Cost Assumptions Research Articles

Estimating realistic costs for strategic management planning of invasive species eradications on islands

Environmental managers regularly face decisions about how to counteract threats. These decisions require an understanding of both the conservation benefits and economic costs of candidate actions. However, transparent frameworks for how to accurately calculate costs for management are rare. We worked with island managers in Australia to develop eradication protocols for six invasive species- four mammals and two weeds. We used the protocols to create an accounting framework for invasive species eradications to produce realistic cost estimates for eradications across multiple locations. We also used our models to test common cost assumptions: (1) that costs scale linearly with area, (2) that terrain does not influence costs, and (3) that eradication costs stay constant through time. By explicating testing assumptions, we found that costs largely scaled linearly with area, that terrain influences costs, and that costs decline as populations decline in response to ongoing management. Estimated mammal eradication costs were driven in large part by the area of an island and the cost of transport. However, when area alone was used as a proxy for costs, the calculated costs deviated from our modelled costs by 40–56%. Weed eradication cost estimates were driven by the size and density of an infestation as well as the terrain of the island, with the effect of terrain becoming more pronounced as area to be treated increased. We provide a method to calculate realistic costs across several sites, which can be used to guide strategic management decision-making, including prioritisation, and on-ground management actions.

Optimal Ordering Policy for Inventory Systems with Quantity-Dependent Setup Costs

We consider a continuous-review inventory system in which the setup cost of each order is a general function of the order quantity and the demand process is modeled as a Brownian motion with a positive drift. Assuming the holding and shortage cost to be a convex function of the inventory level, we obtain the optimal ordering policy that minimizes the long-run average cost by a lower bound approach. To tackle some technical issues in the lower bound approach under the quantity-dependent setup cost assumption, we establish a comparison theorem that enables one to prove the global optimality of a policy by examining a tractable subset of admissible policies. Since the smooth pasting technique does not apply to our Brownian inventory model, we also propose a selection procedure for computing optimal policy parameters when the setup cost is a step function.

Cost-effectiveness of pertuzumab combined with trastuzumab and docetaxel as a first-line treatment for HER-2 positive metastatic breast cancer

ABSTRACTObjective: To provide perspective for the National Health Insurance Bureau (NHIB), we determined the cost-effectiveness of pertuzumab combined with trastuzumab and docetaxel (TDP) versus trastuzumab and docetaxel (TD) as a first-line treatment for HER-2 positive metastatic breast cancer.Methods: We used a Markov model to simulate cost-effectiveness, disease progression, and survival, based on clinical data and transition probabilities extracted from the CLEOPATRA study. Direct medical costs were acquired from the NHIB claims database.The utilities in health state were based on a recent cost-effectiveness study on trastuzumab and pertuzumab. Outcomes included quality-adjusted life-years (QALYs), costs in New Taiwan dollars (NT$), and the incremental cost-effectiveness ratio (ICER). We performed one-way deterministic and probabilistic sensitivity analyses to assess the impact of specific parameters on the model.Results: Modeled median survival was 39.1 months for TD and 50.1 months for TDP. The ICER was NT$18,999,687 (US$593,741) per QALY gained. The sensitivity analyses indicated that TDP could be cost-effective under favorable assumptions; TDP had a 68% chance of being cost-effective, if TDP costs could be reduced with 10% in the stable disease state.Conclusion: Our model predicted that TDP would be cost-effective as a first-line treatment for HER-2 positive metastatic breast cancer, but only under favorable drug cost assumptions.

The role of storage technologies for the transition to a 100% renewable energy system in Ukraine

A transition towards a 100% renewable energy (RE) power sector by 2050 is investigated for Ukraine. Simulations using an hourly resolved model define the roles of storage technologies in a least cost system configuration. Results indicate that the levelised cost of electricity will fall from a current level of 82 €/MWhe to 60 €/MWhe in 2050 through the adoption of low cost RE power generation and improvements in efficiency. If the capacity in 2050 would have been invested for the cost assumptions of 2050, the cost would be 54 €/MWhe, which can be expected for the time beyond 2050. In addition, flexibility of and stability in the power system are provided by increasing shares of energy storage solutions over time, in parallel with expected price decreases in these technologies. Total storage requirements include 0-139 GWhe of batteries, 9 GWhe of pumped hydro storage, and 0-18,840 GWhgas of gas storage for the time period. Outputs of power-to-gas begin in 2035 when renewable energy production reaches a share of 86% in the power system, increasing to a total of 13 TWhgas in 2050. A 100% RE system can be a more economical and efficient solution for Ukraine, one that is also compatible with climate change mitigation targets set out at COP21. Achieving a sustainable energy system can aid in achieving other political, economic and social goals for Ukraine, but this will require overcoming several barriers through proper planning and supportive policies.

