Cost-effectiveness Of Different Strategies Research Articles

Meningococcal Conjugate Vaccines Policy Update: Booster Dose Recommendations

The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Pediatrics approved updated recommendations for the use of quadravalent (serogroups A, C, W-135, and Y) meningococcal conjugate vaccines (Menactra [Sanofi Pasteur, Swiftwater, PA] and Menveo [Novartis, Basel, Switzerland]) in adolescents and in people at persistent high risk of meningococcal disease. The recommendations supplement previous Advisory Committee on Immunization Practices and American Academy of Pediatrics recommendations for meningococcal vaccinations. Data were reviewed pertaining to immunogenicity in high-risk groups, bactericidal antibody persistence after immunization, current epidemiology of meningococcal disease, meningococcal conjugate vaccine effectiveness, and cost-effectiveness of different strategies for vaccination of adolescents. This review prompted the following recommendations: (1) adolescents should be routinely immunized at 11 through 12 years of age and given a booster dose at 16 years of age; (2) adolescents who received their first dose at age 13 through 15 years should receive a booster at age 16 through 18 years or up to 5 years after their first dose; (3) adolescents who receive their first dose of meningococcal conjugate vaccine at or after 16 years of age do not need a booster dose; (4) a 2-dose primary series should be administered 2 months apart for those who are at increased risk of invasive meningococcal disease because of persistent complement component (eg, C5-C9, properdin, factor H, or factor D) deficiency (9 months through 54 years of age) or functional or anatomic asplenia (2-54 years of age) and for adolescents with HIV infection; and (5) a booster dose should be given 3 years after the primary series if the primary 2-dose series was given from 2 through 6 years of age and every 5 years for persons whose 2-dose primary series or booster dose was given at 7 years of age or older who are at risk of invasive meningococcal disease because of persistent component (eg, C5-C9, properdin, factor H, or factor D) deficiency or functional or anatomic asplenia.

Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modelling Study

Antiretrovirals have substantial promise for HIV-1 prevention, either as antiretroviral treatment (ART) for HIV-1-infected persons to reduce infectiousness, or as pre-exposure prophylaxis (PrEP) for HIV-1-uninfected persons to reduce the possibility of infection with HIV-1. HIV-1 serodiscordant couples in long-term partnerships (one member is infected and the other is uninfected) are a priority for prevention interventions. Earlier ART and PrEP might both reduce HIV-1 transmission in this group, but the merits and synergies of these different approaches have not been analyzed. We constructed a mathematical model to examine the impact and cost-effectiveness of different strategies, including earlier initiation of ART and/or PrEP, for HIV-1 prevention for serodiscordant couples. Although the cost of PrEP is high, the cost per infection averted is significantly offset by future savings in lifelong treatment, especially among couples with multiple partners, low condom use, and a high risk of transmission. In some situations, highly effective PrEP could be cost-saving overall. To keep couples alive and without a new infection, providing PrEP to the uninfected partner could be at least as cost-effective as initiating ART earlier in the infected partner, if the annual cost of PrEP is <40% of the annual cost of ART and PrEP is >70% effective. Strategic use of PrEP and ART could substantially and cost-effectively reduce HIV-1 transmission in HIV-1 serodiscordant couples. New and forthcoming data on the efficacy of PrEP, the cost of delivery of ART and PrEP, and couples behaviours and preferences will be critical for optimizing the use of antiretrovirals for HIV-1 prevention. Please see later in the article for the Editors' Summary.

