Canadian Dollars Research Articles

Real-World Cost-Consequence Analysis of an Integrated Chronic Disease Management Program in Saskatchewan, Canada.

An integrated disease management program otherwise called a clinical pathway was recently implemented in Saskatchewan, Canada for patients living with chronic obstructive pulmonary disease (COPD). This study compared the real-world costs and consequences of the COPD clinical pathway program with 2 control treatment programs. The study comprised adult COPD patients in Regina (clinical pathway group, N = 759) matched on propensity scores to 2 independent control groups of similar adults in (1) Regina (historical controls, N = 759) and (2) Saskatoon (contemporaneous controls, N = 759). The study measures included patient-level healthcare costs and acute COPD exacerbation outcomes, both tracked in population-based administrative health data over a one-year follow-up period. Analyses included Cox proportional hazards models and differences in means between groups. The bias-corrected and accelerated bootstrap method was used to calculate 95% confidence intervals (CI). The COPD pathway patients had lower risks of moderate (hazard ratio [HR] =0.57, 95% CI [0.40-0.83]) and severe (HR = 0.43, 95% CI [0.28-0.66]) exacerbations compared to the historical control group, but similar risks compared with the contemporaneous control group. The COPD pathway patients experienced fewer episodes of exacerbations compared with the historical control group (mean difference = -0.30, 95% CI [-0.40, -0.20]) and the contemporaneous control group (mean difference = -0.12, 95% CI [-0.20, -0.03]). Average annual healthcare costs in Canadian dollars were marginally higher among patients in the COPD clinical pathway (mean = $10 549, standard deviation [SD] =$18 149) than those in the contemporaneous control group ($8841, SD = $17 120), but comparable to the historical control group ($10 677, SD = $21 201). The COPD pathway provides better outcomes at about the same costs when compared to the historical controls, but only slightly better outcomes and at a marginally higher cost when compared to the contemporaneous controls.

An Exploratory Analysis of the Cost-Effectiveness of a Multi-cancer Early Detection Blood Test Compared with Standard of Care Screening in Ontario, Canada.

Determining whether multi-cancer early detection (MCED) tests are cost effective is important in deciding whether they should be included in the clinical path of cancer care, especially for cancers where screening tools do not exist. The main objective of this study is to determine the cost effectiveness of including a MCED screening regimen together with existing provincial screening protocols for selected cancers that are prevalent in Ontario, Canada, among average risk persons aged 50-75 years. The selected cancers include breast, colorectal, lung, esophageal, liver, pancreatic, stomach, and ovarian. Cost effectiveness was estimated from a provincial Ministry of Health perspective. A state-transition Markov model representing the decision path of both the proposed and existing screening strategies along the natural history of the selected types of cancers was implemented. The incremental cost-effectiveness ratio (ICER) was calculated using data from available literature and the guidelines published by the Canadian Agency for Drugs and Technologies in Health (CADTH) for conducting a cost-effectiveness analysis, which included a discount rate of 1.5% applied to all costs and outcomes. Costs were also converted to 2022 Canadian dollars. To test the robustness of the model, both univariate and probabilistic sensitivity analyses were conducted. MCED screening resulted in more diagnosed cases of each type of cancer, even at an earlier stage of disease. This was also associated with fewer related deaths compared with standard of care. Notwithstanding, the analysis revealed that the MCED intervention was not cost effective [ICER: CAD$143,369 per quality-adjusted life year (QALY)], given a willingness to pay (WTP) threshold of $100,000 per QALY. The probabilistic sensitivity analyses revealed that the MCED intervention strategy was preferred to standard of care no more than 2% of the time at this WTP for both males and females. The model was most sensitive to the cost of MCED screening, and the levels of specificity of the MCED and colorectal cancer screening tests. The main contribution of the study is to present and execute a methodological approach that can be adopted to test the cost effectiveness of an MCED tool in the Canadian setting. The model is also sufficiently generic that it could be adapted to other jurisdictions, and with consideration for increasing the WTP threshold beyond the common $100,000 per QALY limit, given the life-threatening nature of cancer, to ensure that MCED interventions are cost-effective.

