Alternative Scenario Analyses Research Articles

Centering on economic construction to stabilize general socioeconomic conditions while fully promoting economic recovery: Outlook, policy simulations, and reform implementation—A summary of the annual SUFE macroeconomic report (2022–2023)

AbstractThe Chinese economy upheld a frail recovery in 2022 under the triple superposition of contraction of demand, disruption in supply, and weakening expectations, aggravated by unanticipated adverse shocks in the midst of global turmoil. Over the year, rising income uncertainty set off by the pandemic shock continued depressing household consumption and housing demand. Trade also saw slowing growth, along with consumption and investment, with sluggish residential investment awaiting policy stimulus to take force. Unemployment rate remained high, and was much higher for youth engendered by severe structural imbalances in the labor market. Local government debt burden worsened while revenue shrinking, only to exacerbate the local fiscal financial risk. It fared better on the price side. While growth in producer price index kept falling, consumer price index maintained steady growth. Renminbi depreciated against USD through fluctuations with larger swings, but the exchange rate remained in a manageable band. The Institute for Advanced Research‐China Macroeconomic Model projects the baseline growth rate in real gross domestic product to be 5.4% in 2023. We have also used the model to conduct alternative scenario analyses and policy simulations to assess the impacts of potential downside risks or favorable situations. Our findings call for a focus on economic construction with deepening reform and opening up more comprehensively and initiatively. Only by doing so can China spur market vitality, strengthen business confidence, and forge competitive advantages.

The impact of early remission on disease trajectory and patient outcomes in major depression disorder (MDD): A targeted literature review and microsimulation modeling approach based on the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study

BackgroundWhile literature has suggested that the duration of a major depressive episode (MDE) may affect both symptomatic and functional outcomes in major depressive disorder (MDD), study designs are limited in their ability to isolate a causal relationship. MethodsA targeted literature review was conducted using the MEDLINE database to assess whether there was an association between (1) shorter duration of an MDE, or (2) increased rapidity of symptom improvement, and MDD outcomes in adult patients. Given findings from the literature, we hypothesized that rapid symptom improvement could be associated with other longer-term clinical outcomes and used a previously-developed microsimulation model to test this hypothesis. The base case of the model replicated step-therapy treatment patterns, for 10,000 simulated patients, based on lines of therapy related to standard of care, observed remission rates, and observed time to relapse from the STAR*D study. In alternative scenario analyses, the step 1 remission rate was varied by +25 % and +50 % from the base case value to simulate the potential impact of improved earlier remission on disease trajectory and patient-level clinical outcomes. ResultsThe literature review (N = 35 studies) suggests a statistically significant relationship between the duration of MDE or early symptom improvement and MDD outcomes. The microsimulation model corroborated these findings and demonstrated that increasing the rate of remission in step 1 results in patients experiencing decreased number of treatment steps, faster time to remission, decreased rate of reaching treatment-resistant depression, and delayed time to relapse. LimitationsRates of relapse in STAR*D were deemed unreliable due to the high-loss of follow-up; rates of relapse for the MDD DTM were instead derived using parametric extrapolation methods (i.e., exponential, Weibull, log-logistic, Gaussian, log-normal, logistic). Adherence to treatment was assumed to be 100 %; however, non-adherence is expected to result in lower cumulative remission rates. ConclusionFindings from the literature, coupled with quantification through a novel microsimulation model, demonstrate the potential impact of increased remission on disease trajectory and patient outcomes in MDD. While additional analyses with the model may be warranted to explore the impact of novel interventions on population health, including long-term outcomes (i.e., 5-year follow-up, lifetime follow-up), efforts by clinicians to increase remission early in the disease trajectory may improve long-term outcomes.