Decision Making in Patients with Pulmonary Nodules

Integrating current evidence with fundamental concepts from decision analysis suggests that management of patients with pulmonary nodules should begin with estimating the pretest probability of cancer from the patient's clinical risk factors and computed tomography characteristics. Then, the consequences of treatment should be considered, by comparing the benefits of surgery if the patient has lung cancer with the potential harm if the patient does not have cancer. This analysis determines the "treatment threshold," which is the point around which the decision centers. This varies widely among patients depending on their cardiopulmonary reserve, comorbidities, and individual preferences. For patients with a very low probability of cancer, careful observation with serial computed tomography is warranted. For those with a high probability of cancer, surgical diagnosis is warranted. For patients in the intermediate range of probabilities, either computed tomography-guided fine-needle aspiration biopsy or positron emission tomography, possibly followed by computed tomography-guided fine-needle aspiration biopsy, is best. Patient preferences should be considered because the absolute difference in outcome between strategies may be small. The optimal approach to the management of patients with pulmonary nodules is evolving as technologies develop. Areas of uncertainty include quantifying the hazard of delayed diagnosis; determining the optimal duration of follow-up for ground-glass and semisolid opacities; establishing the roles of volumetric imaging, advanced bronchoscopic technologies, and limited surgical resections; and calculating the cost-effectiveness of different strategies.

P1-S4.17 Interactive demonstration of a model to calculate costs and cost effectiveness of different strategies for chlamydia screening and partner notification

BackgroundWe have developed a model to calculate costs and cost effectiveness of different intervention strategies for chlamydia screening, which can be used by commissioners to evaluate and plan their local service provision. The model and an analysis of national data have been recently published in BMJ. Increasingly, financial constraints will mean that tools such as ours will be vital to provide value for money in healthcare.MethodWe will give a live demonstration of our spreadsheet model using the example from our recent study. We invite delegates to input their own data in real time to a laptop for comparison and testing against the national and international picture. We plan to promote this before the meeting.Main outcome measuresCost effectiveness of screening (as cost per individual tested, cost per positive diagnosis, total cost of screening, number screened, number infected, sex ratio of those tested and treated). We will show how to compare current programmes with a planned change eg, in screening coverage or partner notification efficacy.ResultsIn 2008−2009 screening was estimated to cost £46.3 m and £506 per infection treated. The model results suggest that increasing male screening coverage from 8% to 24% (to match female coverage) would cost an extra £22.9 m and increase the cost per infection treated to £528. Increasing partner notification efficacy from 0.4 to 0.8 partners per index case would cost an extra £3.3 m and reduce the cost per infection diagnosed to £449.ConclusionsThe results are broadly representative of the national picture, but further evaluation of the cost effectiveness of partner notification and screening is urgently needed. We encourage practitioners who want to test this tool in their own setting to contact us (katy.turner@bristol.ac.uk).BMJ2011; 342:c725010.1136/bmj.c7250.

Costs and cost effectiveness of different strategies for chlamydia screening and partner notification: an economic and mathematical modelling study

Objectives To compare the cost, cost effectiveness, and sex equity of different intervention strategies within the English National Chlamydia Screening Programme. To develop a tool for calculating cost effectiveness of...

Cost-effectiveness analysis of human papillomavirus DNA testing and Pap smear for cervical cancer screening in a publicly financed health-care system

Objective:To evaluate the long-term cost-effectiveness of different strategies for human papillomavirus (HPV) DNA testing combined with Pap smear for cervical cancer screening in Taiwan.Methods:This study adopts a perspective of Department of Health in cost-effectiveness analysis to compare a no-screening strategy with nine different screening strategies. These strategies comprise three screening tools (Pap smear alone, HPV DNA testing followed by Pap smear triage, and HPV DNA testing combined with Pap smear), and three screening intervals (annually, every 3 years, and every 5 years). Outcomes are life expectancy, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analyses (PSAs) were conducted to assess parameter uncertainty.Results:When three times gross domestic product per capita is used as the decision threshold, all nine screening strategies were cost-effective compared with the no-screening strategy. Compared with the current screening strategy (an annual Pap smear), HPV DNA testing followed by Pap smear triage every 5 years and every 3 years were cost-effective. Results of PSA also indicated that a HPV DNA testing followed by Pap smear triage every 5 or every 3 years achieved the highest expected net benefits.Conclusions:Possible economic advantages are associated with extending the cervical cancer screening interval from one Pap smear annually to HPV DNA testing followed by Pap smear triage every 5 years with an ICER $1 247 000 per QALY gained, especially in a country with a publicly financed health-care system.

