Acceptable Incremental Cost-effectiveness Ratio Research Articles

OP93 The Cost Effectiveness Of Antiretroviral Therapy Adherence Interventions In HIV/AIDS Patients: A Systematic Review Of Decision Analytic Models

IntroductionPeople living with HIV/AIDS (PLWHA) frequently struggle to maintain optimal adherence to antiretrovirals (ARVs). Different adherence-improving interventions have been developed and examined through decision analytic model-based health technology assessments. Therefore, we aimed to conduct a systematic review of all decision analytic models developed to improve adherence in PLWHA.MethodsThe review protocol was registered on Prospero (CRD42022270039) and relevant studies published from inception to 23 October 2022 were identified through searches of the following databases: PubMed, Embase, the National Health Service Economic Evaluation Database, PsycINFO, the Health Economic Evaluations Database, and EconLit. Studies were included if they were modeling works of full economic evaluations, including cost-effectiveness analyses (CEA), cost-utility analyses, cost-benefit analyses, and cost-consequence analyses. The primary outcome was the cost effectiveness of adherence interventions reported as the incremental cost per additional quality-adjusted life-year (QALY). Study quality was assessed with the Quality of Health Economics Studies instrument. Due to the heterogeneity of the data, a permutation matrix was used for quantitative data synthesis rather than a meta-analysis.ResultsThe 15 studies identified were conducted in North America (8/15), Africa (4/15), and Europe (3/15). The time horizon was one year in one study, ten years in one study, 20 years in three studies, and a lifetime horizon in ten studies. The types of interventions were smartphone-based (5/15), nurse involved (2/15), directly observed therapy (2/15), case manager involved (1/15), simplification of regimens (1/15), Link4Health (1/15), and others (3/15) that involved multicomponent intervention. The interventions gained higher QALYs with cost savings in all 15 studies and gained QALYs at a higher cost at an acceptable incremental cost-effectiveness ratio in 80 percent (12/15) of studies. The studies were of fair (13%) to high quality (87%).ConclusionsThis study is the first systematic review of decision analytic model-based CEAs of adherence interventions in the management of PLWHA. Most of the identified studies recently published good quality cost-effectiveness analyses with an adequate timeframe.

Economic Evaluation of Individualized Nutritional Support for Hospitalized Patients with Chronic Heart Failure.

Background Malnutrition is a highly prevalent risk factor in hospitalized patients with chronic heart failure (CHF). A recent randomized trial found lower mortality and improved health outcomes when CHF patients with nutritional risk received individualized nutritional treatment. Objective To estimate the cost-effectiveness of individualized nutritional support in hospitalized patients with CHF. Methods This analysis used data from CHF patients at risk of malnutrition (N = 645) who were part of the Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial (EFFORT). Study patients with CHF were randomized into (i) an intervention group (individualized nutritional support to reach energy, protein, and micronutrient goals) or (ii) a control group (receiving standard hospital food). We used a Markov model with daily cycles (over a 6-month interval) to estimate hospital costs and health outcomes in the comparator groups, thus modeling cost-effectiveness ratios of nutritional interventions. Results With nutritional support, the modeled total additional cost over the 6-month interval was 15,159 Swiss Francs (SF). With an additional 5.77 life days, the overall incremental cost-effectiveness ratio for nutritional support vs. no nutritional support was 2625 SF per life day gained. In terms of complications, patients receiving nutritional support had a cost savings of 6214 SF and an additional 4.11 life days without complications, yielding an incremental cost-effectiveness ratio for avoided complications of 1513 SF per life day gained. Conclusions On the basis of a Markov model, this economic analysis found that in-hospital nutritional support for CHF patients increased life expectancy at an acceptable incremental cost-effectiveness ratio.