Propelling steady growth and high‐quality development through deeper reform and more comprehensive opening up: Outlook, policy simulations, and reform implementation—A summary of the Annual SUFE Macroeconomic Report (2021–2022)

AbstractChina's economy underwent a steady recovery in 2021. Investment grew steadily with structural improvement. Exports and imports surged while trade surplus expanded. On the other hand, although labor market conditions improved, income distribution worsened, contributing to sluggish growth in consumption, whereas the gap between consumer price index and producer price index widened, and the profits of enterprises of different sizes diverged, which may go beyond how they are correlated with the locations of the enterprises in the chain of production and trade. While proper liquidity was maintained with prudent monetary policy, risk spillover rose in the financial system, particularly for small and medium‐sized banks. Household and local government debts remained at relatively high levels, further dragging down growth in consumption and infrastructure investment. The “dual carbon” goals exerted downward pressure on near‐term growth in trading off their long‐term benefits. The economy also faced challenges in its external environment in the midst of the prolonged COVID‐19 pandemic aboard, trade protectionism, and the readjustment of the global value chain. Moreover, excessive supervision and inadequate implementation disturbed China's economy, resulting in declined market vitality and confidence of market participants. Based on the Institute for Advanced Research‐China Macroeconomic Model, the baseline real gross domestic product growth rate is projected to be 5.5% in 2022. Alternative scenario analyses and policy simulations are conducted, in addition to the benchmark forecast, to reflect the influences of various risks and possible favorable situations. The findings suggest that China should deepen reform and open up more comprehensively and initiatively, while special effort should be placed on providing accommodative policy and friendly public opinion environment, to facilitate steady growth and propel high‐quality development. A comprehensive macroeconomic governance framework with Chinese characteristics must be developed from systems thinking, to resolve the various issues, internal and external, cyclical and secular, structural and institutional, in an all‐inclusive and coherent manner.

Life cycle assessment and life cycle cost of repairing surgical scissors

PurposeThe primary objective of this study was to evaluate the environmental impact and financial cost of repairing surgical scissors.MethodsWe used life cycle assessment (LCA) and life cycle cost analysis to estimate environmental impacts and financial cost of repairing surgical scissors. The functional unit was one use of a reusable surgical scissor (manufactured in Germany and used in the UK), and three baseline scenarios were compared: no repair, onsite (hospital), and offsite (external contract) repair. This ‘cradle-to-grave’ analysis included raw material extraction, manufacture of scissors and materials within primary and secondary packaging, transportation, decontamination, repair (where relevant), and waste disposal. Primary activity data was sourced from the instrument manufacturer, supplier, and from UK repair centres (both onsite and offsite), whilst the Ecoinvent database was used as a secondary data source for the manufacture of scissors. The World ReCiPe Midpoint and Endpoint Hierarchist method (Version 1.1) was used for environmental impact assessment. Scenario analysis was used to evaluate the impact of altering different assumptions, including number of uses, reducing number of repairs, increasing distance to offsite repair centre, and alternative electricity sources and waste handling processes. Life cycle cost analysis was calculated based on purchase cost, and cost of decontamination, repair, and waste disposal.Results and discussionThe carbon footprint of reusable scissors was 70 g CO2e per use, assuming scissors were used 40 times before replacement. This was reduced by 19% through use of offsite repair every 40 uses (57 g CO2e/scissor use), with small additional reductions associated with onsite repair (56 g CO2e/scissor use). Similar patterns of reduction were calculated for eighteen midpoint environmental impact categories (mean impact reduction of 30% for those repaired offsite relative to no repair) and also across three endpoint categories. Decontamination made the biggest contribution to the carbon footprint across all baseline scenarios (76% where no repair, 95–97% where repaired offsite and onsite respectively). Findings were robust to alternative scenario analyses. Life cycle cost was GBP £1.43 per use of reusable scissors, and when repaired either on- or offsite this decreased by 32% to GBP £0.97 per use.ConclusionRepairing surgical scissors rather than replacing them with a new pair can reduce environmental and financial cost. The extent to which repair may play a role in mitigating the environmental impact of other surgical instruments requires further research.