PP33 The Cost-effectiveness Of Regorafenib In The Treatment Of Advanced Hepatocellular Carcinoma From A Canadian Perspective

IntroductionHepatocellular carcinoma (HCC) is the most common form of liver cancer and the fourth leading cause of cancer-related death globally. There are unmet needs for effective systematic therapy. The findings of the RESORCE trial highlighted the improvement in overall survival with regorafenib in advanced HCC patients progressing on sorafenib treatment. This study aimed to assess the cost-effectiveness of regorafenib compared with best supportive care (BSC) for advanced HCC from the Canadian healthcare system perspective.MethodsWe developed a Markov model based on four health states: live with adverse events, live without adverse events, progression, and dead. Health outcomes were measured using life-years (LYs), and quality-adjusted life-years (QALYs), and costs were presented in Canadian dollars (CAD). Clinical inputs were derived from the RESORCE trial. A 1.5 percent discount rate was applied to costs and outcomes. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty in findings due to variability in parameters. TreeAge Pro software was used for model implementation.ResultsThe use of regorafenib results in a gain of 0.38 LYs and 0.25 QALYs as compared to BSC with a high incremental cost of CAD26,954 (USD22,313). The ICER for regorafenib compared with BSC was CAD105,850/QALY (USD87,624/QALY) in the base-case analysis. Further, probabilistic sensitivity analyses revealed regorafenib not to be cost-effective at a willingness-to-pay threshold of CAD50,000/QALY.ConclusionsRegorafenib was not found to be cost-effective in the treatment of advanced HCC because of the lower health benefits and higher incremental costs. Lowering the official price of regorafenib or use for only selected patients who can achieve maximum benefits would enhance its cost-effectiveness and treatment preference value.

The Perceived Value of Liquid Biopsy: Results From a Canadian Validation Study of Circulating Tumor DNA T790M Testing—Patient’s Willingness-to-Pay: A Brief Report

IntroductionLiquid biopsy is recommended to diagnose molecular resistance to targeted therapy in patients with lung cancer. Nevertheless, not all jurisdictions provide funding and patient access. We report patients’ perceived value of liquid biopsy in targeted therapy resistance. MethodsCanadian patients participating in a national EGFR T790M liquid biopsy validation study completed structured interviews measuring perceived value and willingness-to-pay for plasma circulating tumor DNA testing as an alternative to tumor biopsy using open-ended and iterative bidding approaches. ResultsA total of 60 patients with advanced lung cancer participated with a median age of 64 years (range: 31–87 y); 69% were Asian and 45% female. All had received prior EGFR tyrosine kinase inhibitor; 17% also received chemotherapy. All patients preferred to have plasma testing over repeat tumor biopsy. In the context of the Canadian publicly funded system, patients estimated that a median of 300 (interquartile range: 150–800) Canadian dollars was a reasonable price to pay for liquid biopsy. Patients were personally willing to pay a median 100 (interquartile range: 33–350) Canadian dollars. ConclusionsIn a system that covers the cost of standard diagnostic tests, patients with lung cancer indicated high willingness-to-pay out-of-pocket for liquid biopsy in the setting of acquired targeted therapy resistance. Patients have high perceived value of plasma genotyping and prefer it to repeat tumor biopsy.

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BackgroundOlder adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.MethodsThe sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013–2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.ResultsOpioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.ConclusionsPotentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

The Cost-Effectiveness of First-Line Cryoablation vs First-Line Antiarrhythmic Drugs in Canadian Patients With Paroxysmal Atrial Fibrillation