The Demand For Storage Technologies In Energy Transition Pathways Towards 100% Renewable Energy For India

The initiatives taken by India to tap its renewable energy (RE) potential have been extraordinary in recent years. However, large scale deployment of renewables requires various storage solutions to balance intermittency. In this work, a 100% RE transition pathway based on an hourly resolved model till 2050 is simulated for India, covering demand by the power, desalination and non-energetic industrial gas sectors. Energy storage technologies used in the model that provide flexibility to the system and balance the demand are batteries, pumped hydro storage (PHS), adiabatic compressed air energy storage (A-CAES), thermal energy storage (TES) and power-to-gas technology. The optimization for each time period (transition is modeled in 5-year steps) is carried out on assumed costs and technological status of all energy technologies involved. The model optimizes the least cost mix of RE power plants and storage technologies installed to achieve a fully RE based power system by 2050 considering the base year’s (2015) installed power plant capacities, their lifetimes and total electricity demand. Results indicate that a 100% renewable energy based energy system is achievable in 2050 with the levelised cost of electricity falling from a current level of 58 €/MWhe to 52 €/MWhe in 2050 in a country-wide scenario. If the capacity in 2050 would have been invested for the cost assumptions of 2050 the cost would be 42 €/MWhe, which can be expected for the time beyond 2050. With large scale intermittent renewable energy sources in the system, the demand for storage technologies increases from the current level to 2050. Batteries provide 2596 TWh, PHS provides 12 TWh and gas storage provides 197 TWh of electricity to the total electricity demand. Most of the storage demand will be based on batteries, which provide as much as 42% of the total electricity demand. The combination of solar PV and battery storage evolves as the low-cost backbone of Indian energy supply, resulting in 3.2 – 4.3 TWp of installed PV capacities, depending on the applied scenario in 2050. The above results clearly prove that renewable energy options are the most competitive and least-cost solution for achieving a net zero emission energy system. This is the first study of its kind in full hourly resolution for India

Transition towards a 100% Renewable Energy System and the Role of Storage Technologies: A Case Study of Iran

This work presents a pathway for the transition to a 100% renewable energy (RE) system by 2050 for Iran. An hourly resolved model is simulated to investigate the total power capacity required from 2015 to 2050 in 5-year time steps to fulfil the electricity demand for Iran. In addition, shares of various RE resources and storage technologies have been estimated for the applied years, and all periods before in 5-year time steps. The model takes the 2015 installed power plant capacities, corresponding lifetimes and total electrical energy demand to compute and optimize the mix of RE plants needed to be installed to achieve a 100% RE power system by 2050. The optimization is carried out on the basis of assumed costs and technological status of all energy technologies involved. Moreover, the role of storage technologies in the energy system, and integration of the power sector with desalination and non-energetic industrial gas sectors are examined. Our results reveal that RE technologies can fulfil all electricity demand by the year 2050 at a price level of about 41 - 47 €/MWhel depending on the sectorial integration. Moreover, the combination of solar PV and battery storage is found as a least cost solution after 2030 for Iran. If the capacity in 2050 would have been invested for the cost assumptions of 2050 the cost would be 32 - 40 €/MWhel, depending on the sectorial integration, which can be expected for the time beyond 2050.

Cost Effectiveness of Prostate Boost with High-Dose Rate Brachytherapy Versus Intensity Modulated Radiation Therapy in the Treatment of Intermediate-High Risk Prostate Cancer