PND10 Conceptualization and Novel Budget Impact Analysis Framework for Treatments of Myasthenia Gravis

Myasthenia gravis (MG) is a rare chronic autoimmune neuromuscular disorder, which causes debilitating and potentially life-threatening exacerbations of muscle weakness. The objective of this study was to develop a novel United States (US) budget impact analysis framework to assess innovative MG treatments. A targeted literature review was conducted to identify previous economic evaluations of MG. Clinical experts were consulted to ensure model components reflected current clinical practice and understanding. US payers were engaged to provide feedback on the structure and outputs, and how to optimize the utility of the model framework for informing formulary decision-making. Few US economic analyses of MG treatments were identified in the literature. Recent data on direct pharmacy and medical costs were sparse. A novel model framework was developed for assessing the budget impact of an innovative MG therapy, which includes treatment-related costs and medical costs offsets. Modeled costs in the framework include direct pharmacy and medical costs of chronic MG treatments, chronic therapy adverse effects, MG exacerbations and myasthenic crisis events. Myasthenia gravis exacerbations and crisis costs include acute inpatient, emergency department and outpatient care as well as temporary treatment with immunoglobulin or plasma exchange following MG exacerbations. Clinical experts recommended that treatment comparators should include all combinations of conventional and add-on therapies to reflect the individualized treatment pathways observed in practice. Conventional therapies include combinations of corticosteroids, non-steroidal immunosuppressive drugs (e.g. azathioprine, mycophenolate mofetil) and acetylcholinesterase inhibitors. US payers recommended flexibility to adapt treatment market shares and time horizons to conduct alternative scenario analyses. Future budget impact analysis for MG treatments should capture both direct pharmacy and medical costs including those related to disease exacerbations and treatment adverse effects. The framework includes all the identified core components essential to assessing the full budget impact of novel MG treatments on direct pharmacy and medical costs.

Public health impact and cost-effectiveness of catch-up 9-valent HPV vaccination of individuals through age 45 years in the United States

ABSTRACT The Advisory Committee on Immunization Practices (ACIP) recommended catch-up 9-valent Human Papillomavirus (HPV) vaccination through age 26 years, and shared clinical decision-making for adults aged 27–45 years, compared with catch-up through age 26 years and 21 years for females and males, respectively (status quo; pre-June-2019 recommendations). This study assessed the public health impact and cost-effectiveness of expanded catch-up vaccination through age 45 years (expanded catch-up) compared with status quo. We used an HPV dynamic transmission infection and disease model to assess disease outcomes and incremental cost-effectiveness ratio (ICER) of expanded catch-up compared with status quo. Costs (2018 USD), calculated from a healthcare sector perspective, and quality-adjusted life years (QALY) were discounted at 3% annually. Historical vaccination coverage was estimated using NIS-TEEN survey data (NHANES data for sensitivity analysis). Alternative scenario analyses included restricting upper age of expanded catch-up through 26 years (June-2019 ACIP recommendation), 29 years, and further 5-year increments. Our results show expanded catch-up vaccination would prevent additional 37,856 cancers, 314,468 cervical intraepithelial neoplasia-2/3s, 1,743,461 genital warts, and 10,698 deaths compared with status quo over 100 years at cost of $141,000/QALY. With NHANES coverage, the ICER was $96,000/QALY. The June-2019 ACIP recommendation also provided public health benefits with an ICER of $117,000/QALY, compared with status quo. The ICER for expanded vaccination through age 34 years was $107,000/QALY. Expanding catch-up vaccination program through age 45 years-old in the US is expected to provide public health benefits, and cost-effectiveness improves with expanding catch-up through age 34.

Cost-Effectiveness of a 12-Month Fixed Duration of Venetoclax in Combination with Obinutuzumab Versus Chemoimmunotherapy and Other Novel Combinations in First-Line Chronic Lymphocytic Leukemia in Canada