An economic evaluation of triage tools for patients with suspected severe injuries in England

BackgroundMany health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.MethodsA patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.ResultsFour tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.ConclusionsThe cost-effective triage tool depends on the English decision maker’s MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

Cost-effectiveness of screening mammography in a low income country: a Markov simulation analysis

BackgroundBreast cancer is the most common cancer diagnosed in women. Screening mammography is the only imaging screening study for breast cancer with a proven. mortality benefit. This study aims to analyze the cost-effectiveness of screening mammography in Ethiopia.MethodsMultistate Markov model was used for computer simulation to estimate cost and health benefits of screening mammography interventions for age-group of 40–49 years and 50–59 years. The cost-effectiveness analysis was made for 4 policies based on where the screening mammography procedures were conducted: government institution only, the private institution only, 50% ratio for each, and 10% private institution policy. Outputs were expressed in total cost, life-years gained (LYG) incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INMB).ResultsAll 4 policies of annual screening mammography failed to achieve acceptable ICER and lead to a net loss in INMB. The lowest ICER value was for government institution-only policy with 3510.3 USD/LYG and 3224.9 USD/LYG both above the cost-effectiveness threshold of 2808.5 USD. The cost per single death averted for each group was 110,206.7 USD and 77,088.2 USD for age-group 40–49 years and 50–59 years respectively.ConclusionScreening mammography could not be shown to be cost-effective in Ethiopia with the current low cost-effectiveness threshold. Alternative screening approach like annual clinical breast examination may need to be investigated.

PCN122 Cost-Effectiveness of Brentuximab Vedotin for the Frontline Treatment of Peripheral T-Cell Lymphomas in Canada

Health Canada recently expanded the use of brentuximab vedotin in combination with cyclophosphamide, doxorubicin, prednisone (A+CHP) for the frontline treatment of adult patients with systemic anaplastic large cell lymphoma (sALCL), peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) or angioimmunoblastic T-cell lymphoma (AITL), whose tumours express CD30. The approval was based on results from the ECHELON-2 trial that compared A+CHP to CHOP (CHP plus vincristine) in CD30+ PTCL. Median progression-free survival (PFS) for A+CHP was 48.2 vs 20.8 months for CHOP, providing a significant improvement in PFS and overall survival. This economic evaluation estimated the cost-effectiveness of A+CHP for its newly-approved indication by Health Canada. A partitioned survival model with a 3-week cycle length and lifetime time horizon was developed to simulate the disease course for the modelled population. The 3 health states modelled were PFS, post-progression survival, and death. Efficacy, safety and quality of life data were obtained from ECHELON-2 for the 3 subgroups combined. Medical resource use and costs were derived from Canadian literature and standard sources. Incremental cost-effectiveness ratios (ICERs) per life years (LYs) gained and per quality-adjusted life-years (QALYs) gained were calculated. Deterministic and probabilistic sensitivity analyses were performed to account for uncertainty in key parameters. A+CHP was associated with an estimated mean gain of 2.90 LYs and 2.38 QALYs and an estimated mean incremental cost of $76,491 vs CHOP; resulting ICERs were $26,340 per LY gained and $32,177 per QALY gained. In sensitivity analyses, time horizon, patient starting age, regimen cost for A+CHP, and discount rate had notable impacts on the results as the ICER was driven by long-term survival gains associated with A+CHP vs CHOP. A+CHP provides a cost-effective and clinically-meaningful improvement in treatment options for adults with previously untreated, CD30-expressing sALCL, PTCL-NOS or AITL in Canada, and is within acceptable ICER ranges for oncology medicines.

Abstract 171: Endovascular Thrombectomy May Be Cost-Effective for Patients With Large Core Ischemic Strokes: A Cost-Utility Analysis From the SELECT Study

Background: Whether Endovascular Thrombectomy (EVT) is cost-effective in large ischemic core infarcts is unknown. Methods: In the prospective multicenter cohort study of imaging selection study (SELECT), large core was defined as CT ASPECTS &lt; 6 or CTP ischemic core volume (rCBF&lt;30%) ≥ 50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the Incremental Cost-effectiveness Ratio (ICER) of EVT compared to Medical Management (MM) over 20 years life expectancy. The lower and upper willingness to pay (WTP) per QALY were set at $50000 and $100000 and the Net Monetary Benefit (NMB) for EVT were calculated. A probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) assessed EVT cost-effective probability at WTP range values. Results: Of 361 enrolled, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT patients achieved mRS 0-2 vs 6 (14%) MM (aOR: 3.27, 95% CI: 1.11-9.62; P = .03) with a shift towards better mRS (adj cOR: 2.12, 95% CI: 1.05-4.31, P = .04). Over 20 years EVT was associated with $26589 (C.I. $8672- $43978) incremental costs and a gain of 1.18 QALYs (C.I. 0.091- 2.2) per patient. EVT could avert 75 deaths over a theoretical cohort of 1000 patients (MM 861 vs EVT 786) thus the ICER of EVT compared to MM was $22400 per QALY (CI. $10109 - $66140), which is &lt;$50000/QALY, Tab 1. EVT has a higher NMB compared to MM at the lower and upper WTP thresholds (EVT $86,3 and 271,4 million vs MM $53,6-$179,3 million), Tab 2. The PSA confirmed the results (fig 1). The CEAC showed 94% and 97% cost-effectiveness probability of EVT at the lower and upper values respectively of the maximum WTP, fig 2. EVT ICER in SELECT large core ($22400/QALY) was higher but still comparable to those in HERMES ($16882/QALY), DAWN ($7335/QALY) and DEFUSE3 ($14673/QALY), Tab 3. Conclusion: EVT may result in better outcomes and more lives saved in large core patients with higher QALYs, NMB and an acceptable ICER. The results were comparable to other EVT RCTs.

