Cost-effectiveness Acceptability Curves Research Articles

Cost effectiveness of implanting a prosthesis after anterior cervical discectomy for radiculopathy: results of the NECK randomized controlled trial

BACKGROUND CONTEXTIn the treatment of cervical radiculopathy due to a herniated disc, potential surgical treatments include: anterior cervical discectomy (ACD), ACD and fusion using a cage (ACDF), and anterior cervical disc arthroplasty (ACDA). Previous publications yielded comparable clinical and radiological outcome data for the various implants, but research on their comparative costutility has been inconclusive. PURPOSETo evaluate the cost utility of ACD, ACDF, and ACDA. STUDY DESIGNCost-utility analysis. PATIENT SAMPLEAbout 109 patients with cervical radiculopathy randomized to undergo ACD, ACDF, or ACDA as part of the NEtherlands Cervical Kinetics trial. OUTCOME MEASURESQuality-adjusted life-years (QALYs) estimated from patient-reported utilities using the EuroQol-5D questionnaire and EuroQol Visual Analogue Scale (EQ VAS), measured at baseline, 2, 4, 8, 12, 26, 52, and 104 weeks postprocedure. Societal costs including admissions to hospital (related and otherwise), GP visits, specialist visits, physical therapy, medications, home care, aids, informal care, productivity losses, and out of pocket condition-related expenses. METHODSThe cost utility of the competing strategies over 1 and 2 years was assessed following a net benefit (NB) approach, whereby the intervention with the highest NB among competing strategies is preferred. Cost effectiveness acceptability curves were produced to reflect the probability of each strategy being the most cost effective across various willingness-to-pay (WTP) thresholds. Five sensitivity analyses were conducted to assess the robustness of results. RESULTSACDF was more likely to be the most cost-effective strategy at WTP thresholds of €20,000 to 50,000/QALY in all but one of the analyses. The mean QALYs during the first year were 0.750, 0.817, and 0.807 for ACD, ACDF, and ACDA, respectively, with no significant differences between groups. Total healthcare costs over the first year were significantly higher for ACDA, largely due to the higher surgery and implant costs. The total societal costs of the three strategies were €12,173 for ACD, €11,195 for ACDF, and €13,746 for ACDA, with no significant differences between groups. CONCLUSIONOur findings demonstrate that ACDF is likely to be more cost-effective than ACDA or ACD at most WTP thresholds, and this conclusion is robust to most sensitivity analyses conducted. It is demonstrated that the difference in costs is mainly caused by the initial surgical costs and that there are only minimal differences in other costs during follow-up. Since clinical data are comparable between the groups, it is to the judgment of the patient and surgeon which intervention is applied.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data.

This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone. This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included. Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness. From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

AI telemedicine screening in ophthalmology: health economic considerations

AI telemedicine screening in ophthalmology: health economic considerations

Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting

BackgroundPrevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo. MethodsWe leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves. ResultsMean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust. ConclusionsGiven the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.

Cost-effectiveness analysis of ultra-hypofractionated radiotherapy and conventionally fractionated radiotherapy for intermediate- to high-risk localized prostate cancer.

Radiotherapy is an effective curative treatment option for intermediate- to high-risk localized prostate cancer. According to the HYPO-RT-PC trial (ISRCTN45905321), there was no significant difference in 5 years of follow-up in terms of failure-free survival, overall survival, urinary toxicity, and bowel toxicity, while erectile function decreased between ultra-hypofractionated radiotherapy with conventionally fractionated radiotherapy, except that the incidence of urinary toxicity in ultra-hypofractionated radiotherapy was higher at 1 year of follow-up. We evaluated the cost-effectiveness of ultra-hypofractionated radiotherapy and conventionally fractionated radiotherapy for intermediate- to high-risk localized prostate cancer from the Chinese payer's perspective. We developed a Markov model with a 15-year time horizon to compare the cost and effectiveness of ultra-hypofractionated radiotherapy with those of conventionally fractionated radiotherapy for localized intermediate- to high-risk prostate cancer. The outcomes were measured in quality-adjusted life-years (QALYs), incremental cost-effectiveness ratio (ICER), and willingness-to-pay (WTP). Univariable and probability sensitivity analyses were performed to evaluate the robustness of the Markov model. Based on the Markov model, conventionally fractionated radiotherapy yielded 2.32 QALYs compared with 2.14 QALYs in ultra-hypofractionated radiotherapy in China. The cost of ultra-hypofractionated radiotherapy was found to be decreased by about 14% folds ($4,251.04) in comparison with that of conventionally fractionated radiotherapy. The ICER of conventionally fractionated radiotherapy versus that of ultra-hypofractionated radiotherapy was $23,616.89 per QALY in China. The failure-free survival with grade 2 or worse urinary toxicity and the discount rate per annum were the most sensitive parameters utilized in ultra-hypofractionated radiotherapy. The cost-effectiveness acceptability curve showed that conventionally fractionated radiotherapy had 57.7% probability of being cost-effective under the Chinese WTP threshold. From the perspective of Chinese payers, ultra-hypofractionated radiotherapy was not a cost-effective strategy compared with conventionally fractionated radiotherapy for patients with localized intermediate- to high-risk prostate cancer. Nevertheless, reduction of the grade 2 or worse urinary toxicity of ultra-hypofractionated radiotherapy could alter the results.