OBJECTIVES: To estimate the cost-effectiveness of venetoclax + obinutuzumab (GAZYVA®, G), (VEN+G) in the treatment of first-line (1L) chronic lymphocytic leukemia (CLL) from a Canadian health care system cost perspective. METHODS: A three-state partitioned-survival model was used to extrapolate progression-free survival (PFS) and overall survival (OS) over a 10-year time horizon. Cost-effectiveness was estimated comparing 12-month fixed duration of VEN+G versus (vs) G + Chlorambucil (GClb) based on the CLL14 clinical trial (NCT02242942). Other comparators included Bendamustine + rituximab (BR), Chlorambucil + rituximab (Clb+R), Ibrutinib (Ibr), Acalabrutinib (Acala) and Acalabrutinib + GAZYVA (Acala+G). VEN+G was also compared to the combination of fludarabine, cyclophosphamide and rituximab (FCR) in the overall 1L CLL population which included unfit and fit patients. Relative efficacy of VEN+G vs other comparators was estimated using a network meta-analysis. Health state utilities and adverse event disutilities were derived from a systematic literature review and other published sources. Costs included CLL treatment, routine care and monitoring, adverse events, disease progression costs, subsequent treatment costs, and end of life care. Uncertainty was assessed using an underlying probabilistic model (probabilistic analysis of uncertainty generated from 5,000 iterations), through deterministic sensitivity analyses (i.e., one-way sensitivity analyses (OWSA)), and through a series of alternative scenario analyses. RESULTS: For the overall unfit 1L CLL patient population, the probabilistic total discounted costs incurred over a 10-year time horizon were as follows: $217,727 for VEN+G vs $312,287 for GClb, $399,219 for BR, $380,713 for Clb+R, $736,017 for Ibr, $868,797 for Acala and $916,139 for Acala+G. The probabilistic total discounted quality adjusted life years (QALYs) were 4.964 for VEN+G vs 4.750, 4.550, 4.422, 4.709, 5.269, and 5.359, respectively for the comparators. For the overall 1L CLL patient population, the probabilistic total discounted costs were $219,651 for VEN+G vs $312,570 for GClb, $342,195 for FCR, $397,262 for BR, $380,551 for Clb+R, $757,129 for Ibr, $868,388 for Acala, and $916,798 for Acala+G. The probabilistic total discounted QALYs were 5.888 for VEN+G vs 5.519, 5.067, 5.198, 5.073, 5.597, 6.259 and 6.380, respectively for the comparators. VEN+G was found to be less costly and more efficacious (i.e., dominant) compared to GClb, BR, Clb+R, Ibr and FCR. As a result, incremental cost utility ratios (ICERs) were not calculated for these comparators. Acala and Acala+G resulted in ICERs ranging from $1.4-$2.1 million per QALY gained relative to VEN+G, which is not cost-effective. Based on the probabilistic model and 5,000 simulations, VEN+G was found to be at least 97% cost-effective across all decision maker willingness-to-pay thresholds. The results from the deterministic model were found to be similar to the probabilistic model. Using the deterministic model, and in comparison to the most commonly prescribed treatment for 1L CLL in Canada (i.e., Ibr), the OWSA comparing VEN+G to Ibr found that the most influential variables in the model were the PFS and OS hazard ratios for Ibr and the utility values for PFS and post-progression survival. CONCLUSION: VEN+G is an effective novel fixed duration treatment option which leads to deep and durable responses for the treatment of patients with unfit 1L CLL and provides excellent value-for-money compared with existing chemoimmunotherapy and treat to progression novel combinations. Disclosures Chatterjee: Pharmerit: Current Employment. Van de Wetering:Pharmerit: Current Employment. Goeree:AbbVie Inc.: Consultancy. Desbois:AbbVie Inc.: Current Employment, Current equity holder in publicly-traded company. Manzi:AbbVie Inc.: Current Employment, Current equity holder in publicly-traded company. Manzoor:AbbVie: Current equity holder in publicly-traded company. Owen:AbbVie, F. Hoffmann-La Roche, Janssen, Astrazeneca, Merck, Servier, Novartis, Teva: Honoraria. Sail:AbbVie Inc.: Current Employment, Current equity holder in publicly-traded company.