BackgroundThe EARLY-AF (NCT02825979), STOP AF First (NCT03118518), and Cryo-FIRST (NCT01803438) randomised controlled trials (RCTs) demonstrated that cryoballoon pulmonary vein isolation reduces atrial fibrillation (AF) recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). The present study developed a cost-effectiveness model (CEM) of first-line cryoablation compared with first-line AADs for PAF, from the Canadian health care payer’s perspective. MethodsData from the 3 RCTs were analysed to estimate key CEM parameters. The model structure used a decision tree for the first 12 months and a Markov model with a 3-month cycle length for the remaining lifetime time horizon. Costs were set at 2023 Canadian dollars, health benefits were expressed as quality-adjusted life years (QALYs), and both were discounted 3% annually. Probabilistic sensitivity analysis (PSA) considered parameter uncertainty. ResultsThe statistical analysis estimated that first-line cryoablation generates a 47% reduction (P < 0.001) in the rate of AF recurrence, a 73% reduction in the rate of subsequent ablation (P < 0.001), and a 4.3% (P = 0.025) increase in health-related quality of life, compared with first-line AADs. The PSA indicates that an individual treated with first-line cryoablation accrues less costs (−$3,862) and more QALYs (0.19) compared with first-line AADs. Cryoablation is cost-saving in 98.4% of PSA iterations and has a 99.9% probability of being cost-effective at a cost-effectiveness threshold of $50,000 per QALY gained. Cost-effectiveness results were robust to changes in key model parameters. ConclusionsFirst-line cryoballoon ablation is cost-effective when compared with AADs for patients with symptomatic PAF.

The current and future total health care costs of atrial fibrillation

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, yet detailed information on the cost burden remains sparse. These data are essential for determining resource allocation, benchmarking care, identifying areas for more efficient healthcare delivery and to measure effects of alternative treatment strategies. Purpose We sought to examine costs for inpatient, ambulatory, physician, and drugs for AF and model future costs. Methods In this retrospective population-based cohort study, we used linked administrative databases to identify all adult patients presenting to any healthcare setting with nonvalvular AF (NVAF) as the most responsible diagnosis in our city, Canada, from fiscal years 2010-2018. Costs for inpatient, ambulatory, physician, and drugs were estimated, in 2019 Canadian dollars, by using Statistics Canada Consumer Price Index. A two-part cost model with logit and gamma generalized linear model was developed to predict costs from 2019 to 2030. Results There were 48,854 NVAF patients. The median age was 70 [59.0,80.0] years, 55% were male, and median CHADS-Vasc score = 3.0 [1.0,4.0]. NVAF-related costs were $1.4 billion dollars (inpatient $1.1 billion, ambulatory $107.0 million, physician $59.6 million, drugs $140.1 million) and represented 36.8% of total costs (Figure 1). The per patient cost of NVAF was $30.1 thousand. Over the study period, costs increased by 2.2% for inpatient, 40.5% for ambulatory, 67.1% for physician, and 214.2% for drugs. By 2030, we estimate there will be 54,523 NVAF patients. NVAF-related costs from 2019 to 2030 are estimated to be $3.6 billion (inpatient $2.5 billion, ambulatory $310.5.0 million, physician $197.5 million, drugs $610.4 million) and will represent 32.1% of total costs (Figure 1). Conclusions Costs for AF are on the rise and the distribution of costs are changing. Although inpatient costs represent the highest proportion of total AF costs, they are projected to decrease while costs due to ambulatory, physician and drug costs are increasing.

Cost-effectiveness analysis of nirsevimab and maternal RSVpreF vaccine strategies for prevention of Respiratory Syncytial Virus disease among infants in Canada: a simulation study