IJU this issue

This issue contains three Review Articles, four Original Articles and four Urological Notes. Huge differences in the incidence and mortality rate of prostate cancer were detected between the USA and Japan. Such differences, however, have been decreasing over time, and were only twofold in 2017. Ito et al. (Takasaki, Japan) describe the important issue of screening for prostate cancer. They propose their screening strategies based on baseline prostate-specific antigen with a reasonable incremental cost-effectiveness ratio. In their perspectives, prostate cancer management might not only be aimed at decreasing the mortality of prostate cancer, but also aimed at achieving a significant increase in the quality-adjusted life year with an acceptable incremental cost-effectiveness ratio. The cancer-specific mortality among patients with localized prostate cancer has been reported to be very low irrespective of the treatment modalities. Nakamura et al. (Hamamatsu, Japan) focus on the patients’ quality of life after external beam radiotherapy using X-ray for prostate cancer, compared with other modalities, including radical prostatectomy and brachytherapy. In conclusion, the patients’ quality of life after external beam radiotherapy is strongly related to the total dose, fractionation regimens, dose parameters of the critical organs, beam delivery techniques and treatment plan quality, with a trade-off between the radicality of external beam radiotherapy and potentially increased toxicity. Particle beam radiotherapy (RT) for prostate cancer in Japan has changed considerably, and it is eligible for insurance coverage as of April 2018. Ishikawa et al. (Tsukuba, Japan) review the results of previous particle beam RT studies compared with photon beam RT, and introduce ongoing studies and prospects to establish high-quality evidence for particle beam RT for prostate cancer. Androgen deprivation therapy (ADT), a standard treatment for metastatic and locally advanced prostate cancer, is known to increase the risks of osteoporosis and fractures. Kimura et al. (Tokyo, Japan) prospectively investigated changes in bone quality, turnover markers and bone mineral density before and after ADT in castration-sensitive prostate cancer. They found that bone quality markers did not change significantly after ADT, whereas bone mineral density decreased significantly after ADT. Bone turnover markers might play an important role in monitoring bone health during ADT. Simone et al. (Rome, Italy) carried out propensity score-matched analysis to compare long-term renal functional outcomes after either off-clamp partial nephrectomy (PN) or on-clamp PN in patients with cT1–2/N0 M0 renal tumors. This study shows that off-clamp PN is associated with a significantly higher probability of maintaining 100% estimated glomerular filtration rate after surgery compared with on-clamp PN in patients with good baseline renal function. It also showed that patients treated with on-clamp PN had a 7.3-fold increased risk of developing a severe chronic kidney disease during long-term follow up. Molecular-targeted therapies have been generally used for treatment of metastatic renal cell carcinoma (mRCC), resulting in improvement in prognoses of mRCC. Konishi et al. (Hirosaki, Japan) retrospectively investigated the impact of C-reactive protein/albumin ratio (CAR) on prognosis, and the effect of adding CAR in the International Metastatic Renal Cell Carcinoma Database Consortium model for prognosis discrimination in Japanese patients who were treated with first-line tyrosine kinase inhibitor for mRCC. They concluded that CAR is an independent predictor of prognosis in patients with mRCC. Predictive activity was significantly improved in the International Metastatic Renal Cell Carcinoma Database Consortium-CAR model compared with the International Metastatic Renal Cell Carcinoma Database Consortium model. Kam et al. (Sydney, Australia) compared the operative performance of two single-use digital flexible ureteroscopes (fURS) with a reusable video fURS in order to show that single-use fURS would have a similar performance to reusable fURS with a lower scope failure rate. In conclusion, these single-use scopes offer a feasible alternative to reusable fURS, especially in complex stone cases where the risk of scope damage is high. None declared.