Cost-Effectiveness of Evolocumab Therapy for Myocardial Infarction: The Chinese Healthcare Perspective.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are an indispensable lipid-lowering treatment option, but their cost-effectiveness has been questioned. This study aimed to perform a health economic evaluation of evolocumab versus placebo in patients with myocardial infarction (MI) in China. A Markov cohort state-transition model was developed in decision analysis software to estimate the incremental cost-effectiveness ratio (ICER), defined as cost per quality-adjusted life-year (QALY) saved. The simulation subjects could undergo non-fatal MI and/or stroke, or vascular or non-vascular death event. We integrated the Chinese population-specific demographics and event rates with the risk reduction of evolocumab based on the FOURIER trial and/or lowering of low-density lipoprotein cholesterol (LDL-C). Age-related change, event costs and utilities were included from published sources. At its current list price [33,748 Chinese yuan (CNY) annually per person], the ICER for evolocumab therapy was 927,713 CNY per QALY gained when integrating the FOURIER trial with absolute reduction of LDL-C. The probability of cost-effectiveness of evolocumab versus placebo was 1.96%, with a generally accepted threshold of 212,676 CNY per QALY gained. A reduction in acquisition price by approximately 70% (to less than 10,255 CNY annually) was needed to be cost-effective. Alternative scenario analyses of therapeutic benefit showed that the ICER for evolocumab in MI patients with uncontrolled familial hypercholesterolemia (FH) was 187,736 CNY per QALY gained. Evolocumab in patients with MI was not cost-effective based on the price in 2019 in China; however, treatment with evolocumab was more favorable in MI patients with FH.

The impact of maternal RSV vaccine to protect infants in Gavi-supported countries: Estimates from two models

BackgroundInterventions to protect young infants against respiratory syncytial virus (RSV) are in advanced phases of development and are expected to be available in the foreseeable future. Gavi, the Vaccine Alliance, included maternal vaccines and infant monoclonal antibodies for RSV as part of the 2018 vaccine investment strategy (VIS) and decided to support these products subject to licensure, World Health Organization prequalification, Strategic Advisory Group of Experts recommendation, and meeting the financial assumptions used as the basis of the investment case. Impact estimates reported in this manuscript were used to inform the Gavi VIS. MethodsWe compared two independent vaccine impact models to evaluate a potential maternal RSV vaccine’s impact on infant health in 73 Gavi-supported countries. Key inputs were harmonized across both models. We analyzed various scenarios to evaluate the effect of uncertain model parameters such as vaccine efficacy, duration of infant protection, and infant disease burden. Estimates of averted cases, severe cases, hospitalizations, deaths, and disability-adjusted life years (DALYs) were calculated over the 2023–2035 horizon. FindingsA maternal RSV vaccine with 60% efficacy offering 5 months of infant protection implemented across 73 low- and middle-income countries could avert 10.1–12.5 million cases, 2.8–4.0 million hospitalizations, 123.7–177.7 thousand deaths, and 8.5–11.9 million DALYs among infants under 6 months of age for the duration of analysis (2023–2035). Maternal RSV vaccination was projected to avert up to 42% of estimated RSV deaths among infants under 6 months in year 2035. Alternative scenario analyses with higher disease burden assumptions showed that a maternal vaccine could avert as many as 325–355 thousand deaths among infants under 6 months. InterpretationRSV maternal immunization is projected to substantially reduce mortality and morbidity among young infants if introduced across Gavi-supported countries. FundingThis work was supported by Bill & Melinda Gates Foundation, Seattle, WA, and Respiratory Syncytial Virus Consortium in Europe. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation or of the Respiratory Syncytial Virus Consortium. LW is supported by Research Foundation–Flanders (1234620 N).

Environmental Sustainability Assessment of Dairy Farms Rearing the Italian Simmental Dual-Purpose Breed