The recently published ASCENDE-RT randomized clinical trial demonstrated improved biochemical control, albeit with increased toxicity, for a prostate boost with brachytherapy versus external beam radiation therapy alone. Our single-institution retrospective review demonstrated similar findings. It is unknown whether the increased biochemical control of a prostate brachytherapy boost outweighs its increased cost and toxicity. In this study, we investigated the cost-effectiveness of these two modalities in the treatment of intermediate-high risk prostate cancer. A multi-state Markov decision tree was created to model a patient with intermediate-high risk prostate cancer. The two treatment options modeled were: (1) 23 fractions of IMRT and 2 fractions of HDR prostate brachytherapy (brachytherapy boost), and (2) 44 fractions of IMRT (IMRT alone). Each patient received 1 year of hormone therapy, per the ASCENDE-RT protocol. Model assumptions, including clinical outcomes, toxicity, and utilities were obtained from the medical literature. Costs were estimated using Medicare reimbursement data. The expected lifetime costs and quality-adjusted life years (QALY) were then estimated. If applicable, an Incremental Cost-Effectiveness Ratio (ICER) was computed. One-way sensitivity analyses were performed over a range of cancer progression rates, utilities, and cost assumptions. We assumed a maximum willingness to pay of $50,000/QALY. The estimated expected lifetime costs of brachytherapy boost were $71,978, compared to $81,543 for IMRT alone. While having a higher upfront cost, brachytherapy boost reduced expected lifetime costs because it decreased the incidence of metastatic castration-resistant prostate cancer (mCRPC), cutting the use of expensive targeted therapy for mCRPC. Brachytherapy boost had an expected QALY of 11.20 years, compared to 9.1 years for IMRT alone. Therefore, brachytherapy boost is a dominant treatment strategy over IMRT alone. One-way sensitivity analyses found brachytherapy boost to be cost-effective over a range of cost, utility, and cancer progression rate assumptions. IMRT with HDR brachytherapy boost is a cost-effective treatment for intermediate-high risk prostate cancer compared to IMRT alone.

Electricity system based on 100% renewable energy for India and SAARC.

The developing region of SAARC (South Asian Association for Regional Cooperation) is home to a large number of people living below the poverty line. In future, providing affordable, universally accessible, reliable, low to zero carbon electricity in this region will be the main aim. A cost optimal 100% renewable energy system is simulated for SAARC for the year 2030 on an hourly resolved basis. The region was divided into 16 sub-regions and three different scenarios were set up based on the level of high voltage direct current (HVDC) grid connections. The results obtained for a total system levelised cost of electricity (LCOE) showed a decrease from 71.6 €/MWh in a decentralized to 67.2 €/MWh for a centralized grid connected scenario. An additional scenario was simulated to show the benefits of integrating industrial gas production and seawater reverse osmosis desalination demand, and showed the system cost decreased by 5% and total electricity generation decreased by 1%. The results show that a 100% renewable energy system could be a reality in the SAARC region with the cost assumptions used in this research and it may be more cost competitive than nuclear and fossil carbon capture and storage (CCS) alternatives. One of the limitations of this study is the cost of land for installation of renewables which is not included in the LCOE calculations, but regarded as a minor contribution.

Optimized, Budget-constrained Monitoring Well Placement Using DREAM

Defining the ideal suite of monitoring technologies to be deployed at a carbon capture and storage (CCS) site presents a challenge to project developers, financers, insurers, regulators and other stakeholders. The monitoring, verification, and accounting (MVA) toolkit offers a suite of technologies to monitor an extensive range of parameters across a wide span of spatial and temporal resolutions, each with their own degree of sensitivity to changes in the parameter being monitored. Understanding how best to optimize MVA budgets to minimize the time to leak detection could help to address issues around project risks, and in turn help support broad CCS deployment. This paper presents a case study demonstrating an application of the Designs for Risk Evaluation and Management (DREAM) tool using an ensemble of CO2 leakage scenarios taken from a previous study on leakage impacts to groundwater. Impacts were assessed and monitored as a function of pH, total dissolved solids (TDS), and trace metal concentrations of arsenic (As), cadmium (Cd), chromium (Cr), and lead (Pb). Using output from the previous study, the DREAM tool was used to optimize monitoring system designs based on variable sampling locations and parameters. The algorithm requires the user to define a finite budget to limit the number of monitoring wells and technologies deployed, and then iterates well placement, sensor type and location until it converges on the configuration with the lowest time to first detection of the leak averaged across all scenarios. To facilitate an understanding of the optimal number of sampling wells, DREAM was used to assess the marginal utility of additional sampling locations. Based on assumptions about monitoring costs and replacement costs of degraded water, the incremental cost of each additional sampling well can be compared against its marginal value in terms of avoided aquifer degradation. Applying this method, DREAM identified the most cost-effective ensemble with 14 monitoring locations. While this preliminary study applied relatively simplistic cost and technology assumptions, it provides an exciting proof-of-concept for the application of DREAM to questions of cost-optimized MVA system design that are informed not only by site-specific costs and technology options, but also by reservoir simulation results developed during site characterization and operation.