The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review.

BackgroundWith the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model–based health technology assessment approach.ObjectiveThe aim of this study was to perform a systematic review of the decision analytic model–based studies evaluating the cost-effectiveness of DHIs on the management of CVDs.MethodsA literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients’ cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards.ResultsA total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50%) and stroke (4/14, 29%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64%) studies were published between 2015 and 2018 and 5 (36%) published between 2011 and 2014. The time horizon was ≤1 year in 3 studies (21%), >1 year in 10 studies (71%), and 1 study (7%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7%), telephone support (1/14, 7%), mobile app (1/14, 7%), video conferencing system (5/14, 36%), digital transmission of physiologic data (telemonitoring; 5/14, 36%), and wearable medical device (1/14, 7%). The DHIs gained higher QALYs with cost saving in 43% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57% (8/14) of studies. The studies were classified as excellent (0/14, 0%), good (9/14, 64%), moderate (4/14, 29%), and low (1/14, 7%) quality.ConclusionsThis study is the first systematic review of decision analytic model–based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective.

Modelling the risk of transfusion-transmitted syphilis: a reconsideration of blood donation testing strategies.

Donor syphilis testing began in the 1940s amidst widespread transfusion-transmitted syphilis (TTS). Since then, the introduction of penicillin, pre-donation screening questionnaires and improved storage conditions have contributed to reducing transmission risk. Consequently, universal testing may no longer be cost-effective. This study analysed alternative options for donor syphilis testing to determine the optimal strategy. A model was developed using conservative parameter estimates for factors affecting TTS and 2009-2015 Australian donations to calculate risk outcomes (TTS infections, tertiary syphilis in recipients and transfusion-associated congenital syphilis) and cost-effectiveness of alternative testing strategies. The strategies modelled were as follows: universal testing, targeted-testing of high-risk groups (males ≤50 years old and first-time donors) and no testing. The estimated risk of TTS is one in 49·5 million transfusions for universal testing, one in 6 million for targeted-testing of males ≤50 years old, one in 4 million for targeted-testing of first-time donors and one in 2·8 million for no testing. For all strategies, the risk of tertiary and congenital syphilis is <1 in 100 million. Universal testing is the least cost-effective strategy with an incremental cost-effectiveness ratio (ICER) estimated at $538·5 million per disability-adjusted life year averted. Universal testing is not required to maintain the risk of TTS within tolerable limits and is estimated to greatly exceed acceptable ICERs for blood safety interventions. However, despite a strong economic and risk-based rationale, given the epidemiology of syphilis in Australia is changing, feedback from critical stakeholders is not currently supportive of reducing testing.

Transcatheter aortic valve implantation economics: a grisly reality.

Transcatheter aortic valve implantation (TAVI), an established treatment for inoperable and high-risk operable symptomatic patients with severe aortic stenosis with growing numbers of procedures and expanding indications, is an expensive therapy. Cost-effectiveness analyses rely on the value of the incremental cost-effectiveness ratio (ICER), which is the difference in cost between two possible interventions, divided by the difference in their effect. Several analyses have demonstrated that TAVI is cost-effective with an acceptable ICER for the inoperable patient alone and only via the iliofemoral route, while TAVI is more costly and is either less or equally effective as surgery in high-risk operable patients. When use of TAVI is extended to include a larger number of patients suitable for surgery, the overall results become less favorable. Acceptable ICERs should practically equate to the value of the gross domestic product (GDP) per capita in each country; however, the cost of the TAVI kit alone already exceeds the GDP per capita of all moderate- and low-income countries. An overview of the current cost-efficacy issues of TAVI is presented and this grisly reality is discussed, which may hopefully be improved in the future.