Cost‐Effectiveness of Adult Circumcision in a Resource‐Rich Setting for HIV Prevention among Men Who Have Sex with Men

We examined the effects and cost-effectiveness of 4 strategies of circumcision in a resource-rich setting (Australia) in a population of men who have sex with men (MSM). We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost-effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35-44 years, circumcision of all insertive MSM aged 18 years, and circumcision of all MSM aged 18 years . All costs are reported in US dollars, with a cost-effectiveness threshold of $42,000 per quality-adjusted life-year. We find that 2%-5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from $3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save $21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35-44 years would be cost-effective; the latter would require a smaller investment. The least cost-effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition. Circumcision of adult MSM may be cost-effective in this resource-rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.

O692 Determining cost-effectiveness of different strategies for post-partum hemorrhage (PPH) prevention

O692 Determining cost-effectiveness of different strategies for post-partum hemorrhage (PPH) prevention

Asymptomatic pancreatic cystic neoplasm: a cost-effectiveness analysis of different strategies of management

Optimal management of asymptomatic pancreatic cystic neoplasm is not known. In a decision analysis, the cost-effectiveness of different strategies for managing solitary, asymptomatic pancreatic cystic neoplasm were compared. Three strategies were examined in a Markov model with a third-party-payer perspective. In strategy I, the natural history of the lesion was followed without any specific intervention. In strategy II, an aggressive surgical approach was considered in that all patients were considered for resection. In strategy III, an initial EUS-guided FNA with cyst fluid analysis was performed for risk stratification, and patients with mucinous cysts were considered for resection. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life years were obtained from published information. An operability risk score based on patient age, comorbidity, and size and location of the cyst was developed to estimate the probability of surgical resection. In the baseline analysis, strategy III yielded the highest quality-adjusted life years with an acceptable incremental cost-effectiveness ratio. In a Monte Carlo analysis, the relative risk of patients developing unresectable pancreatic cancer was decreased in strategy III compared to the other strategies. Although threshold analyses identified few important parameters influencing the conclusion of the analysis, operability risk score was the critical determinant of the optimal management strategy. Indirect costs were not considered in this analysis. For asymptomatic patients with incidental solitary pancreatic cystic neoplasm, a blanket policy of surgical resection for all patients cannot be justified. A strategy based on risk stratification of malignant potential by EUS-guided FNA and cyst fluid analysis is the most cost-effective strategy.

Cost-effectiveness of conservation strategies implemented in boreal forests: The area selection process

To protect land from commercial exploitation is a common conservation practice. However, this requires large financial resources and it is therefore important to evaluate the cost-effectiveness of different strategies used in the selection of these conservation areas. In this study we compare four strategies and relate the differences in cost-effectiveness to differences in the selection process. We measure conservation benefits both as the amount of three tree structures and as the number of species in three species groups. We also estimate both the information cost associated with selecting conservation areas and the opportunity cost. We found the key habitat strategy to be the over-all most cost-effective. In this strategy, the areas have a flexible size and are selected by the authorities in a national field survey. The least cost-effective strategy was one where the selection was based only on forest classes in a satellite map. Intermediate were the retention group strategy, where small areas are left by the forest owner at harvesting, and the nature reserve strategy, where large areas are selected by the authorities. We emphasize that the differences we found are associated with the selection process and that other aspects, such as long-term survival of species, may rank the strategies differently. We conclude that the cost-effectiveness of a selection strategy depends on the size of the planning area for selection of conservation areas, the size of the conservation areas, the objective of the agent making the selection, and the amount and type of information on which the selection is based.

Cost-Effectiveness of Different Strategies for Amplified Mycobacterium tuberculosis Direct Testing for Cases of Pulmonary Tuberculosis

We conducted a decision analysis to assess and compare four algorithms for amplified Mycobacterium tuberculosis direct (MTD) testing of respiratory specimens in terms of cost-effectiveness. The most cost-effective strategy was one in which smear-positive specimens but not smear-negative specimens were diluted prior to MTD testing.