The cost-effectiveness of immunisation strategies with a long-acting monoclonal antibody (nirsevimab) and/or a protein-based maternal vaccine (RSVpreF) for protecting infants from Respiratory Syncytial Virus (RSV)-associated illness has not been previously determined for Canada. We estimated the health benefits and cost-effectiveness of nirsevimab for immunising the entire birth cohort, regardless of gestational age or other risk factors. Additionally, we evaluated the health benefits and cost-effectiveness of a combined strategy of year-round vaccination of pregnant women with RSVpreF and immunisation of infants at high risk, including those born preterm or with chronic conditions, with nirsevimab during the RSV season. We developed a discrete-event simulation model, parameterized with the data on medically-attended RSV infections among infants under one year of age from 2010 to 2019, including outpatient care, hospitalisations, and deaths. Intervention scenarios targeting twelve monthly birth cohorts and pregnant women, reflecting the 2021 census data for Ontario, Canada were evaluated over a follow-up time horizon of one year from birth. Taking into account the costs (in 2023 Canadian dollars) associated with RSV-related outcomes, we calculated the net monetary benefit using the quality-adjusted life-year (QALY) gained. Further, we determined the range of price-per-dose (PPD) for nirsevimab and RSVpreF within which the program was cost-effective. Cost-effectiveness analyses were conducted from both healthcare and societal perspectives. Using a willingness-to-pay of CAD$50,000 per QALY gained, we found that immunising the entire birth cohort with nirsevimab would be cost-effective from a societal perspective for a PPD of up to $290, with an annual budget impact of $83,978 for 1113 infants per 100,000 population. An alternative, combined strategy of vaccinating pregnant women and immunising only infants at high risk of severe disease would lead to a lower budget impact of $49,473 per 100,000 population with a PPD of $290 and $195 for nirsevimab and RSVpreF vaccine, respectively. This combined strategy would reduce infant mortality by 76%-85%, comparable to a 78% reduction achieved through a nirsevimab-only program of the entire birth cohort. The PPD for cost-effective programs with nirsevimab was sensitive to the target population among infants. Passive immunisation of infants under 6 months of age with nirsevimab and vaccination of pregnant women with RSVpreF could be a cost-effective strategy for protecting infants during their first RSV season. This study was supported by the Canadian Immunisation Research Network (CIRN) and the Canadian Institutes of Health Research (CIHR). Seyed M. Moghadas acknowledges support from the Natural Sciences and Engineering Research Council of Canada (MfPH and Discovery grants). Alison P. Galvani acknowledges support from the The Notsew Orm Sands Foundation.

Abstract 12585: The Impact of Remote Patient Monitoring and Digital Therapeutics on Major Clinical Events and Costs in Heart Failure Patients: Early Experience in the Quebec Public Healthcare System

Introduction: There is increasing use of digital health solutions in heart failure (HF), but few studies have demonstrated its impact on public healthcare systems in North America. The Continuum project developed a mobile app for remote patient monitoring (RPM) and a digital therapeutics (DTx) solution aimed at assisting clinicians in medication optimization and preventing hospitalizations among HF outpatients. Research Question: Are RPM and DTx cost-effective for care of outpatients with HF? Methods: A 3-month randomized controlled trial for HF outpatients at risk of hospitalisation evaluated the Continuum program versus standard of care alone. This 12-week program included: 1. A self-care app via smartphone or tablet where patients entered vital signs, weight, and HF symptoms; 2. Remote monitoring of these data by clinical nurses; 3. DTx automated medication suggestions sent to the treating medical team; and 4. HF educational modules for patients. Results: A total of 171 patients were included. Preliminary results are available for the first 63 patients that completed the study, 32 intervention (INT) and 31 control (CTRL). Patients were similar in age (70±12 vs 69±13y), NYHA class (II 81 vs 87%), patients with ejection fraction &lt;40% (56 vs 48%) and comorbidities such as diabetes (38 vs 45%; INT vs CTRL). The number of emergency room (ER) visits and/or hospitalisations (all cause) per patient was 0.19±0.47 for the INT group and 0.55±0.89 for the CTRL one (P=0.05). Survival analysis (Figure) showed a trend in favor of the INT group (95 days (CI95% 87-104) vs 78 days (CI95% 68-89); P=0.08). The total cost of healthcare consumption (hospitalizations + ER visits) in the INT group was 134,088 Canadian dollars vs 174,924 in the CTRL group (+30%). Conclusions: Our preliminary results show potential benefits of a mobile app incorporating self-care, remote monitoring, and digital therapeutics in preventing major events in HF outpatients at a reduced cost for the healthcare system.