Economic evaluation of telephone-based concussion management for combat-related mild traumatic brain injury

Introduction Mild traumatic brain injury (mTBI) is an unfortunately common repercussion of military service in a combat zone. The CONTACT study tested an individualized telephone support intervention employing problem solving therapy (PST) for mTBI in soldiers recently returned from deployment. We sought to determine the cost effectiveness of this intervention from a military healthcare system perspective. Methods We conducted an intent-to-treat post-hoc analysis by building a decision analytic model that evaluated the choice between using PST or education only (EO). The model included cost-minimization and cost-effectiveness analyses. The incremental cost-effectiveness ratios (ICERs) were calculated as the differences in costs of PST versus EO relative to the differences in the outcomes of participants. Results The PST intervention resulted in an annual per-enrolee cost of $1027 (95% CI: $836 to $1248), while EO costs were $32 (95% CI: $25 to $39), resulting in a net incremental cost of $996 per enrolee (95% CI: $806 to $1,217). The ICERs were $68,658/QALY based on EQ-5D (95% CI: -$463,535 to $596,661) and $49,284/QALY based on SF-6D (95% CI: $26,971 to $159,309). Estimates of treatment costs in a real-world setting were accompanied by substantially lower ICERs that are within accepted thresholds for willingness-to-pay. Discussion Although the intervention had short-term benefits sufficient to yield acceptable ICERs, there was no long-term effect of PST over EO observed in the study. Consequently, we suggest that future studies examine the use of low-cost approaches, such as booster relapse-prevention calls, that may lead to a sustained treatment benefit for this population.

OP03 Trends In The National Institute For Health And Care Excellence (NICE) Cancer Drugs Fund Reconsiderations

INTRODUCTION:As of July 2016, funding from England's Cancer Drugs Fund (CDF) is dispensed based on the results of National Institute for Health and Care Excellence (NICE) technology appraisal guidances instead of independent CDF appraisals (1). As part of this transition, NICE is reconsidering drugs previously funded through the CDF (2). This analysis examines CDF reconsiderations conducted between the inception of the new process in July and the end of 2016 to identify any possible trends.METHODS:We collected all NICE final technology appraisal guidances (3) completed before the end of 2016 and noted whether each drug was a CDF reconsideration, what the final decision was, and which factors impacted the decisions.RESULTS:We identified twenty-one NICE oncology reviews competed between July 2016 and the end of 2016. Of these reviews, eight were reconsiderations of drugs previously funded through the old CDF; the rest were new reviews. Only one drug evaluated in the reconsiderations received a negative decision. All the reconsiderations included confidential manufacturer discounts and all noted updated clinical data. End of life (EOL) criteria expanded the acceptable incremental cost-effectiveness ratio (ICER) range for some of the CDF reconsiderations.CONCLUSIONS:All the reconsiderations included updated clinical data and analyses, though it does not appear that updated clinical data were sufficient to bring ICERs to acceptable levels. This is to be expected as the old CDF process served as an alternate funding source for many drugs that did not or were unlikely to fare well under NICE's evaluations. The updated clinical data may have at least increased NICE's confidence in the accuracy of the ICERs. All of the reconsiderations included confidential manufacturer discounts to reach acceptable ICER ranges. The results of this first round of reconsiderations suggest that manufacturers prefer offering their drugs at lower prices to potentially losing National Health Service (NHS) reimbursement entirely.

Rethinking cost-effectiveness in the era of zero healthcare spending growth.

BackgroundThe global economic crisis imposes severe restrictions on healthcare budgets, limiting the coverage of new interventions, even when they are cost-effective. Our objective was to develop a tool that can assist decision-makers in comparing the impact of medical intervention alternatives on the entire target population, under a pre-specified budget constraint.MethodsWe illustrated the tool by using a target population of 1,000 patients, and a budget constraint of $1,000,000. We compared two intervention alternatives: the current practice that costs $1,000 and adds 0.5 quality-adjusted-life-years (QALYs) per patient and a new technology that costs 100 % more, and provides 20 % more QALYs per patient. We also developed a formula for defining the maximum premium price for a higher-cost/higher-effectiveness intervention that can justify its adoption under a constrained budget.ResultsUsing the new therapy will add 300 QALYs, compared to 500 QALYS when using the lower-cost, lower-effective intervention, despite a favorable incremental cost-effectiveness ratio (ICER) of $10,000. The maximum price for the higher-efficacy therapy that will preserve the target population outcomes is 20 % higher than the lower-cost therapy.ConclusionsAlthough an intervention associated with higher costs and higher efficacy may have an acceptable ICER, it could provide inferior outcomes in the target population under budget constraints, depending on the relative effectiveness and costs of the interventions. The cost premium that can be justified for a higher-efficacy intervention is directly correlated to its effectiveness premium. Using the proposed tool may assist decision-makers in improving overall healthcare outcomes, especially in times of economic downturn.