Competitiveness of advanced and conventional biofuels: Results from least-cost modelling of biofuel competition in Germany

Techno-economic variables for advanced biofuels produced from lignocellulosic biomass have been scrutinized and combined with a newly developed transparent model for simulating the competitiveness between conventional and advanced biofuels for road transport in the medium to long term in Germany. The influence of learning effects and feedstock cost developments has been highlighted, including also gaseous fuels. Thorough sensitivity analyses were undertaken. Previously reported cost assumptions for advanced biofuels were found to have been too optimistic. The most cost-competitive biofuels for most of the time period remained conventional biodiesel and bioethanol, but the costs of these options and biomethane and Synthetic Natural Gas (bio-SNG) converged in the medium term and thus other factors will play a decisive role for market developments of biofuels. Feedstock cost uncertainties for the future remain a challenge for long-term planning, and low-cost short-rotation coppice may change the picture more than any other parameter. Of the advanced biofuels, bio-SNG was found significantly more cost-competitive and resource efficient than Fischer-Tropsch-diesel and lignocellulose-based ethanol, but still requiring a dedicated long-term policy. The results and the large sensitivities of biofuel competitiveness stress the need for more data transparency and for thorough sensitivity analyses of the results in similar system studies.

Sustainable Construction Practices: “A Lazy View” of Construction Professionals in the South Africa Construction Industry

The construction industry has been found to cause damaging effects to the environment by means of waste generation, energy and water depletion and several other forms of damage to the environment. This damage has led to experts and environmentalist calling for a sustainable way of carrying out construction activities. Thus, this study addresses the challenges hindering the adoption of sustainable construction practices in the South Africa construction industry. The data used in this research were sourced from both primary and secondary sources. The primary data was collected through a questionnaire aimed at practicing construction professional in the South African construction industry. Indicative Findings from the questionnaire survey revealed that the foremost challenges faced by South African construction industry towards the adoption of sustainable construction practices is the assumption (a lazy view) of additional cost to building projects, followed by limited understanding of the benefits of sustainable construction amongst others. The study contributes to sustainability thinking in the South African construction industry; and it is recommended that strategies and actions should be pursued actively to speed up the process in creating a sustainable-oriented construction industry, which is paramount towards building a sustainable future.

A Cost Optimized Fully Sustainable Power System for Southeast Asia and the Pacific Rim

In this paper, a cost optimal 100% renewable energy based system is obtained for Southeast Asia and the Pacific Rim region for the year 2030 on an hourly resolution for the whole year. For the optimization, the region was divided into 15 sub-regions and three different scenarios were set up based on the level of high voltage direct current grid connections. The results obtained for a total system levelized cost of electricity showed a decrease from 66.7 €/MWh in a decentralized scenario to 63.5 €/MWh for a centralized grid connected scenario. An integrated scenario was simulated to show the benefit of integrating additional demand of industrial gas and desalinated water which provided the system the required flexibility and increased the efficiency of the usage of storage technologies. This was reflected in the decrease of system cost by 9.5% and the total electricity generation by 5.1%. According to the results, grid integration on a larger scale decreases the total system cost and levelized cost of electricity by reducing the need for storage technologies due to seasonal variations in weather and demand profiles. The intermittency of renewable technologies can be effectively stabilized to satisfy hourly demand at a low cost level. A 100% renewable energy based system could be a reality economically and technically in Southeast Asia and the Pacific Rim with the cost assumptions used in this research and it may be more cost competitive than the nuclear and fossil carbon capture and storage (CCS) alternatives.

Cost-effectiveness of early versus delayed antiretroviral therapy in tuberculosis patients infected with HIV in sub-Saharan Africa

Background:The most challenging issue physicians are facing is the appropriate timing of introducing antiretroviral therapy (ART) along with ongoing tuberculosis (TB) therapy in HIV and TB co-infected patients. This study examined the cost-effectiveness of early versus delayed ART initiation in TB patients, infected with HIV (co-infected patients) in a sub-Saharan Africa setting. Methods:A decision analytic model based on previously published and real-world evidence was applied to evaluate clinical and economic outcomes associated with early versus delayed ART in TB and HIV co-infection. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs). Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses. Results:In base case analysis, the expected cost of giving early ART to TB patients infected with HIV was $1372, with a QALY gain of 0.68, while the cost of delayed ART was $955, with a QALY gain of 0.62. The ICER shows $6775 per QALYs, which suggests that it is not as cost-effective, since it is greater than 3 x GDP per capita ($5,086) for sub-Saharan Africa willingness to pay (WTP) threshold. At $10,000 WTP, the probability that early ART is cost effective compared to delayed ART is 0.9933. At cost-effectiveness threshold of $5086, the population expected value of perfect information becomes substantial (≈US$5 million), and is likely to exceed the cost of additional investigation. This suggests that further research will be potentially cost-effective. Conclusions:From the perspective of the health-care payer in sub-Saharan Africa, early initiation of ART in HIV and TB co-infection cannot be regarded as cost-effective based on current information. The analysis shows that further research will be worthwhile and potentially cost-effective in resolving uncertainty about whether or not to start ART early in HIV and TB co-infection.

