from ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations were used for data collection. Data analysis was performed using the methods described by Miles and Huberman (1994). Eight beliefs were found that gave meaning to ICU nurse's practices regarding the health economics. 1. The registration of medications and supplies disrupt the nursing care; 2.Monitoring and auditing improve consumption; 3.There is a fear of possible shortage in the future; 4.Supply and replacement of equipment is difficult; 5.Higher prices lead to more accurate consumption; 6.The quality of care precedes the costs; 7. Clinical Guidelines are abundant but useful; and 8.Patient economy has priority over hospital economy. Maintaining the quality of patient care with least attention to hospital costs was the main focus of the beliefs formed up in the ICU regarding the health economics. ICU nurses' belief systems have significantly shaped in relation to providing a high-quality care. Although high quality of care can lead to a rise in the effectiveness of nursing care, cost control perspective should also be considered in planning for improve the quality of care. Therefore, it is necessary to involve the ICU nurses in decision-making about unit cost management. They must become familiar with the principles of heath care economics and productivity by applying an effective cost management program. It may be optimal to implement the reforms in various aspects, such as the hospital's strategic plan and supply chain management system.

A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes.

PubMed

Elia, Marinos; Stratton, Rebecca J

2008-06-01

A cost-utility analysis was undertaken of enteral tube feeding (ETF) in patients with cerebrovascular accident (CVA). Mortality during ETF was established in nursing homes (n7007) or at home (n2888). Quality of life was measured (EuroQol) on a sub-sample (n25). Quality adjusted life years (QALYs) over 3 years and the cost/QALY were calculated. The cost/QALY (1 pound=1.482 euros; 30/06/05) for patients receiving ETF at home was 12,817 pounds (10,351 pounds-16,826 pounds using 95% CI for quality of life) and insensitive to the frequency of home visits (50-150% of the average frequency; 11,851 pounds-13,782 pounds), outcome of patients reverting to full oral feeding (0-100% survival; 11,023 pounds-14,440 pounds), and computed outcome of a 'control' group not given ETF (0.125-0.25 year survival; 12,991 pound-14,006 pounds). The cost/QALY in nursing homes (10,304 pounds-68,064 pounds) varied depending on the state contribution to non-medical costs and is above and below the threshold (30,000 pounds/QALY). The data suggest the cost-effectiveness of ETF in patients with CVA receiving ETF at home or in nursing homes, where the non-medical costs are paid privately, compares favourably with other interventions. The cost-effectiveness of ETF in nursing homes when the state pays all non-medical costs compares unfavourably with other treatments, raising economic, clinical, and ethical concerns.