PRM153 - Rethinking Cost-Effectiveness In The Era Of Zero Healthcare Spending Growth

The global economic crisis imposes severe restrictions on healthcare budgets, limiting the coverage of new interventions, even when they are cost-effective. Our objective was to develop a tool that can assist decision-makers in comparing the impact of medical intervention alternatives on the entire target population, under a pre-specified budget constraint. We illustrated the tool by using a target population of 1,000 patients, and a budget constraint of $1,000,000. We compared two intervention alternatives: the current practice that costs $1,000 and adds 0.5 quality-adjusted-life-years (QALYs) per patient and a new technology that costs 100 % more, and provides 20 % more QALYs per patient. We also developed a formula for defining the maximum premium price for a higher-cost/higher-effectiveness intervention that can justify its adoption under a constrained budget. Using the new therapy will add 300 QALYs, compared to 500 QALYS when using the lower-cost, lower-effective intervention, despite a favorable incremental cost-effectiveness ratio (ICER) of $10,000. The maximum price for the higher-efficacy therapy that will preserve the target population outcomes is 20 % higher than the lower-cost therapy. Although an intervention associated with higher costs and higher efficacy may have an acceptable ICER, it could provide inferior outcomes in the target population under budget constraints, depending on the relative effectiveness and costs of the interventions. The cost premium that can be justified for a higher-efficacy intervention is directly correlated to its effectiveness premium. Using the proposed tool may assist decision-makers in improving overall healthcare outcomes, especially in times of economic downturn.

Incremental Cost-Effectiveness of Surgical vs. Percutaneous Treatment of Patent Ductus Arteriosus with the Amplatzer™ Duct Occluder in Children: A Systematic Review

Introducao: A persistencia do canal arterial (PCA) e uma cardiopatia congenita relativamente comum e as alternativas para o tratamento de canais > 2,5 mm sao a cirurgia ou a oclusao percutânea com proteses do tipo rolha. Essas ultimas, apesar de consideradas o metodo de escolha, nao estao previstas pelo Sistema Unico de Saude (SUS). Nosso objetivo foi comparar a razao de custo-efetividade incremental (RCEI) de ambas as estrategias. Metodos: Revisao sistematica em relacao a desfechos clinicos e criacao de modelo de decisao para avaliacao da RCEI do Amplatzer® Duct Occluder (ADO) em comparacao ao tratamento cirurgico, para o fechamento da PCA. Os custos para ambos os metodos foram aqueles reembolsados pelo SUS em 2010, e o custo do conjunto (dispositivo + materiais de apoio) foi estimado em R$ 10.000,00. Foi considerado como limiar uma disposicao para pagar equivalente a tres vezes o Produto Interno Bruto brasileiro, resultando em R$ 57.000,00 por ano de vida salvo. Resultados: As duas tecnicas foram seguras e eficazes, com menor morbidade e tempo de internacao no fechamento percutâneo. A expectativa de vida ajustada foi similar nos dois grupos, sendo um pouco melhor para o ADO. O custo total foi calculado em R$ 8.507,00 para cirurgia e em R$ 11.000,00 para o ADO. A RCEI foi calculada em R$ 71.380,00 por ano de vida ganho. Uma analise de limiar demonstrou que a reducao do valor do conjunto completo do ADO em R$ 492,65 traria a RCEI para o limiar aceitavel para incorporacao ao SUS nos dias de hoje. Conclusoes: O tratamento percutâneo apresentou morbidade e tempo de internacao menores, alem de efetividade incremental semelhante aquela do tratamento cirurgico. Com os valores diretos estipulados neste estudo e partindo do pressuposto de que toda a populacao de pacientes com PCA seria tratada com o ADO, o fechamento percutâneo foi menos custo-efetivo. Entretanto, com pequena reducao nos valores do conjunto, o procedimento percutâneo estaria dentro de um limiar aceitavel de RCEI para possivel incorporacao.