Abstract 12085: Emergency Heart Failure Mortality Risk Grade (EHMRG) Score Quintiles Correlate With Short and Long-Term Healthcare Costs

Introduction: The use of the EHMRG model in the emergency department (ED) has been demonstrated to improve outcomes for patients presenting with acute heart failure (HF). It is unknown if the EHMRG model also correlates with healthcare costs, which has not been examined in other HF risk models. Hypothesis: We hypothesized that patients with higher EHMRG risk scores, i.e., sicker, would have higher costs of care in short-term (30-day) and longer-term (up to 2 year) time horizons. Methods: We examined direct costs of care from a health payer perspective using the original EHMRG derivation cohort of 11,857 patients hospitalized with acute HF in Ontario, Canada (from 2004) and linking to population-based case-costing databases. Costs were stratified by the quintiles of the EHMRG risk score (Q1 = lowest risk, Q5 = highest risk). Costs (in 2021 Canadian dollars) were categorized into hospital, physician, drug, home care, long term care (LTC), and other costs. Results: Patients in the lowest EHMRG risk quintile (Q1), compared to higher quintiles (Q2-Q5) had lower total cost of care in both the short-term ($8,113 vs $9,442, $10,557, $12,078 and $15,005, p &lt;0.001) and long-term ($46,661 vs $55,904, $58,904, $63,286 and $64,229, p&lt;0.001). This positive correlation between EHMRG risk quintile and cost of care was also observed for hospital costs ($26,388 [Q1] vs $35,659 [Q5], p&lt;.0001) and LTC costs ($1,236 [Q1] vs $6,316 [Q5], p&lt;.0001) at all time intervals, including at 2 years shown here. Physician costs and drug costs were positively correlated with EHMRG risk quintiles at 30 days (physician: $1,241 [Q1] vs $1,762 [Q5], p&lt;0.0001; drug: $219 [Q1] vs $282 [Q5], p&lt;.0001), and negatively correlated at 2 years (physician: $7,943 [Q1] vs $7,175 [Q5], p&lt;.0001; drug: $4,539 [Q1] vs $4,377 [Q5], p&lt;.0001). There was an increasing trend of costs irrespective of the formulation of the EHMRG risk score as 7-day risk quintile, 30-day risk quintile, or 30-day risk tertile. Conclusion: The EHMRG7 risk score was positively correlated with healthcare costs from 30 days to 2 years after initial ED presentation. This novel correlational study demonstrated that in the absence of an associated intervention, higher mortality risk in HF patients portends higher costs in short and long-term follow-up.

Evaluating the impact of novel oncology drug coverage through patient assistance programs in British Columbia (BC), Canada.

13 Background: Despite a universal public healthcare system, Canadian oncology patients often enroll in patient assistance programs (PAPs) through drug manufacturers to access oncology drugs that are awaiting funding decisions by national and provincial regulatory bodies. Our multicenter study evaluated the pharmacoeconomic and clinical impact of PAPs for cancer patients in BC. Methods: Eligible patients were diagnosed with cancer and enrolled in a PAP for an oncology drug between January 1, 2016 - December 31, 2019 in 3 BC centres. Charts were reviewed for treatment details and survival data. We referenced median overall survival (mOS) or median progression-free survival (mPFS) data from phase III trials. mPFS data was used if mOS was unavailable or not statistically significant. For each drug indication, the hazard ratio from trial data was multiplied by the mOS or mPFS of our cohort to estimate the mOS or mPFS if the drug was not received. Life-years gained (LYG) was defined as the difference between the actual mOS or mPFS in our cohort and the estimated mOS or mPFS if the drug was not received. Mean OS was used if median OS was not reached by the cut-off date January 1, 2021. Quality-adjusted life years (QALY) and cost per drug were obtained from the Canadian Agency for Drugs and Technologies in Health (CADTH). QALY gained per drug was calculated as QALY multiplied by LYG. Assuming $100,000 Canadian dollars (CAD) for 1 QALY gained (based on prior studies), the economic value of QALY gained was calculated as $100,000 CAD multiplied by QALY gained per drug. Results: Our cohort consisted of 1025 patients that accessed 40 oncology drugs via PAP. By the cut-off date, 290 patients continued on treatment while 735 had stopped, most often due to disease progression (69%) or toxicity (14%). 74 patients then accessed another drug in their second exposure to PAP, and 5 patients accessed drugs in their third exposure to PAP. Median time from Health Canada approval to public funding was 2.04 years (IQR 1.53 – 2.34). QALY gained per drug ranged from 0.007-2.997 years for OS and 0.001-1.339 years for PFS. This translated to a total of 268.3 QALY gained in OS and 117.6 QALY gained in PFS. In the first exposure group, total economic value gained from PAP was $26,788,512 for those with OS benefits, $11,763,571 for those with PFS benefits, and total drug costs were $94,150,774. In the second exposure group, total economic value gained was $566,253 for those with OS benefits, $947,134 for those with PFS benefits, and total costs were $4,917,017. In the third exposure group, $44,754 total economic value was gained and total costs were $931,207. Conclusions: Nearly $100 million CAD of non-public funding was required to bridge gaps between regulatory approval and public funding. The economic value and QALY gained from PAPs are substantial. Future studies should focus on strategies to optimize the funding process for novel cancer therapies.