Simple SummaryThe milk and meat production systems are responsible for more than 5% of greenhouse gas emissions in the world; therefore, there is a strong need to propose strategies for reducing the carbon footprint. The aim of this paper was to assess the environmental footprint of dairy farms rearing a dual-purpose breed and to evaluate the fattening of calves directly in farms and the cultivation of alternative crops, such as hemp, as possible strategies for reducing the environmental footprint of dairy farms. In order to produce 1 kg of milk with 4.0% of fat and 3.3% of protein, the emissions were 1.1–1.4 kg CO2eq, 14.8–19.0 g SO2eq and 5.0–6.4 g PO43−eq. These emissions could be reduced by 8–11% by fattening the calves directly in the farms, and by 1–5% by cultivating hemp and using its by-product, hempseed cake, in the diets of animals. Moreover, the results of this study showed that the environmental footprint can be reduced, improving the productive efficiency of the farms.This study aimed to assess the environmental footprint of dairy farms rearing a dual-purpose breed, and to evaluate, through alternative scenario analyses, the fattening of calves and the cultivation of hemp as strategies for reducing the environmental impact of these farms. Eleven farms were evaluated for global warming (GWP), acidification (AC) and eutrophication (EUP) potential. The Life Cycle Assessment method with three scenarios, REAL, based on real data, BEEF, where calves were fattened in farm, and HEMP, where hemp was cultivated in farms, were considered. If referred to 1 m2 of utilizable agricultural land, the GWP, AC and EUP were 1.6 kgCO2eq, 21.7 gSO2eq and 7.1 gPO43−eq, respectively. If referring to 1 kg of fat and protein corrected milk, the emissions were 1.1–1.4 kgCO2eq, 14.8–19.0 gSO2eq, and 5.0–6.4 gPO43−eq, depending on the allocation method adopted. The emissions were associated positively with culling rate and negatively with production intensity. In BEEF and HEMP scenarios, the emissions were reduced by 8–11% and by 1–5%, respectively. Fattening the calves, evaluating the cultivation of alternative plants and improving the productive and reproductive efficiency of animals could be effective strategies for reducing the environmental footprint of the farm.

PBI14 COST-EFFECTIVENESS OF SECUKINUMAB VERSUS OTHER BIOLOGICS AND APREMILAST IN THE TREATMENT OF ACTIVE PSORIATIC ARTHRITIS: A SPANISH PERSPECTIVE

To assess the cost-effectiveness of secukinumab, an interleukin-17A inhibitor, with other biologics and apremilast in psoriatic arthritis (PsA) patients from a Spanish payers’ perspective. Secukinumab 150 mg and 300 mg were evaluated against etanercept, certolizumab pegol, adalimumab, golimumab, ustekinumab, infliximab, and apremilast over a lifetime horizon in a semi-Markov model. Both biologic-naïve (with or without moderate to severe psoriasis) and biologic-experienced PsA patients were considered. To assess treatment response, the 12-week PsA Response Criteria (PsARC) was used as a primary criterion. Model inputs were derived from PsA clinical trials, published literature, and other Spanish sources. Quality-adjusted life years (QALYs) gained and incremental cost-effectiveness ratio were key model outcomes. Impact of input variations were evaluated through sensitivity analyses and alternative scenario analyses. Secukinumab 150 mg dominated all subcutaneous (S.C.) biologics and apremilast with highest QALYs of 9.22 and lowest lifetime cost of €192,445, while it was cost-effective against the intravenous (I.V.) infliximab in biologic-naïve patients without psoriasis. Among biologic-naïve patients with psoriasis and biologic-experienced patients, secukinumab 300 mg was cost-effective against all S.C. branded biologics and apremilast, while it dominated I.V. infliximab. PsARC response at 3-months, drug acquisition costs, and Health Assessment Questionnaire score change were identified as the most important parameters affecting model results as per one-way sensitivity analysis. Probabilistic sensitivity analysis showed maximum net monetary benefits with both secukinumab doses. Results from scenario analyses confirmed these results. Secukinumab is a cost-effective biologic treatment for PsA patients from a Spanish payer’s perspective.

Cost savings with a novel algorithm for early detection of systemic sclerosis-related pulmonary arterial hypertension: alternative scenario analyses.

Pulmonary arterial hypertension is an important cause of death and disability in patients with systemic sclerosis (SSc). Yearly screening of all SSc patients with transthoracic echocardiography (TTE) is recommended in international guidelines and currently utilised by the Australian Scleroderma Interest Group (ASIGSTANDARD ). Owing to the limitations of TTE, the ASIG developed a new screening algorithm (ASIGPROPOSED ) utilising a serum biomarker, NT-proBNP, in place of TTE, which has been shown to be equally accurate as the current algorithm. The aim of this study was to compare the cost of these two algorithms using different scenarios. The new algorithm resulted in significant yearly cost savings of between AU$42 913.35 and AU$84 570 in screening and diagnosis of an Australian cohort which, if extrapolated to the Australian population, would result in a yearly cost saving of between AU$367 066 and AU$725 564. There was no scenario in which the proposed algorithm did not result in a cost saving.