Education plus exercise for persistent gluteal tendinopathy improves quality of life and is cost-effective compared with corticosteroid injection and wait and see: economic evaluation of a randomised trial.

For patients with gluteal tendinopathy, what is the cost utility from health system and societal perspectives of three management approaches: education plus exercise, ultrasound-guided corticosteroid injection or wait and see? Economic evaluation alongside a three-group, parallel, randomised clinical efficacy trial. People aged between 35 and 70 years with image-confirmed gluteal tendinopathy were recruited via advertisements. Education plus exercise, consisting of 14 visits to a physiotherapist, with detailed instruction on tendinopathy management, twice weekly supervised exercise sessions, daily home exercises, a handout and a CD; corticosteroid injection, consisting of one ultrasound-guided injection and a handout on general tendon care; and 'wait and see', consisting of one visit to a physiotherapist with assurance and advice on staying active whilst respecting pain. Economic outcome measures were quality-adjusted life years (QALYs) calculated from EuroQol EQ-5D-3L using Australian population preference weights, and total economic costs obtained from participant-reported data collected over the 1-year follow-up period. Missing data (<12% per group) were imputed. Linear regression was used to estimate incremental QALYs and costs between interventions; uncertainty was assessed by calculating 90% confidence intervals, cost-effectiveness acceptability curves and confidence ellipses. A total of 204 individuals (82% women) were enrolled. Incremental cost-effectiveness ratio favoured education plus exercise over corticosteroid injection (AU$12,719 and $5,592 on societal and health system perspectives, respectively) and over wait and see ($29,258 and $3,444 on societal and health system perspectives, respectively). Complete case analysis and varying the direct intervention costs did not change the (imputed analysis) results, with the exception that corticosteroid injection was less cost-effective. Education plus exercise for gluteal tendinopathy improves health-related quality of life and is cost-effective compared with corticosteroid injection and wait and see for treating gluteal tendinopathy. ACTRN12612001126808.

Mechanical thrombectomy is cost-effective versus medical management alone around Europe in patients with low ASPECTS

ObjectiveTo demonstrate, by a cost-effectiveness analysis, the efficiency of mechanical thrombectomy (MT) versus medical management (MM) in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) from the...

Cost and cost-effectiveness of abstinence contingent wage supplements

BackgroundSubstance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care. MethodsTo calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment. ResultsACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915. ConclusionsACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.

Cost-effectiveness analysis of androgen deprivation therapy with relugolix for the treatment of advanced prostate cancer