Cost-effectiveness analysis of bevacizumab biosimilars for metastatic colorectal cancer: A comparative study using real-world data.

9 Background: MVASI (Amgen) and Zirabev (Pfizer) are two of the earliest bevacizumab biosimilars approved for the first-line treatment of metastatic colorectal cancer (mCRC). While the introduction of biosimilars present an opportunity to alleviate the financial toxicity owing to the escalating costs of novel biologics, biosimilars should be comparatively assessed against the reference biologic in a real-world setting to confirm that they are indeed cost-saving or cost-effective after implementation. In this study, we aimed to confirm and quantify the real-world cost-savings of MVASI and Zirabev relative to originator bevacizumab (Avastin) for patients with mCRC. Methods: We conducted a population-based, retrospective cohort study in Ontario, Canada, where originator and biosimilar bevacizumab are universally publicly funded. Capturing the entire population of Ontario, we assessed all mCRC patients who received originator bevacizumab between January 1, 2008, and August 11, 2019, or biosimilar bevacizumab between August 12, 2019, and March 31, 2021. Biosimilar cases and originator bevacizumab controls were matched 1:4 using propensity score methods to adjust for differences at baseline. We calculated 1-year total patient-level costs (in Canadian dollars) and effects (in life years and quality-adjusted life years (QALY)) from the public health payer’s perspective. The primary outcomes for estimating cost-effectiveness were incremental net monetary benefit (INMB) and incremental net health benefit (INHB), calculated at willingness-to-pay (WTP) thresholds ranging from $50,000-200,000 per life year gained. Sensitivity analyses included a subgroup analysis by biosimilar type (MVASI/Zirabev) and an analysis using a 2-year time horizon. Results: The final propensity score matched cohort included 747 biosimilar cases and 2,945 controls. Bevacizumab biosimilars were associated with an incremental cost of -$6,379 (95% confidence interval (CI): -9,417, -3,537) (i.e., cost-saving) and an incremental effect of 0.0 (95% CI: -0.02, 0.02) life years gained and -0.01 (95% CI: -0.03, 0) QALY gained. INMB and INHB estimates indicated that biosimilar bevacizumab is cost-effective at all WTP thresholds assessed, with results remaining consistent across our biosimilar type subgroups and 2-year sensitivity analyses. Conclusions: Bevacizumab biosimilars demonstrated real-world cost-savings while providing similar survival benefit as originator bevacizumab, confirming the initial expectations of their implementation.

Pembrolizumab vs chemotherapy in the first-line setting of PD-L1≥50% metastatic non-small cell lung cancer: A real-world cost-effectiveness analysis.