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis

BackgroundRisk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk. MethodQuality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions. ResultsThe formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0–£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk. LimitationsOur primary model depended on the assumption that high-intensity care reduced patients’ risk of further self-harm. ConclusionThe use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.

Screening fathers for postpartum depression can be cost-effective: An example from Sweden

Background: Postpartum depression negatively affects the whole family and its prevalence in Sweden ranges between 6–10% for fathers and 13–16% for mothers. However, only mothers in Sweden are currently routinely screened. Aim: The aim of this study was to determine if a postpartum depression screening for fathers in Stockholm County could be cost-effective. Methods: National Swedish databases were used to find registry data and a literature review was undertaken to identify the model data inputs associated with postpartum depression in Sweden. The generated evidence was used to build a Markov model in TreeAge. One-way and probabilistic sensitivity analyses were performed to account for parameter uncertainties. Alternative scenario analyses were further undertaken to test the assumptions in the base case analysis. Results: A postpartum screening for depression in fathers is cost-effective in base case and alternative scenarios. The results indicate that the screening program is associated with lower costs and higher health effects. The results were sensitive to variables of quality adjusted life years for the depressed fathers, probabilities of remission in treatment and no treatment groups and start age and productivity losses. The probabilistic sensitivity analysis resulted in a 70% probability of the postnatal depression screening intervention being cost-effective. Limitations: The current study only uses secondary data; therefore future research should assess the cost-effectiveness of screening fathers for depression. Conclusion: The postpartum screening intervention for fathers could be cost-effective compared to no screening. Future research should replicate the potential cost-effectiveness for screening fathers for postpartum depression.

Cost-effectiveness analysis on the use of fidaxomicin and vancomycin to treat Clostridium difficile infection in France

Background: Fidaxomicin is a macrocyclic antibiotic with proven efficacy against Clostridium difficile infection (CDI) in adults. It was licensed in France in 2012, but, due to higher acquisition costs compared with existing treatments, healthcare providers require information on its cost/benefit profile.Objective: To compare healthcare costs and health outcomes of fidaxomicin and vancomycin, as reference treatment for CDI.Methods: A Markov model was used to simulate the treatment pathway, over 1 year, of adult patients with CDI receiving fidaxomicin or vancomycin. Several patient sub-groups (severe CDI; recurrent CDI; concomitant antibiotics; cancer; renal failure; elderly) were evaluated. Cost-effectiveness was analyzed based on cure and recurrence rates derived from published randomized clinical trials comparing fidaxomicin and vancomycin, and costs calculated from the payer perspective using French hospitalization data and drug cost databases. Model outputs included costs in euros (reference year 2014) and health outcomes (recurrence; sustained cure rates). Alternative scenario and sensitivity analyses were performed using data from other clinical trials in CDI, including one conducted in real-life clinical practice in France.Results: Drug acquisition costs were €1,692 higher in fidaxomicin-treated patients, but this was offset by the lower hospitalization costs with fidaxomicin, which were reduced by €1,722. The reduction in the cost of hospitalization was driven by the significantly lower number of recurrences in fidaxomicin-treated patients, offsetting the acquisition cost of fidaxomicin in all sub-groups except recurrent CDI and concomitant antibiotics.Conclusion: This study demonstrated that, despite higher acquisition costs, the lower recurrence rate with fidaxomicin resulted in cost savings or low incremental costs compared with vancomycin.

Epidemiological impact and cost-effectiveness of introducing vaccination against serogroup B meningococcal disease in France