COMPLETION ANGIOGRAPHY FOR SURGICALLY TREATED CEREBRAL ANEURYSMS

Abstract OBJECTIVE To compare cost-effectiveness of different strategies for completion angiography after cerebral aneurysm clipping. METHODS A literature search was used to determine the outcome probabilities and costs of various strategies. The pooled results were used in a Markov cost-effectiveness model to compare quality-adjusted life-years and costs of each strategy. Sensitivity (threshold) analyses and Monte Carlo simulation were used to test variation in the model. RESULTS Routine (for all cases) intraoperative angiography proved to be slightly more cost-effective than selective (only for cases deemed “high risk”) intraoperative angiography, being both less costly and more effective. Routine postoperative angiography was the least cost-effective. However, in centers whose rates of clip-induced arterial compromise are much lower than the averages reported in the literature, selective angiography might be warranted. CONCLUSION Routine intraoperative angiography remains the most cost-effective form of completion angiography after aneurysm clipping, at least at our present state of technology.

The association between advertising and calls to a tobacco quitline

Objective:This study assessed the cost effectiveness of different types of television and radio advertisements and the time of day in which advertisements were placed in generating calls to the Oregon...

Residual infectious disease risk in screened blood transfusion from a high‐prevalence population: Santa Catarina, Brazil

Infectious disease testing has improved but viral infection transmission through transfusion continues to occur. Residual risk, however, is now so low in some countries that it can only be estimated by mathematical modeling. With hierarchical Bayesian methods, this study estimates the residual risk of transfusion-transmitted infections in Santa Catarina, Brazil. Data from the six state blood collection services covering Santa Catarina between 1998 and 2002 were used. Information was obtained on donor profiles, screening and confirmatory test results, and records of all allogeneic blood donations for repeat donors. Residual risk estimates of hepatitis B virus (HBV), human immunodeficiency virus (HIV), hepatitis C virus (HCV), and human T-cell leukemia virus (HTLV) were separately derived from posterior distributions of incidence rates and preseroconversion window-period lengths. Estimated risks of a donation infectious for HBV and HIV entering the blood supply are 1:10,700 (95% confidence interval [CI], 1:4900-1:28,200) and 1:26,200 (95% CI, 1:14,800-1:64,100) donations, respectively. Estimated risks for HCV and HTLV were 1:19,300 (95% CI, 1:10,400-1:44,800) and 1:116,300 (95% CI, 1:40,200-1:1,000,000) donations, respectively. HBV risk is 1.8 times greater than HCV risk, 2.4 times greater than HIV risk, and 10.8 times that of HTLV. Actual risks would be lower due to immune recipients and subinfectious levels of undetected viremia. The major factor contributing to risk differences between Santa Catarina and countries with similar testing regimes is the much higher source population diseases prevalence. Payoff for nucleic acid testing would be low, thus additional investment in safety should be based on studies of the cost-effectiveness of different strategies to reduce overall transmission.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

2007;50;e159-e242; originally published online Sep 27, 2007; J. Am. Coll. Cardiol. Tarkington, and Clyde W. Yancy Lytle, Rick Nishimura, Joseph P. Ornato, Richard L. Page, Barbara Riegel, Lynn G. W. Valentin Fuster, Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce Christopher E. Buller, Mark A. Creager, Steven M. Ettinger, David P. Faxon, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, K. Kasper, Judy R. Kersten, Barbara Riegel, John F. Robb, Sidney C. Smith, Jr, Chaikof, Kirsten E. Fleischmann, William K. Freeman, James B. Froehlich, Edward Lee A. Fleisher, Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliott L. Vascular Surgery Interventions, Society for Vascular Medicine and Biology, and Society for and Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography Society of Nuclear Cardiology, Heart Rhythm Society, Society of Collaboration With the American Society of Echocardiography, American Developed in Cardiovascular Evaluation for Noncardiac Surgery) (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiology/American Heart Association Task Force on Practice Guidelines Care for Noncardiac Surgery: A Report of the American College of ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and This information is current as of March 25, 2009 http://content.onlinejacc.org/cgi/content/full/50/17/e159 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research

Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research

Treatment-resistant depression: managed care considerations.