An economic analysis comparison of stationary and dual-axis tracking grid-connected photovoltaic systems in the US Upper Midwest

ABSTRACTThis paper presents an economic analysis of stationary and dual-axis tracking photovoltaic (PV) systems installed in the US Upper Midwest in terms of life-cycle costs, payback period, internal rate of return, and the incremental cost of solar energy. The first-year performance and energy savings were experimentally found along with documented initial cost. Future PV performance, savings, and operating and maintenance costs were estimated over 25-year assumed life. Under the given assumptions and discount rates, the life-cycle savings were found to be negative. Neither system was found to have payback periods less than the assumed system life. The lifetime average incremental costs of energy generated by the stationary and dual-axis tracking systems were estimated to be $0.31 and $0.37 per kWh generated, respectively. Economic analyses of different scenarios, each having a unique set of assumptions for costs and metering, showed a potential for economic feasibility under certain conditions when compared to alternative investments with assumed yields.

Economical and operational issues for CIGS in the future PV panorama

Due to the low costs of multi-crystalline Si ($0.6/Wp present average, and $0.38/Wp projected by 2018), Cu(InGa)(Se, S)2 (CIGS) thin film is facing a competitive environment as product needs to be aligned in efficiency, reliability and fabrication costs with main stream modules. Moreover, into the final quarter of 2016, the PV industry has been again confronted to an overcapacity panorama, which has demonstrated very harmful for manufacturers and module producers that have not been able to follow the costs reduction learning curve together with increasing in efficiency and product reliability. However, just follow the leader could not be enough, and without innovations leading to new advanced solutions to the stablished market and/or create new ones, the survival of the technology is compromised.In this paper, an approach to the present and a projection of near future competitiveness of CIGS respect to the expected performances in conventional markets is provided. For this efficiency and manufacturing issues related with costs assumptions and bankability are discussed. An example of an industrial line targeting enough flexibility to address present and future emerging markets need is discussed. The main aim is give clues to CIGS manufacturers to develop a competitive product within the future PV panorama and to innovate not only in materials and product, but also in market and business models. At this step, innovation in products, markets, and financial issues seem mandatory for the technology to survive in a very competitive growing global market, and for this flexible manufacturing facilities with reduced costs need to be developed.

Can Australia Power the Energy-Hungry Asia with Renewable Energy?

The Paris Agreement points out that countries need to shift away from the existing fossil-fuel-based energy system to limit the average temperature rise to 1.5 or 2 °C. A cost-optimal 100% renewable energy based system is simulated for East Asia for the year 2030, covering demand by power, desalination, and industrial gas sectors on an hourly basis for an entire year. East Asia was divided into 20 sub-regions and four different scenarios were set up based on the level of high voltage grid connection, and additional demand sectors: power, desalination, industrial gas, and a renewable-energy-based synthetic natural gas (RE-SNG) trading between regions. The integrated RE-SNG scenario gives the lowest cost of electricity (€52/MWh) and the lowest total annual cost of the system. Results contradict the notion that long-distance power lines could be beneficial to utilize the abundant solar and wind resources in Australia for East Asia. However, Australia could become a liquefaction hub for exporting RE-SNG to Asia and a 100% renewable energy system could be a reality in East Asia with the cost assumptions used. This may also be more cost-competitive than nuclear and fossil fuel carbon capture and storage alternatives.

The Impact of Shale Gas on the Cost and Feasibility of Meeting Climate Targets—A Global Energy System Model Analysis and an Exploration of Uncertainties

There exists considerable uncertainty over both shale and conventional gas resource availability and extraction costs, as well as the fugitive methane emissions associated with shale gas extraction and its possible role in mitigating climate change. This study uses a multi-region energy system model, TIAM (TIMES integrated assessment model), to consider the impact of a range of conventional and shale gas cost and availability assessments on mitigation scenarios aimed at achieving a limit to global warming of below 2 °C in 2100, with a 50% likelihood. When adding shale gas to the global energy mix, the reduction to the global energy system cost is relatively small (up to 0.4%), and the mitigation cost increases by 1%–3% under all cost assumptions. The impact of a “dash for shale gas”, of unavailability of carbon capture and storage, of increased barriers to investment in low carbon technologies, and of higher than expected leakage rates, are also considered; and are each found to have the potential to increase the cost and reduce feasibility of meeting global temperature goals. We conclude that the extraction of shale gas is not likely to significantly reduce the effort required to mitigate climate change under globally coordinated action, but could increase required mitigation effort if not handled sufficiently carefully.