IntroductionDespite its low incidence in France, invasive serogroup B meningococcal disease remains a public health concern. A new vaccine against the disease, Bexsero®, has been licensed in the EU. We studied the epidemiological impact and cost-effectiveness of routine vaccination using Bexsero® in order to inform the decision-making process regarding its potential inclusion in the vaccination schedule. MethodsA multi-generational Markov model was used. Time horizon was set to 100 years. Five vaccination strategies were evaluated: infants at 3, 5, 6 and 13 months, toddlers at 13, 15 and 27 months and adolescents at 15 years provided 2 doses one month apart. A booster dose at 15 years old and a catch-up for 15 years old subjects during the first 15 years of the programme were added to the infant and toddler strategies. Costs per QALY gained were computed from a restricted societal perspective including direct costs only. Herd immunity was simulated in an alternative base-case scenario and sensitivity analyses. ResultsIn the base-case analysis without herd immunity and with all cohorts vaccinated, at €40 per vaccine dose, routine infant vaccination would provide the lowest cost per QALY gained (€380,973) despite only preventing 18% of cases. Under the assumption of herd immunity, the adolescent vaccination would provide the lowest cost per QALY gained (€135,902) preventing 24% of cases. Infant vaccination with a late booster and catch-up would prevent 51% of cases with a cost of €188,511 per QALY gained. ConclusionsGiven current meningococcal epidemiology in France and the available data on the protection provided by Bexsero®, our modelling work showed that routine vaccination against serogroup B meningococcal disease is not cost-effective.

Cost-Effectiveness of Renin-Guided Treatment of Hypertension

A plasma renin activity (PRA)-guided strategy is more effective than standard care in treating hypertension (HTN). However, its clinical implementation has been slow, presumably due in part to economic concerns. We estimated the cost effectiveness of a PRA-guided treatment strategy compared with standard care in a treated but uncontrolled HTN population. We estimated costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER) of PRA-guided therapy compared to standard care using a state-transition simulation model with alternate patient characteristic scenarios and sensitivity analyses. Patient-specific inputs for the base case scenario, males average age 63 years, reflected best available data from a recent clinical trial of PRA-guided therapy. Transition probabilities were estimated using Framingham risk equations or derived from the literature; costs and utilities were derived from the literature. In the base case scenario for males, the lifetime discounted costs and QALYs were $23,648 and 12.727 for PRA-guided therapy and $22,077 and 12.618 for standard care, respectively. The base case ICER was $14,497/QALY gained. In alternative scenario analyses varying patient input parameters, the results were sensitive to age, gender, baseline systolic blood pressure, and the addition of cardiovascular risk factors. Univariate sensitivity analyses demonstrated that results were most sensitive to varying the treatment effect of PRA-guided therapy and the cost of the PRA test. Our results suggest that PRA-guided therapy compared with standard care increases QALYs and medical costs in most scenarios. PRA-guided therapy appears to be most cost effective in younger persons and those with more cardiovascular risk factors.

Cost-Effectiveness of a Recommendation of Universal Mass Vaccination for Seasonal Influenza in the United States

ObjectivesWe evaluated the cost-effectiveness of universal mass vaccination (UMV) against influenza compared with a targeted vaccine program (TVP) for selected age and risk groups in the United States. MethodsWe modeled costs and outcomes of seasonal influenza with UMV and TVP, taking a societal perspective. The US population was stratified to model age-specific (< 5, 5–17, 18–49, 50–64, and 65+ years) vaccine coverage and efficacy. Probability of influenza-related illness (ILI) and complications, health-care utilization, costs, and survival were estimated. For a season's intervention, ILI cases in that year, lifetime costs (2008 US$), and quality-adjusted life years (QALYs) lost (both discounted at 3% per annum) were calculated for each policy and used to derive incremental cost-effectiveness ratios. A range of sensitivity and alternative-scenario analyses were conducted. ResultsIn base-case analyses, TVP resulted in 63 million ILI cases, 859,000 QALYs lost, and $114.5 billion in direct and indirect costs; corresponding estimates for UMV were 61 million cases, 825,000 QALYs lost, and $111.4 billion. UMV was therefore estimated to dominate TVP, saving $3.1 billion and 34,000 QALYs. In probabilistic sensitivity analyses, UMV was dominant in 82% and dominated in 0% of iterations. In alternative-scenario analyses, UMV dominated TVP when lower estimates of vaccine coverage were used. Lower estimates of ILI risk among unvaccinated, vaccine effectiveness, and risk of complications resulted in ICERs of $2800, $8100, and $15,900 per QALY gained, respectively, for UMV compared with TVP. ConclusionsUMV against seasonal influenza is cost saving in the United States under reasonable assumptions for coverage, cost, and efficacy.