BackgroundRelugolix treatment of advanced prostate cancer (APC), like other gonadotropin-releasing hormone-antagonists, results in rapid decrease in testosterone concentrations without the risk of flare, as seen in leuprolide. Despite this benefit over leuprolide, no economic evaluation assessment to ascertain the cost-effectiveness of relugolix has been conducted. Therefore, this study aims to assess the cost-effectiveness of androgen deprivation therapy (ADT) with 120 mg relugolix against 7.5 mg leuprolide for the treatment of APC. MethodsA Markov model was used to assess and compare the costs of APC treatment from a health care payer's perspective and the effectiveness of ADT with relugolix and leuprolide at the 3 lines of APC treatment among modified intent-to-treat patients. Relative progression-free (PFS) and overall survival (OS) rates were estimated. Outcomes measured in the analyses included costs of the drugs and therapies, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), cost-effectiveness acceptability, and probability curves. ResultsThe cost-effectiveness analysis showed the ICER for ADT with relugolix to be US $49,571.1 per QALY. At the ICER value, the sensitivity analysis indicated that ADT with leuprolide was dominant in 100% of the simulations. ADT acceptance with relugolix was 100% when a willingness-to-pay threshold was set at US $100,000/QALY. At 5-years, the relative PFS and OS rates for relugolix at the first line of therapy were 72.7% and 86.0%, respectively, compared to 61.0% and 85.90% for leuprolide. ConclusionThough the influence of adverse events was not considered in the analysis, ADT with relugolix was not a cost-effective choice for APC management. While the analysis revealed a slight chance of sustaining testosterone suppression with relugolix, ADT with relugolix provided no significant survival advantages over ADT with leuprolide. Therefore, this analysis confirms no need for further assessment of APC interventions to make informed decisions beneficial to the APC patients, oncologists, and other stakeholders.

Cost-Effectiveness of the Early Arthritis Clinic Organizational Model.

Early diagnosis and tight control improve outcomes of rheumatoid arthritis (RA). However, whether establishing an early arthritis clinic (EAC) is sustainable for national health systems is not known. This analysis aimed to compare effectiveness and costs of an EAC compared to patients followed by the current standard of care. A retrospective study on administrative health databases of patients with a new diagnosis of RA was conducted: 430 patients followed in an EAC were enrolled, and 4 non-EAC controls were randomly matched for each. During 2 years of follow-up, the mean health care costs (outpatient, inpatient, pharmaceutical, and global) and 3 effectiveness measures (number and length of hospitalization and quality of care) of the EAC and non-EAC were estimated. The incremental cost-effectiveness ratio was calculated as well as the cost-effectiveness acceptability curve. The cohorts included patients with a mean age of 55.4 years, and 1,506 patients (70%) were female. The mean pharmaceutical (2,602 versus 1,945 euros) and outpatient (2,447 versus 1,778 euros) costs were higher in the EAC cohort. Conversely, a higher rate of non-EAC patients had a low adherence to quality-of-care indicators. The expected number of hospitalizations and the length of stay were statistically significantly higher in the non-EAC versus EAC. Despite an expected increase in outpatient costs (visits and diagnostic tests) and pharmaceutical costs, the reduction in terms of number and length of hospitalizations and the higher adherence to international quality-of-care guidelines support the effectiveness of the EAC model.

Is the cost-effectiveness of an early-childhood sleep intervention to prevent obesity affected by socioeconomic position?

This study aimedto determine whether the cost-effectiveness of an infant sleep intervention from the Prevention of Overweight in Infancy (POI) trial was influenced by socioeconomic position (SEP). An SEP-specific economic evaluation of the sleep intervention was conducted. SEP-specific intervention costs and effects at age 5 years, derived from the trial data, were applied to a representative cohort of 4,898 4- to 5-year-old Australian children. Quality-adjusted life years and health care costs were simulated until age 17 years using a purpose-built SEP-specific model. Incremental cost-effectiveness ratios and acceptability curves were derived for each SEP group. The incremental cost-effectiveness ratios, in Australian dollars per quality-adjusted life year gained, were smaller in the low- ($23,010) and mid-SEP ($18,206) groups compared with the high-SEP group ($31,981). The probability that the intervention was cost-effective was very high in the low- and mid-SEP groups (92%-100%) and moderately high in the high-SEP group (79%). An infant sleep intervention is more cost-effective in low- and mid-SEP groups compared with high-SEP groups. Targeting this intervention to low-SEP groups would not require trade-offs between efficiency and equity.

A Cost-Effectiveness Analysis of Prehabilitation for High-Risk Surgical Patients in Canada: Results from a Nonrandomized Clinical Trial