Cost-effectiveness of counselling as a treatment option for methamphetamine dependence

Introduction and aims: Illicit methamphetamine (MA) use is an important public health concern. There is a dearth of knowledge about effective and cost-effective treatments for methamphetamine (MA) dependence in Australia. This article evaluates the cost-effectiveness of counselling as a treatment option for illicit MA use compared with no treatment option.Design and methods: Data are from 501 individuals recruited into Methamphetamine Treatment Evaluation Study (MATES). The population of MA users from MATES is extrapolated to a total number of 1000 MA users in the intervention group (counselling treatment) and control group (non-treatment group). A decision analytic model is developed that examines the costs and health outcomes [measures as quality adjusted life years (QALYs) gained] for the treatment and comparison group over a 3-year period. A societal perspective is adopted and model inputs are subject to sensitivity and uncertainty analysis to test the robustness of results to parameter variability. Results are discounted by using 3% discount rate and expressed in 2011 Australian dollars.Results: The incremental cost-effectiveness analysis suggests that counselling is a dominant health care intervention, i.e. saves money and is more effective than a do nothing intervention. The incremental difference in costs is −AU$18.36 million (95% CI −AU$22.80 million to −AU$14.31 million) and the incremental difference in QALY is 107 (95% CI −640 to 820) with a probability of 78.64% of counselling being a dominant and cost-effective treatment within the acceptable incremental cost-effectiveness ratio (ICER) of $63 832 per QALY in the Australian society. The results of the sensitivity analysis show that the ICER is most sensitive to change in five major inputs: baseline utility, utility at 3 months, dealing crime costs, property crime costs and fraud crime costs.Discussion and Conclusions: The economic evaluation of the cost-effectiveness of counselling for MA dependence, as a first cost-effectiveness study to assess psychosocial treatment options for MA dependence, shows that greater investment in this cost-effective strategy will produce significant cost-savings and improve health outcomes as well as improve a lot of externality issues associated with drug use.

Früherkennung von Lungenkrebs – eine Übersicht über Chancen und Risiken

Lung cancer is a leading cause of death worldwide. Patients are usually diagnosed at an advanced stage and have a very poor prognosis. In Switzerland, lung cancer is the most frequent cause of cancer death in men and the second most frequent cause of cancer death in women. Programmes to prevent individuals from initiating to smoke and to support smokers to quit are the most effective lung cancer prevention strategy. Whether routine screening for lung cancer in smokers is effective to reduce lung cancer related morbidity and mortality remains questionable. We summarize the evidence of five recent randomised controlled trials on routine screening for lung cancer in smokers. One study found no benefit of periodic conventional chest X-rays as compared to usual care without regular imaging for reducing lung cancer death. In four other trials, low-dose computer tomography (LDCT) was compared to conventional chest X-rays and to usual care. Only the largest trial, the US based National Lung Cancer Screening Trial (NLST), demonstrated a statistically significant reduction of lung cancer mortality of LDCT compared to conventional chest X-rays whereas three European trials could not prove any benefit. The results of the NLST need to be interpreted with care due to limited generalizability to European settings. LDCT screening had an unacceptable high rate of false positive findings resulting in an enormous use of resources for diagnostic work-up. Whether LDCT screening is associated with an acceptable incremental cost-effectiveness ratio still warrants further investigation.

A ‘Polypill’ Aimed At Preventing Cardiovascular Disease Could Prove Highly Cost-Effective For Use In Latin America

We evaluated the cost-effectiveness of administering a daily "polypill" consisting of three antihypertensive drugs, a statin, and aspirin to prevent cardiovascular disease among high-risk patients in Latin America. We found that the lifetime risk of cardiovascular disease could be reduced by 15 percent in women and by 21 percent in men if the polypill were used by people with a risk of cardiovascular disease equal to or greater than 15 percent over ten years. Attaining this goal would require treating 26 percent of the population at a cost of $34-$36 per quality-adjusted life-year. Offering the polypill to women at high risk and to men age fifty-five or older would be the best approach and would yield acceptable incremental cost-effectiveness ratios. The polypill would be very cost-effective even in the country with the lowest gross national income in our study. However, policy makers must weigh the value of intervention with the polypill against other interventions, as well as their country's willingness and ability to pay for the intervention.