Treatment-resistant depression (TRD) presents a unique challenge in managed care, requiring review of both the clinical and economic components of care. To review the TRD disease state as well as data supporting the various therapeutic options available for the treatment of persistent depression in managed care. While there is no consensus on the definition of TRD, persistent disease can generally be defined as depression that fails to respond to adequate treatment. When initial treatment is not effective or tolerable after 6 to 8 weeks of therapy, the American Psychiatric Association (APA) treatment guidelines recommend dose titration, augmentation, or switching. In the case of a therapy switch, the body of evidence suggests that selection of an agent with a different mechanism of action than the initial agent may be the most effective treatment. Furthermore, when patients maintain continuous therapy for the recommended treatment duration, outcomes are improved compared with patients who discontinue therapy early. As a result, the most effective treatment strategies promote improved patient compliance as well as the use of agents associated with a reduced incidence of premature discontinuation and therapy change early in the treatment program. While data supporting these clinically effective components of therapy exist, few data are available demonstrating the most cost-effective therapeutic options for TRD. This analysis suggests that managed care providers could benefit from a model that they can customize to evaluate the overall costeffectiveness of different strategies in the management of depression.

Chapter 18: Public health policy for cervical cancer prevention: The role of decision science, economic evaluation, and mathematical modeling

Several factors are changing the landscape of cervical cancer control, including a better understanding of the natural history of human papillomavirus (HPV), reliable assays for detecting high-risk HPV infections, and a soon to be available HPV-16/18 vaccine. There are important differences in the relevant policy questions for different settings. By synthesizing and integrating the best available data, the use of modeling in a decision analytic framework can identify those factors most likely to influence outcomes, can guide the design of future clinical studies and operational research, can provide insight into the cost-effectiveness of different strategies, and can assist in early decision-making when considered with criteria such as equity, public preferences, and political and cultural constraints.

Optimal Management of Pancreatic Cysts - A Cost-Effectiveness Analysis

The management of asymptomatic pancreatic cysts, increasingly identified as incidental findings on abdominal imaging tests is a dilemma. A small proportion of mucinous cysts may progress to invasive cancer and an aggressive strategy of surgical resection of all cysts is often pursued with the attendant risk of surgery. Objective: We performed a decision analysis comparing the cost-effectiveness of different strategies for managing solitary, asymptomatic pancreatic cysts. Methods: Incremental cost-effectiveness ratio (ICER) of three primary strategies were examined in a Markov model with a societal perspective. Strategy I was a wait and watch approach with follow-up MRI every 3 years. Development of specific alarm symptoms or imaging features suggesting malignant transformation during surveillance would trigger further evaluation with EUS-FNA and appropriate management, including resection. In Strategy II, an initial EUS-FNA was performed and patients with increased cyst fluid CEA or positive cytology underwent resection. A. Strategy III was surgical resection of all cysts without prior EUS evaluation. Results: In a 60 year old person Strategy I yielded highest quality adjusted life years (QALY) with an acceptable ICER (Table) in both the baseline and a second order Monte Carlo analysis. Strategy II dominated strategy III, and was both cheaper and yielded more QALYs. Test characteristics of EUS-FNA, surgical risk score and the annual mortality rate of malignant mucinous cystic neoplasm were the three important threshold variables that influenced the optimal strategy. Conclusion: A conservative strategy is generally more cost-effective than surgical resection in managing incidental asymptomatic pancreatic cysts. An initial EUS-FNA based strategy is favored in selecting patients who may benefit from resection.

Comparison of three larviciding options for malaria vector control

A field study was carried out over 27 weeks in the south Batinah region of Oman to assess the efficiency and cost-effectiveness of different strategies for vector control of malaria. Three larviciding strategies for Anopheles spp. were applied to intervention areas and compared with a control area, with over 2000 breeding sites monitored for 6 months. The normal method of spraying 1 ppm temephos larvicide fortnightly was found to be less efficient and less cost-effective than using 0.5 ppm temephos applied weekly. A third, more environmentally favourable method, to search for vector larvae and treat only those breeding places, was more effective than fortnightly spraying but less effective than the weekly half dose and was the most expensive strategy.