<h3>Research Objectives</h3> To evaluate the cost-effectiveness of a pragmatic model of prehabilitation for high-risk surgical candidates from a hospital perspective. <h3>Design</h3> A cost-effectiveness analysis (CEA) from a hospital perspective was performed using data from a nonrandomized clinical trial of a pragmatic model of prehabilitation compared to usual care (UC) for high-risk surgical patients. <h3>Setting</h3> A large academic hospital in Toronto, Ontario, Canada. <h3>Participants</h3> High-risk surgical candidates referred by their physician at the time of surgical planning. <h3>Interventions</h3> The prehabilitation group underwent baseline assessments from a multidisciplinary healthcare team followed by shared-decision making concerning allocation to facility-based, home-based, or virtual prehabilitation. Prehabilitation modalities included individualized exercise, nutrition, psychological support, and smoking cessation over the preoperative period. The control group received UC. <h3>Main Outcome Measures</h3> The primary endpoint was an incremental cost-effectiveness ratio (ICER) with surgical complications as the effect measure. Nonparametric bootstrapping methods were employed to investigate the joint distribution of incremental costs and incremental effects, estimate ICER uncertainty, and generate cost-effectiveness acceptability curves (CEACs). Results were presented for overall prehabilitation and stratified by each prehabilitation delivery strategy. <h3>Results</h3> Sixty-seven patients were included (prehabilitation n=49; UC n=18). Prehabilitation was associated with averting more surgical complications but came at greater costs compared to UC. Results indicate the potential cost-effectiveness of prehabilitation for reducing surgical complications, although data limitations and point-estimate uncertainty preclude conclusive recommendations. When stratified by prehabilitation delivery strategy, estimated cost-effectiveness varied considerably, and beckon future research to clarify economically optimal prehabilitation protocols within an implementation context. <h3>Conclusions</h3> This was the first CEA of a pragmatic model of prehabilitation for high-risk surgical patients, contributing an increasingly relevant economic perspective regarding the potential role of prehabilitation implementation from a hospital perspective. Future economic evaluations of prehabilitation are necessary to clarify optimal prehabilitation protocols and definitively inform implementation decisions. <h3>Author(s) Disclosures</h3> No disclosures.

Cost-Effectiveness Analyses of First Line Ibrutinib Versus Acalabrutinib Versus Zanubrutinib Followed By Second Line Venetoclax Plus Rituximab in Previously Untreated Chronic Lymphocytic Leukemia (CLL) Patients

Background. Targeted therapy with Bruton's tyrosine kinase inhibitors (BTKI) has significantly improved progression-free (PFS) and overall survival (OS) outcomes when compared with chemoimmunotherapy in the front line setting of CLL. Following the approval of the first generation of BTKI (ibrutinib, IBR) in 2016 as first line (1L) treatment of CLL, second generation BTKIs with more favorable safety profiles were approved/recommended in 2020 (acalabrutinib, ACA) and 2021 (zanubrutinib, ZAN). We performed a network meta-analysis (NMA) of these three BTKIs in terms of PFS in support of cost-effectiveness analyses from US payer perspective. Methods. We conducted a NMA of 5 trials (Woyach 2018, Burger 2015, Sharman 2020, Tam 2021, Goede 2014) on the PFS hazard ratios (HR) of the 3 BTKIs and any other CLL interventions that connected in the network. We specified a 5-state Markov model to capture the disease and clinical pathway for CLL patients over a 10 years' time horizon: progression free (PF) on 1L treatment [PF1]; progression before initiating second line (2L) treatment [P1]; PF on 2L treatment [PF2]; progression after 2L treatment [P2]; and death. Patients started PF on 1L treatment with a BTKI and moved to other states based on extracted transition probabilities from lognormal parametric distributions fitted to Kaplan-Meier PFS curves of phase III trials of IBR, ACA and ZAN. Venetoclax plus rituximab (VR) was considered the 2L treatment with PF2, P2 and death in 2L extracted from Seymour 2018. The transition probabilities of PF on 1L treatment and progression after 1L were adjusted based on the NMA results. OS and time to next treatment (TTNT) after first progression were considered the same for the three BTKIs. Costs of regimens (wholesale acquisition cost), adverse event (AE) management, and disease progression were incorporated into the appropriate health states. Utilities of PF1 (0.799), P1 (0.66), PF2 (0.55) and P2 (0.42) were obtained from literature. Annual discount rate of 3.0% was applied. Life years (LY), quality adjusted LY (QALY), and incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR) were estimated. Probabilistic sensitivity analyses (PSA; 10,000 iterations) were performed to obtain cost-effectiveness acceptability curves (CEAC). Results. Compared with IBR, ACA (HR=0.54; 95%CI=0.41-0.72) but not ZAN (HR=1.03; 95%CI=0.80-1.34) was associated with a statistically significant lower HR of progression or death. At 10 years, 77% of ACA patients were in PF1 and 9% in PF2, compared to 49% and 28% of ZAN patients, and 50% and 27% of IBR patients. As shown in the table, in base case analyses, total costs of IBR treatment were higher by $104,331 over ACA and by $350,340 over ZAN; with ACA being higher by $246,009 over ZAN. Survival was estimated to be 6.83 LYs for IBR, 7.02 LYs for ACA (+0.19) and 6.82 LYs for ZAN (-0.01). QALYs were estimated to be 5.00 for IBR, 5.46 for ACA (+0.46) and 5.09 for ZAN (+0.09). This yielded negative (cost saving) ICER of $-549,110/LYg and ICUR of $-226,806/QALYg for ACA over IBR. The statistically non-significant survival benefit, the 0.01 LY lost but 0.09 QALY gained, and the lower cost of ZAN over IBR yielded an ICER of $35,034,000/LYg and a negative (cost saving) ICUR of $3,892,666/QALYg. Compared to ZAN, treatment with ACA was associated with incremental costs of $246,009, 0.20 LY and 0.37 QALY differentials, yielding ICER of $1,230,045/LYg yet ICUR of $664,889/QALYg. All estimates were confirmed with negligible differences in PSAs. In a scenario analysis for the PF1 state only, QALY gains were 5.25 for ACA, 4.40 for ZAN and 4.34 for IBR. Considering cost differentials of $-69,138 for ACA and $-352,297 for ZAN relative to IBR, the corresponding ICURs were $-75,975/QALYg and $-5,871,617/QALYg, resp. Conclusion. Clinically over the course of 1L treatment with a BTKI followed by 2L treatment with VR, ACA in 1L is associated with greater reductions in the risk of progression or death compared to IBR and ZAN over 10 years. This benefit comes at lower cost than IBR, which resulted in cost-saving ICUR and ICER estimates; but at higher cost than ZAN, which resulted in an ICUR of ~$665,000 per QALY gained. Proportionately, QALY results came out more favorably than LY results. This rather unusual result is attributable to the better safety profiles and lower AE costs of ACA and ZAN, coupled with lower pricing. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 13987: Cost-Effectiveness of Direct Oral Anticoagulant vs Warfarin Among Atrial Fibrillation Patients With Intermediate Stroke Risk