1219 - Cost-Utility Analysis of Maintenance Therapy with Either Gemcitabine or Erlotinib versus Observation with Predefined Second-Line Treatment after Cisplatin-Gemcitabine Induction Chemotherapy in Advanced Nsclc: Ifct-Gfpc 0502-ECO Phase III Study

ABSTRACT Rationale The IFCT–GFPC 0502 phase III reported prolongation of progression-free survival with maintenance with either gemcitabine or erlotinib versus observation after cisplatin-gemcitabine chemotherapy in advanced NSCLC. Their incremental cost-effectiveness ratio (ICER) was assessed in global population and in pre specified sub-groups. Methods A cost-utility analysis was performed to evaluate ICER of maintenance therapy with either gemcitabine or erlotinib, compared to observation. Direct medical costs (drugs costs, hospitalization, examinations, second-line treatments and palliative costs) were prospectively collected per patient alongside the trial, until death, from the third party payer perspective. Utility were extracted from literature. Sensitivity analyses were performed. Results ICER for maintenance therapy with gemcitabine and erlotinib were respectively 76 625 and 184 733 €/quality-adjusted life years (QALY). Gemcitabine maintenance therapy had favourable ICER in patients with PS = 0 (52 213 €/QALY), in responders to induction chemotherapy (64 296 €/QALY) and in patients with adenocarcinoma (62 292 €/QALY); erlotinib had favourable ICER if PS = 0 (94 908 €/QALY), in patients with adenocarcinoma (97 160 €/QALY) and objective response to induction (101,186 €/QALY), but it is not cost-effective in patients with PS = 1, other histology or if stable disease. Conclusion Gemcitabine and erlotinib maintenance therapy have acceptable ICER but with wide variation, function of histology, PS and response to the first line chemotherapy. Disclosure I. Borget: Honoraria from Roche for set up a class in health economy (no relation with the present study). M. Perol: consultant or advisory board with Roche, Lilly (myself) Honoraria from Lilly, Roche, Pfizer, Boehringer Ingelheim (myself) Research funding from Lilly, Roche (myself). D. Perol: Honoraria : Roche (myself). G. Zalcman: Honoraria from Lilly, Roche Research funding from Lilly, Roche. A. Vergnenegre: honoraria and research funding from Roche. C. Chouaid: Honoraria from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Hoffman la Roche, Astra Zeneka, Sanofi Aventis, Lilly, Novartis and Amgen Research funding from AstraZeneca, Lilly, Novartis and Amgen. All other authors have declared no conflicts of interest.

Cost-utility analysis of maintenance therapy with either gemcitabine or erlotinib versus observation with predefined second-line treatment after cisplatin-gemcitabine induction chemotherapy in advanced NSCLC: IFCT-GFPC 0502-eco phase III study.

e16560 Background: The IFCT–GFPC 0502 phase III study reported a prolongation of progression-free survival with maintenance with either gemcitabine or erlotinib versus observation after cisplatin-gemcitabine induction chemotherapy in advanced NSCLC. The aim of this analysis is to assess the incremental cost-effectiveness ratio (ICER) of these strategies in the global population and in pre specified sub-groups. Methods: A cost-utility analysis was performed to evaluate ICER of maintenance therapy with either gemcitabine or erlotinib, compared to observation, from randomization until end of follow up. Direct medical costs (including drugs costs, hospitalization, follow-up examinations, second-line treatment and palliative costs) were prospectively collected per patient alongside the trial, until death, from the third party payer perspective. Utility data were extracted from literature. Sensitivity analyses were performed. Results: The ICER for maintenance therapy with gemcitabine and erlotinib were respectively 84,011 and 183,261 euros per quality-adjusted life years (QALY). Gemcitabine maintenance therapy had a favourable ICER in patients with PS = 0 (51,168 €/Qaly), in responders to induction chemotherapy (65,554€/Qaly) and in patients with squamous cell carcinoma (44,884€/Qaly); erlotinib had a favourable ICER in patients with PS = 0 (162,371 €/Qaly) and objective response to induction (101,569 €/Qaly ). Conclusions: Gemcitabine and erlotinib maintenance therapy have acceptable ICER but with a wide variation function of histology, PS and response to the first line chemotherapy.