Societal implications of medical insurance coverage for imatinib as first-line treatment of chronic myeloid leukemia in China: a cost-effectiveness analysis

Objectives: Imatinib (Glivec) and nilotinib (Tasigna) have been covered by critical disease insurance in Jiangsu province of China since 2013, which changed local treatment patterns and outcomes of patients with chronic myeloid leukemia (CML). This study evaluated the long-term cost-effectiveness of insurance coverage with imatinib as the first-line treatment for patients with CML in China from a societal perspective.Methods: A decision-analytic model based on previously published and real-world evidence was applied to simulate and evaluate the lifetime clinical and economic outcomes associated with CML treatments before and after imatinib was covered by medical insurance. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs) discounted at 3% annually. Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses.Results: In base case analysis, both cost and effectiveness of CML treatments increased after imatinib was covered by the medical insurance; on average, the incremental QALY and cost were 5.5 and ¥277,030 per patient in lifetime, respectively. The ICER of insurance coverage with imatinib was ¥50,641, which is less than the GDP per capita of China. Monte Carlo simulation resulted in the estimate of 100% probability that the insurance coverage of imatinib is cost-effective. Total cost was substantially saved at 5 years after patients initiated imatinib treatment with insurance coverage compared to no insurance coverage, the saved cost at 5 years was ¥99,565, which included the cost savings from both direct (e.g. cost of bone marrow or stem cell transplant) and indirect costs (e.g. productivity loss of patients and care-givers).Conclusions: The insurance coverage of imatinib is very cost-effective in China, according to the local cost and clinical data in Jiangsu province. More importantly, the insurance coverage of imatinib and nilotinib have changed the treatment patterns of CML patients, thus dramatically increasing life expectancy and quality-of-life (QoL) saving on productivity losses for both CML patients and their caregivers.

Cost vs. time in stochastic games and Markov automata

Abstract Costs and rewards are important tools for analysing quantitative aspects of models like energy consumption and costs of maintenance and repair. Under the assumption of transient costs, this paper considers the computation of expected cost-bounded rewards and cost-bounded reachability for Markov automata and Markov games. We provide a fixed point characterization of this class of properties under early schedulers. Additionally, we give a transformation to expected time-bounded rewards and time-bounded reachability, which can be computed by available algorithms. We prove the correctness of the transformation and show its effectiveness on a number of Markov automata case studies.

VP101 Medical Devices For Treatment-resistant Hypertension: Health Technology Assessment Report

INTRODUCTION:While optimal medical therapy (OMT) represents the current standard of care for treatment-resistant hypertension, non-pharmaceutical therapeutic approaches, such as renal denervation and carotid baroreceptor stimulation therapy, have been proposed. The present Health Technology Assessment (HTA) project was aimed at assessing benefits and risk of those approaches versus OMT.METHODS:A systematic review of evidence on effectiveness and safety was performed together with a review of economic studies. A contextual analysis of market availability and use of the technology in Italy was also performed.RESULTS:In Italy, ninety-nine renal denervation procedures were performed in 2014. Ten studies from six trials were included in the review and meta-analysis. No evidence of dominance or increased harms of renal denervation compared to OMT were found. Four economic evaluations were included and reported dominance of renal denervation. These were based on short-term clinical data and three evaluations used the same Markov model assuming dominance of renal denervation. Estimated average prospective cost of the procedure was EUR6,129.90 (range EUR3,821.15 – EUR9,714.23). We updated the results of an earlier assessment published by an Italian Regional agency on carotid baroreceptor stimulation therapy (1). None of the three studies identified as ongoing in 2015 were completed or had published preliminary results and the technology was not assessed further within the present HTA project.CONCLUSIONS:Even if follow-up was limited to 6 months, randomised evidence showed no benefits of the procedure. Economic evaluations were unreliable, based on unrealistic assumptions of effectiveness and contrived therapy regimes. Further investment in renal denervation should await the results of well-designed and adequately followed-up trials assessing the impact of renal denervation on major cardiovascular events compared to OMT. Future economic evaluations should be based on realistic assumptions of cost and effectiveness.