Background: Several studies have shown the cost-effectiveness of direct oral anticoagulants (DOACs), compared with warfarin, to prevent atrial fibrillation (AF) related complications. However, few have reported cost-effectiveness of DOACs in AF patients with intermediate stroke risk. Thus, we investigated the cost-effectiveness of DOACs vs. warfarin in non-valvular AF patients with intermediate stroke risk using national representative data. Methods: We identified 7,954 newly diagnosed non-valvular AF patients (≥18 years) with intermediate stroke risk (CHA2DS2-VASc score: 1 for men and 2 for women) using the national healthcare utilization data from August 1, 2016, to July 31, 2019. Annual incidence rate of AF-related composite outcomes (heat failure, myocardial infarction, ischemic stroke, intracerebral hemorrhage, and gastrointestinal bleeding) was estimated. Cost-effectiveness was estimated using a Markov chain model with the transition probability of 1 year. The willingness-to-pay (WTP) was set at $32,000 per quality-adjusted life-year (QALY) gained. Results: The total cost of warfarin, rivaroxaban, apixaban, dabigatran and edoxaban was $2,874, $5,761, $5,151, $5,761 and $5,851, respectively. The QALYs gained were 10.83, 10.95, 11.10, 10.49 and 10.99 years, respectively. The incremental cost-effectiveness ratio of rivaroxaban, apixaban, dabigatran and edoxaban was $29,743.99, $8,426.71, -$8,483.04 and $18,483.55, respectively. The WTP was set at $32,000. DOACs (except dabigatran) were more cost-effective compared with warfarin because they did not exceed the WTP in the base-case analysis. Conclusion: Our findings showed that DOACs were more cost-effective than warfarin in non-valvular AF patients with intermediate stroke risk. Figure 1. Cost-effectiveness acceptability curve of Warfarin vs. DOACs in AF patients with intermediate stroke risk.

Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial

Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh. We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh. We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results. Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings. These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh. This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.

Cost Effectiveness of a Shorter Moxifloxacin Based Regimen for Treating Drug Sensitive Tuberculosis in India.