21 Background: Despite the voiced concerns around the initial economic decision models for first-line pembrolizumab in PD-L1≥50% metastatic non-small cell lung cancer (mNSCLC), there has been a paucity of evidence on the anticipated cost-effectiveness of pembrolizumab in the real world. To resolve the uncertainties associated with the initial assessment, we evaluated the real-world cost-effectiveness of first line pembrolizumab versus platinum-based chemotherapy for mNSCLC patients with PD-L1≥50%. Methods: We retrospectively identified a population-based cohort of mNSCLC patients who received first-line pembrolizumab or platinum-based chemotherapy between April 1, 2013, and March 31, 2021, in Ontario, Canada. Employing a public payer’s perspective, all costs (in Canadian dollars) and effects were estimated over a 4-year horizon, adjusted for censoring and discounted at 1.5% yearly. The primary outcomes were incremental cost-effectiveness ratios (ICERs) for life-years gained (LYG) and quality-adjusted life year (QALY). To examine the sensitivity of the ICER to drug acquisition costs and discounting, we conducted a price reduction analysis and a scenario analysis of different discount rates. Results: Propensity-score matching resulted in a total of 1,142 pairs of matched mNSCLC patients. Pembrolizumab extended survival with an incremental effect of 0.37 LYG and 0.35 QALY, but at an incremental cost of $56,681; the resulting ICERs were $154,941/LYG and $163,039/QALY. Though the ICERs were not sensitive to discounting rate, 31% and 55% reductions to the price of pembrolizumab brought the ICER below $100,000/QALY and $50,000/QALY, respectively. Conclusions: In the real world, first-line pembrolizumab is not considered to be cost-effective for mNSCLC patients with PD-L1≥50%. Improvements in cost-effectiveness, however, may be achievable through price renegotiations for pembrolizumab.

Challenges and Opportunities in Recruiting Research Participants Using Facebook: Lessons Learned from an Exemplar Study.

Facebook is a prominent social medial platform frequently used for business marketing. Researchers are starting to recognize the utility of this platform for developing research awareness, information dissemination, and more recently participant recruitment. This paper will provide an overview of methods used in Facebook recruitment through an exemplar study. It will highlight successes and challenges and provide insight into future opportunities for its' use. Two methods of Facebook recruitment are outlined in this paper: the use of Facebook groups and paid advertising. A step-by-step guide highlights how researchers can implement these specific methods of Facebook recruitment. Facebook was successfully utilized to recruit participants in the exemplar study. Recruitment was completed over a period of 82 days with a total cost of $157.09 Canadian dollars. Facebook is a viable method of recruiting research participants. This method can be cost-effective, timely, and efficient in comparison to traditional research recruitment methods. However, one must balance the benefits and challenges of this type of recruitment.

Resource use and cost associated with computerized decision support system and usual care in managing patients with atrial fibrillation: analysis of IMPACT-AF randomized trial data

BackgroundIMPACT-AF is a prospective, randomized, cluster design trial comparing atrial fibrillation (AF) management with a computerized decision support system (CDS) to usual care (control) in the primary care setting of Nova Scotia, Canada. The objective of this analysis was to compare the resource use and costs between CDS and usual care groups.MethodsCase costing data, 12-month self-administered questionnaires, and monthly diaries from IMPACT-AF were used in this analysis. Descriptive statistics were used to compare costs and resource use between groups. All costs are presented in 2021 Canadian dollars and cover the 12-month period of participation in the study.ResultsA total of 1,145 patients enrolled in the trial. Case costing data were available for 466 participants (41.1%), 12-month self-administered questionnaire data for 635 participants (56.0%) and monthly diary data for 223 participants (19.7%). Emergency department visits and hospitalizations comprised the most expensive component of AF care. Across all three datasets, there were no statistically significant differences in costs or resource use between CDS and usual care groups.ConclusionsAlthough there were no significant differences in resource use or costs among CDS and usual care groups in the IMPACT-AF trial, this study provides insight into the methodology and practical challenges of collecting economic data alongside a trial.RegistrationClinicaltrials.gov (registration number: NCT01927367, date of registration: 2013-08-20).