Globally efforts are underway to shorten the existing 6-month tuberculosis (TB) treatment regimen for drug-sensitive patients, which would be equally effective and safe. At present, there is a lack of evidence on the cost implications of a shorter 4-month TB regimen in India. This economic modeling study was conducted in the Indian context with a high TB burden. We used a hybrid economic model comprising of a decision tree and Markov analysis. The study estimated the incremental costs, life years (LYs), and quality-adjusted life years (QALYs) gained by the introduction of a Moxifloxacin-based shorter 4-month treatment regimen for pulmonary TB patients. The outcomes are expressed in incremental cost-effectiveness ratios (ICERs) per QALYs gained. The cost per case to be treated under the 4-month regimen was USD 145.94 whereas for the 6-month regimen it was USD 150.39. A shorter 4-month TB regimen was cost-saving with USD 4.62 per LY and USD 5.29 per QALY. One-way sensitivity analysis revealed that the cost of the drugs for the 4-month regimen, hospitalization cost for adverse drug reactions, and human resources incurred for the 6-month regimen had a higher influence on the ICER. The probability sensitivity analysis highlighted that the joint incremental cost and effectiveness using QALY were less costly and more effective for 67% of the iteration values. The cost-effectiveness acceptability curve highlights that the 4-month regimen was dominant to both patients and the National TB Elimination Programme in India as compared to the 6-month regimen at different cost-effectiveness threshold values.

Economic Analysis of Infectious Disease Consultation for Staphylococcus aureus Bacteremia Among Hospitalized Patients

Staphylococcus aureus bacteremia is associated with a significant burden of mortality, morbidity, and health care costs. Infectious disease consultation may be associated with reduced mortality and bacteremia recurrence rates. To evaluate the cost-effectiveness of infectious disease consultation for Staphylococcus aureus bacteremia. In this economic evaluation, a decision-analytic model was constructed comparing infectious disease consult with no consult. The population was adult hospital inpatients with Staphylococcus aureus bacteremia diagnosed with at least 1 positive blood culture. Cost-effectiveness was calculated as deaths averted and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Costs and outcomes were calculated for a time horizon of 6 months. The analysis was performed from a societal perspective and included studies that had been published by January 2022. Patients received or did not receive formal bedside consultation after positive blood cultures for Staphylococcus aureus bacteremia. The main outcomes were incremental difference in effectiveness (survival probabilities), incremental difference in cost (US dollars) and incremental cost-effectiveness ratios (US dollars/deaths averted). This model included 1708 patients who received consultation and 1273 patients who did not. In the base-case analysis, the cost associated with the infectious disease consult strategy was $54 137.4 and the associated probability of survival was 0.77. For the no consult strategy, the cost was $57 051.2, and the probability of survival was 0.72. The incremental difference in cost between strategies was $2913.8, and the incremental difference in effectiveness was 0.05. Overall, consultation was associated with estimated savings of $55 613.4/death averted (incremental cost-effectiveness ratio, -$55613.4/death averted). In the probabilistic analysis, at a willingness-to-pay threshold of $50 000, infectious disease consult was cost-effective compared with no consult in 54% of 10 000 simulations. In cost-effectiveness acceptability curves, the consult strategy was cost-effective in 58% to 73%) of simulations compared with no consult for a willingness-to-pay threshold ranging from $0 to $150 000. These findings suggest that infectious disease consultation may be a cost-effective strategy for management of Staphylococcus aureus bacteremia and that it is associated with health care cost-savings.

Economic evaluation of using polygenic risk score to guide risk screening and interventions for the prevention of type 2 diabetes in individuals with high overall baseline risk.

Type 2 diabetes (T2D) with increasing prevalence is a significant global public health challenge. Obesity, unhealthy diet, and low physical activity are one of the major determinants of the rise in T2D prevalence. In addition, family history and genetic risk of diabetes also play a role in the process of developing T2D. Therefore, solutions for the early identification of individuals at high risk for T2D for early targeted detection of T2D, prevention, and intervention are highly preferred. Recently, novel genomic-based polygenic risk scores (PRSs) have been suggested to improve the accuracy of risk prediction supporting the targeting of preventive interventions to those at highest risk for T2D. Therefore, the aim of the present study was to assess the cost-utility of an additional PRS testing information (as a part of overall risk assessment) followed by a lifestyle intervention and an additional medical therapy when estimated 10-year overall risk for T2D exceeded 20% among Finnish individuals screened as at the high-risk category (i.e., 10%–20% 10-year overall risk of T2D) based on traditional risk factors only. For a cost-utility analysis, an individual-level state-transition model with probabilistic sensitivity analysis was constructed. A 1-year cycle length and a lifetime time horizon were applied in the base-case. A 3% discount rate was used for costs and QALYs. Cost-effectiveness acceptability curve (CEAC) and estimates for the expected value of perfect information (EVPI) were calculated to assist decision makers. The use of the targeted PRS strategy reclassified 12.4 percentage points of individuals to be very high-risk individuals who would have been originally classified as high risk using the usual strategy only. Over a lifetime horizon, the targeted PRS was a dominant strategy (i.e., less costly, more effective). One-way and scenario sensitivity analyses showed that results remained dominant in almost all simulations. However, there is uncertainty, since the probability (EVPI) of cost-effectiveness at a WTP of 0€/QALY was 63.0% (243€) indicating the probability that the PRS strategy is a dominant option. In conclusion, the results demonstrated that the PRS provides moderate additional value in Finnish population in risk screening leading to potential cost savings and better quality of life when compared with the current screening methods for T2D risk.

Cost-effectiveness and cost-utility of hypertension and hyperlipidemia collaborative management between pharmacies and primary care in portugal alongside a trial compared with usual care (USFarmácia®).

Background: There is little experience in the economic evaluation of pharmacy/primary care collaborative health interventions using interprofessional technology-driven communication under real-world conditions. This study aimed to conduct cost-effectiveness and cost-utility analyses of a collaborative care intervention in hypertension and hyperlipidemia management between pharmacies and primary care versus usual (fragmented) care alongside a trial. Methods: An economic evaluation was conducted alongside a 6-month pragmatic quasi-experimental controlled trial. Data sources included primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. The target population was adult patients on hypertension and/or lipid-lowering medication. The perspective was societal. We collected patient-level data on resource use to estimate trial costs. Effect outcomes included blood pressure (BP) and quality-adjusted life years (QALYs). Bootstrapping was used to estimate uncertainty around the incremental cost-effectiveness and cost-utility ratios. Cost-effectiveness planes and acceptability curves were estimated. Results: The intervention was not shown to have reasonable levels of cost-effectiveness or cost-utility when compared to usual care as denoted by the levels of uncertainty expressed in wide confidence intervals. The probability of the intervention being cost-effective is 28% at the threshold of €20,000 per QALY gained and 57% at the threshold of €500 per mmHg systolic BP decrease. Conclusion: Considering the limitations of the trial which affected effectiveness and economic outcomes, our results are not generalizable for community pharmacy and primary care in Portugal. This research offers, however, valuable lessons on methods and strategies that can be used in future economic evaluations of collaborative public health interventions with the potential for reimbursement. Clinical trial registration: https://www.isrctn.com/ISRCTN13410498, identifier ISRCTN13410498

Cost-effectiveness analysis of mesh fixation techniques for laparoscopic and open inguinal hernia surgeries

PurposeThis study reports economic evaluation of mesh fixation in open and laparoscopic hernia repair from a prospective real-world cohort study, using cost-effectiveness analysis (CEA) and cost-utility analysis (CUA).MethodsA prospective real-world cohort study was conducted in two university-based hospitals in Thailand from November 2018 to 2019. Patient data on hernia features, operative approaches, clinical outcomes, associated cost data, and quality of life were collected. Models were used to determine each group’s treatment effect, potential outcome means, and average treatment effects. An incremental cost-effectiveness ratio was used to evaluate the incremental risk of hernia recurrences.ResultsThe 261 patients in this study were divided into six groups: laparoscopic with tack (LT, n = 47), glue (LG, n = 26), and self-gripping mesh (LSG, n = 30), and open with suture (OS, n = 117), glue (OG, n = 18), and self-gripping mesh (OSG, n = 23). Hernia recurrence was most common in LSG. The mean utility score was highest in OG and OSG (both 0.99). Treatment costs were generally higher for laparoscopic than open procedures. The cost-effectiveness plane for utility and hernia recurrence identified LSG as least cost effective. Cost-effectiveness acceptability curves identified OG as having the highest probability of being cost effective at willingness to pay levels between $0 and $3,300, followed by OSG.ConclusionGiven the similarity of hernia recurrence among all major procedures, the cost of surgery may impact the decision. According to our findings, open hernia repair with adhesive or self-gripping mesh appears most cost-effective.