A Frailty Index to Predict Mortality, Resource Utilization and Costs in Patients Undergoing Coronary Artery Bypass Graft Surgery in Ontario

BackgroundPeople living with frailty are vulnerable to poor outcomes and incur higher health care costs after coronary artery bypass graft (CABG) surgery. Frailty-defining instruments for population-level research in the CABG setting have not been established. The objectives of the study were to develop a preoperative frailty index for CABG (pFI-C) surgery using Ontario administrative data; assess pFI-C suitability in predicting clinical and economic outcomes; and compare pFI-C predictive capabilities with other indices. MethodsA retrospective cohort study was conducted using health administrative data of 50,682 CABG patients. The pFI-C comprised 27 frailty-related health deficits. Associations between index scores and mortality, resource use and health care costs (2022 Canadian dollars [CAD]) were assessed using multivariable regression models. Capabilities of the pFI-C in predicting mortality were evaluated using concordance statistics; goodness of fit of the models was assessed using Akakie Information Criterion. ResultsAs assessed by the pFI-C, 22% of the cohort lived with frailty. The pFI-C score was strongly associated with mortality per 10% increase (odds ratio [OR], 3.04; 95% confidence interval [CI], [2.83,3.27]), and was significantly associated with resource utilization and costs. The predictive performances of the pFI-C, Charlson, and Elixhauser indices and Johns Hopkins Aggregated Diagnostic Groups were similar, and mortality models containing the pFI-C had a concordance (C)-statistic of 0.784. Cost models containing the pFI-C showed the best fit. ConclusionsThe pFI-C is predictive of mortality and associated with resource utilization and costs during the year following CABG. This index could aid in identifying a subgroup of high-risk CABG patients who could benefit from targeted perioperative health care interventions.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BackgroundDupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.MethodsA cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.ResultsOmalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.ConclusionWhen comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.

Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health.

Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health. We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health. The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731). Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.

The British Columbia Farmers’ Market Nutrition Coupon Program Reduces Short-Term Household Food Insecurity Among Adults With Low Incomes: A Pragmatic Randomized Controlled Trial

BackgroundThe British Columbia Farmers’ Market Nutrition Coupon Program (BC FMNCP) provides households with low incomes with coupons to purchase healthy foods from farmers’ markets. ObjectiveTo examine the impact of the BC FMNCP on the short-term household food insecurity, malnutrition risk, mental well-being, sense of community (secondary outcomes), and subjective social status (exploratory outcome) of adults with low incomes post-intervention and 16 weeks post-intervention. DesignSecondary analyses from a pragmatic randomized controlled trial conducted in 2019 that collected data at baseline, post-intervention, and 16 weeks post-intervention. Participants/settingAdults ≥18 years with low incomes were randomized to an FMNCP group (n = 143) or a no-intervention control group (n = 142). InterventionParticipants in the FMNCP group received 16 coupon sheets valued at $21 Canadian dollars (CAD)/sheet over 10 to 15 weeks to purchase healthy foods from farmers’ markets and were eligible to participate in nutrition skill-building activities. Main outcome measuresOutcomes included short-term household food insecurity (modified version of Health Canada’s 18-item Household Food Security Survey Module), malnutrition risk (Malnutrition Universal Screening Tool), mental well-being (Warwick-Edinburgh Mental Well-Being Scale), sense of community (Brief Sense of Community Scale), and subjective social status (MacArthur Scale of Subjective Social Status community scale). Statistical analysisMixed-effects linear regression and multinomial logistic regression examined between-group differences in outcomes post-intervention and 16 weeks post-intervention. ResultsThe risk of marginal and severe short-term household food insecurity was lower among those in the FMNCP group compared with those in the control group (relative risk ratio [RRR] 0.15, P = 0.01 and RRR 0.16, P = 0.02) post-intervention, with sustained reductions in severe household food insecurity 16 weeks post-intervention (RRR 0.11, P = 0.01). No statistically significant differences were observed in malnutrition risk, mental well-being, sense of community, or subjective social status post-intervention or 16 weeks post-intervention. ConclusionsThe BC FMNCP reduced short-term household food insecurity but was not found to improve malnutrition risk or psychosocial well-being among adults with low incomes compared with a no-intervention control group.

Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation

BackgroundHealthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs. MethodsAll patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$). ResultsAmong 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001). ConclusionsDespite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients.