Extra Quality-adjusted Life Year Research Articles

Cost-Effectiveness and Budget Impact Analyses of Selective Internal Radiation Therapy versus Atezolizumab Plus Bevacizumab from a German Statutory Health Insurance Perspective.

To compare personalized dosimetry with yttrium-90 (90Y)-loaded glass microspheres (SIRT) vs atezolizumab and bevacizumab (A+B) in hepatocellular carcinoma (HCC) treatment in terms of cost-effectiveness and budget impact from a German statutory health insurance (SHI) perspective. Cost-effectiveness analysis (CEA) and budget impact analysis (BIA) models were developed in MS Excel. The available key studies (IMbrave150 and DOSISPHERE-01) suggest that both strategies are comparable in terms of progression-free survival and overall survival in HCC, but a difference in severe adverse events (SAE) in favor of SIRT was observed. Accordingly, the CEA model investigates the endpoints "cost per SAE avoided" and "cost per quality-adjusted life year (QALY) gained", whereas the BIA simulates the impact of a stepwise re-allocation of current market share to the option which emerges as more cost-effective from the CEA. The model suite estimated a mean annual total per-patient costs of € 29,984 for SIRT, compared to € 75,725 for A+B. SIRT was associated with a lower number of SAE and a higher number of QALYs compared to A+B. Switching additionally 25% of the eligible patients (≈500) from systemic therapy to SIRT could generate annual savings of approximately € 22.6 million Euros to the SHI. SIRT was identified as dominant treatment strategy. SIRT use not only saves SHI expenditure compared to systemic immunotherapy but also yields extra QALYs. This positions SIRT as the dominant and more cost-effective treatment strategy for patients with HCC. The savings to the SHI system, derived from the BIA conducted, become increasingly significant with rising adoption rates of SIRT.

Lost Therapeutic Benefit of Delayed Low-Density Lipoprotein Cholesterol Control in Statin-Treated Patients and Cost-Effectiveness Analysis of Lipid-Lowering Intensification

ObjectivesAttainment of low-density lipoprotein cholesterol (LDL-C) therapeutic goals in statin-treated patients remains suboptimal. We quantified the health economic impact of delayed lipid-lowering intensification from an Australian healthcare and societal perspective. MethodsA lifetime Markov cohort model (n = 1000) estimating the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment in statin-treated patients with uncontrolled LDL-C, at moderate to high risk of CHD with no delay or after a 5-year delay, compared with standard of care (no intensification), starting at age 40 years. Intensification was tested with high-intensity statins or statins + ezetimibe. LDL-C levels were extracted from a primary care cohort. CHD risk was estimated using the pooled cohort equation. The effect of cumulative exposure to LDL-C on CHD risk was derived from Mendelian randomization data. Outcomes included CHD events, quality-adjusted life-years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICERs). All outcomes were discounted annually by 5%. ResultsOver the lifetime horizon, compared with standard of care, achieving LDL-C control with no delay with high-intensity statins prevented 29 CHD events and yielded 30 extra QALYs (ICERs AU$13 205/QALY) versus 22 CHD events and 16 QALYs (ICER AU$20 270/QALY) with a 5-year delay. For statins + ezetimibe, no delay prevented 53 CHD events and gave 45 extra QALYs (ICER AU$37 271/QALY) versus 40 CHD events and 29 QALYs (ICER of AU$44 218/QALY) after a 5-year delay. ConclusionsDelaying attainment of LDL-C goals translates into lost therapeutic benefit and a waste of resources. Urgent policies are needed to improve LDL-C goal attainment in statin-treated patients.

Cost-Utility of Venetoclax Plus Obinutuzumab for Treatment-Naïve Patients with Chronic Lymphocytic Leukemia without Del17p/TP53-Mutation Compared to Chlorambucil Plus Obinutuzumab

INTRODUCTION: Recently presented 6-year follow-up data from the CLL14 trial for chronic lymphocytic leukemia (CLL) showed increased overall survival (OS) and progression-free survival (PFS) using venetoclax plus obinutuzumab (VenO) as 1st line treatment when compared to chlorambucil plus obinutuzumab (ClbO) (Al-Sawaf, 2022). However, the higher treatment cost of VenO compared to off-patent chemotherapy requires evaluation of the potential trade-offs of added costs and improved health outcomes to inform decision-making. In Denmark, targeted agents are only reimbursed for treatment-naïve CLL patients with del17p/TP53-mutation. The objective of this study was to investigate the cost-effectiveness of VenO compared to ClbO in treatment-naïve CLL without del17p/TP53-mutation, including the course of disease until death. METHODS: A cost-utility analysis was conducted to simulate a hypothetical cohort of CLL patients with characteristics corresponding to the CLL14 cohort without del17p/TP53-mutation receiving either VenO or ClbO as 1st line treatment followed by either venetoclax plus rituximab (VenR) or ibrutinib (Ibr) as 2nd line treatment or no treatment after progression. Second line treatment was assumed to begin one month after progression. Model outcomes were the expected cost, quality-adjusted life-years (QALYs) and life-years (LY) per patient. Outcomes were used to calculate the incremental cost-effectiveness ratio (ICER) i.e. the added cost per extra QALY gained. A Markov model was constructed with a lifetime time horizon (Figure 1) and was set to replicate recently presented data for OS and PFS for 72 months from the CLL14 study. Parametric survival functions were estimated for the remaining life years, assuming a log-normal and exponential distribution for OS and PFS, respectively in the base-case. A Danish health sector perspective was applied with all costs estimated in EUR. Costs and quality of life decrements related to administration of both 1st and 2nd line treatment, as well as adverse event treatment, were included. Best available published data from the MURANO trial (VenR) (Kater et al., 2020) and Danish real-world evidence (Ibr) (Aarup et al., 2020) for 2nd line treatment was utilized to reflect current clinical practice in Denmark. Deterministic and probabilistic sensitivity analyses (PSA) were performed. Due to the absence of an official threshold of marginal cost per QALY in Denmark, results were compared to the British National Institute for Health and Care Excellence (NICE) threshold of GBP 20,000-30,000 (EUR 23,600-35,600). RESULTS: First-line treatment with VenO provided 5.28 QALY (7.54 LY) for the average patient compared to 3.80 QALY (6.12 LY) in the ClbO group (Table 1). Total costs per patient were EUR 202,821 for VenO and EUR 195,781 for ClbO, resulting in a base-case ICER of EUR 4,808 per QALY. The PSA showed that VenO was recommendable in 97% of the simulations at the lower NICE threshold. Results were robust to the assumptions on choice of 2nd line treatment, while exclusion of all costs and effects of 2nd line treatment showed cost-effectiveness results favoring ClbO. Cost of 2nd line treatment constituted up to 70% of the total patient cost, and especially the use of Ibr in 2nd line was associated with a higher total cost per patient. At a discount of 15% on the list price of venetoclax, 1st line VenO provided savings compared to ClbO. CONCLUSIONS: VenO was more effective in terms of QALY but at a higher cost than ClbO. VenO was cost-effective with inclusion of costs and effects of 2nd line treatment when using the NICE threshold indicating that VenO may also be cost-effective in Danish, and potentially other European, healthcare settings. While additional sensitivity analyses are awaited, these findings, along with previously published OS and PFS data, suggest that moving VenO into 1st line treatment may be beneficial and cost-effective also for patients without del17p/TP53-mutation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Optimal Cost-Effective Screening Strategy for Unruptured Intracranial Aneurysms in Female Smokers.

The prevalence of intracranial aneurysms among female cigarette smokers was shown to be high in previous studies, yet the cost-effectiveness of screening them has never been explored. To explore the most cost-effective screening strategy for female smokers. A decision analytical study was performed with a Markov model to compare different screening strategies with no screening and to explore the most optimal screening strategy for female smokers. Input data for the model were extracted from literature. A single screening at different ages and multiple screening every 15 years, 10 years, 5 years, and 2 years were performed for female smokers in different age ranges. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of the model. Finally, value of information analysis was performed to investigate the value of collecting additional data. Screening female smokers for unruptured intracranial aneurysm is cost-effective. All screening strategies yield extra quality-adjusted life years. Screening at younger age brings more health benefit at lower cost. Frequent screening strategies decrease rupture rate of aneurysms more with higher costs per quality-adjusted life year. Screening after age 70 years and frequent screening (every 2 years) after age 60 years is not optimal. Among all the parameters in the model, collecting additional data on utility of the unscreened population would be most valuable. Screening female smokers for intracranial aneurysms once at younger age is most optimal. However, in clinical practice, the duration and intensity of exposure to cigarettes should be taken into consideration.

Cost-Effectiveness Analysis of Antithyroid Drug (Propylthiouracil) Compared to Radioactive Iodine for the Treatment of Graves' Disease in Ethiopia.

BackgroundGraves’ disease is an autoimmune disorder caused by stimulating antibodies. The peak incidence of Graves’ disease occurs among patients aged 30 to 60 years. Radioactive iodine (RAI) and antithyroid drug (ATD) have been well-established therapies for the treatment of Graves’ disease for several decades. However, there remain large variations in practice among physicians in the preferred modality and the method of administration.ObjectiveTo assess the cost-effectiveness of ATD (propylthiouracil) compared to RAI from a health care payer perspective in Ethiopia.MethodsMarkov model was constructed by using TreeAge software 2021 with different parameters, such as ATD, RAI, treatment failure, treatment success, hypothyroidism, and supplemental thyroxine to conduct a cost-effectiveness analysis. A hypothetical 40-year-old female patient with symptomatic Graves’ hyperthyroidism was simulated to estimate expected lifetime health outcomes, quality-adjusted life years (QALYs) and costs, discounted at 3%.ResultsRAI has lesser QALYs (14.19) and is less expensive (US$ 3583.22), while ATD has higher QALYs (16.54) and is more expensive (US$ 12531.68). The result showed that there was no dominant treatment option. The incremental cost-effectiveness ratio was US$ 3811.6 per QALY which was greater than one to three times the cost-effectiveness threshold of Ethiopia (US$ 783).ConclusionIn this cost-effectiveness analysis, RAI was the preferred treatment strategy for Graves’ disease, since the cost needed to get one extra QALY through ATD was greater than one to three times the cost-effectiveness threshold of Ethiopia.

Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data

Knowledge about the costs and benefits of hand surgical interventions is important for surgeons, payers, and policy makers. Little is known about the cost-effectiveness of surgery for thumb carpometacarpal osteoarthritis. The objective of this study was to examine patients' quality of life and economic costs, with focus on the cost-utility ratio 1 year after surgery for thumb carpometacarpal osteoarthritis compared with that for continued nonsurgical management. Patients with thumb carpometacarpal osteoarthritis indicated for resection arthroplasty were included in a prospective study. The quality of life (using European Quality of Life-5 Dimensions-5 Level), direct medical costs, and productivity losses were assessed up to 1 year after surgery. Baseline data at recruitment and costs sustained over 1 year before surgery served as a proxy for nonsurgical management. The total costs to gain 1 extra quality-adjusted life year and the incremental cost-effectiveness ratio were calculated from a health care system and a societal perspective. The mean European Quality of Life-5 Dimensions-5 Level value for 151 included patients improved significantly from 0.69 to 0.88 (after surgery). The productivity loss during the preoperative period was 47% for 49 working patients, which decreased to 26% 1 year after surgery. The total costs increased from US $20,451 in the preoperative year to US $24,374 in the postoperative year. This resulted in an incremental cost-effectiveness ratio of US $25,370 per quality-adjusted life year for surgery compared with that for simulated nonsurgical management. The calculated incremental cost-effectiveness ratio was clearly below the suggested Swiss threshold of US $92,000, indicating that thumb carpometacarpal surgery is a cost-effective intervention. Economic and Decision Analyses II.

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke

ObjectivesStandard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH. Materials and MethodAll costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation. ResultsThe incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57. DiscussionFrom the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Intensive home treatment in comparison with care as usual: Cost-utility analysis from a pre-randomized controlled trial in the netherlands

IntroductionThe implementation of Intensive Home Treatment (IHT) aims to decrease the pressure on acute inpatient services that could lead to prevent hospitalization and reduce the number of hospitalization days and, ultimately, reduce cost in the mental health services. Although there are studies assessing the effectiveness of IHT, there is a shortage of research studying the cost-effectiveness.ObjectivesThe aim of this study is to present an cost-utility analysis of IHT compared to care as usual (CAU)MethodsPatients between 18 and 65 years of age whose mental health professionals considered hospitalization were included. These patients were pre-randomized in either IHT or CAU and followed up for 12-months. For this study, the base case analysis was performed from the societal and healthcare perspective. For the cost-utility analyses the Euroqol 5D was used to calculate quality adjusted life years (QALYs) as a generic measure of health gains.ResultsData of 198 patients were used. From a sociatal perspective, the cost-utility analysis resulted in an incremental cost-effectiveness ratios (ICERs) of €58 730, and a 37% likelihood that IHT leads to higher QALYs at lower costs. The probability of IHT being cost-effective was &gt;50% if there was no willingness to pay more for extra QALY than in the current situation under CAU.ConclusionsProfessionals working in crisis care are able to offer IHT with the same effect as other crisis care interventions at lower costs. IHT seem to be cost-effective compared with CAU over 52 weeks follow-up for patients who experience psychiatric crises.DisclosureNo significant relationships.

Economic evaluation of CPAP therapy for obstructive sleep apnea: a scoping review and evidence map.

To synthesize findings of economic evaluations investigating cost-effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) and of strategies of organization of care related to CPAP therapy. Scoping review with searches conducted in MEDLINE, CRD, LILACS, and Embase in August 2020. Eligible studies were economic evaluations comparing CPAP to other alternative or assessing strategies of care for CPAP therapy. Results were presented narratively, and incremental cost-effectiveness ratios (ICER) were presented in evidence maps. Of 34 studies, 3 concluded that CPAP is less costly and more effective when compared to usual care. Most studies indicated that CPAP is associated with better health outcomes, but at higher prices. ICER ranged from USD 316 to 98,793 per quality-adjusted life years (QALY) gained (median 16,499; IQR 8267 to 33,119). One study concluded that CPAP is more costly and less effective, when treatment is applied to all patients, regardless of disease severity. Variability of ICER was mainly due to definition of population and applied time horizons. When CPAP was compared to mandibular advancement device, ICER ranged from USD 21,153 to 361,028 (median 89,671; IQR 26,829 to 295,983), which represents the investment in CPAP therapy required to obtain one extra QALY. Three studies assessed the effects of organizing CPAP therapy in primary care, which was cost-effective or cost-saving. Compared to usual care, CPAP is cost-effective after the second year of treatment, when indicated for moderate-to-severe OSA. CPAP therapy may be even more cost-effective by using different strategies of organization of care. These findings may inform decision making related to CPAP reimbursement in health systems. Not applicable.

Impact of the 2003 to 2018 Population Salt Intake Reduction Program in England: A Modeling Study.

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An exploratory study to estimate cost-effectiveness threshold value for life saving treatments in western Iran

BackgroundCost-effectiveness analysis provides a crucial means for evidence-informed decision-making on resource allocation. This study aims to elicit individuals' willingness to pay (WTP) for one additional quality-adjusted life-year (QALY) gained from life-saving treatment and associated factors in Kermanshah city, western Iran.MethodsWe conducted a cross-sectional study on a total of 847 adults aged 18 years and above to elicit their WTP for one additional QALY gained by oneself and a family member using a hypothetical life-saving treatment. We used a multistage sampling technique to select the samples, and the Iranian version of EQ-5D-3L, and visual analogue scale (VAS) measures to obtain the participants’ health utility value. The Tobit regression model was used to identify the factors affecting WTP per QALY values.ResultsThe mean WTP value and standard deviation (SD) was US$ 862 (3,224) for the respondents. The mean utility values using EQ-5D-3L and VAS methods for respondents were 0.779 and 0.800, respectively. Besides, the WTP for the additional QALY gained by the individual participants using the EQ-5D-3L and VAS methods were respectively US$ 1,202 and US$ 1,101, while the estimated value of the family members was US$ 1,355 (SD = 3,993). The Tobit regression models indicated that monthly income, education level, sex, and birthplace were statistically significantly associated (p < 0.05) with both the WTP for the extra QALY values using the EQ-5D-3L and the VAS methods. Educational level and monthly income also showed statistically significant relationships with the WTP for the additional QALY gained by the family members (p < 0.05).ConclusionOur findings indicated that the participants' WTP value of the additional QALY gained from the hypothetical life-saving treatment was in the range of 0.20–0.24 of the gross domestic product (GDP) per capita of Iran. This value is far lower than the World Health Organization (WHO) recommended CE threshold value of one. This wide gap reflects the challenges the health system is facing and requires further research for defining the most appropriate CE threshold at the local level.

Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data

PurposeTo assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperative management, using real-world evidence.MethodsPatients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF = 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included more intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis.ResultsFor 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226 CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95% confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001).ConclusionsFor RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management.Level of EvidenceEconomic Analyses – Developing an Economic Model, Level II

Cost-effective Analysis of Proton Pump Inhibitors in Long-term Management of Gastroesophageal Reflux Disease: A Narrative Review.

Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H2RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies. Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H2RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied.

PMH31 COST-EFFECTIVENESS OF GUIDED INTERNET-DELIVERED COGNITIVE BEHAVIORAL THERAPY IN COMPARISON WITH CARE-AS-USUAL FOR PATIENTS WITH INSOMNIA IN GENERAL PRACTICE

Insomnia is associated with significant economic consequences, mainly due to work absenteeism. Although cognitive behavioral therapy for insomnia (CBT-I) has been shown to be effective for insomnia, general practitioners (GPs) do not regularly subscribe CBT-I as first line of treatment. Internet-delivered CBT-I presents an alternative to bridge this gap while efficiently using scarce resources. The aim of this study was to estimate the cost-effectiveness of a guided, internet-delivered intervention compared to care-as-usual for insomnia patients in general practice from a societal perspective. An economic evaluation was conducted alongside a randomized clinical trial with 26 weeks follow-up. Primary outcomes were insomnia severity (score on and clinically relevant response measured by the Insomnia Severity Index, ISI) and Quality-Adjusted Life Years (QALYs). Societal costs were assessed at baseline, and at 8 and 26 weeks. Missing data was imputed using multiple imputation. Statistical uncertainty around cost and effect differences and incremental cost-effectiveness ratios (ICERs) were estimated using bootstrapping, and presented using cost-effectiveness acceptability curves. Mean societal costs in the intervention group were statistically non-significantly lower than in the care-as-usual group (-€318; 95% CI -1282 to 645). Cost-effectiveness analyses revealed a 95% probability of the intervention being cost-effective as compared to care-as-usual at ceiling ratios of €450/extra point of decrease in ISI and €7,000/additional response to treatment, respectively. At a ceiling ratio of 30,000 €/extra QALY gained, the probability of the intervention being cost-effective was 69%. Sensitivity analyses gave similar results. The intervention was considered cost-effective in comparison with care-as-usual for patients with insomnia treated in general practice from the societal perspective. However, the probability of the intervention being cost-effective as compared to care-as-usual was lower for the QALY outcome. We conclude that internet-delivered CBT-I is a promising and efficient intervention to reduce the personal and societal burden associated with insomnia.

Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial.

BackgroundCognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability.ObjectiveThis pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT.MethodsPatients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations.ResultsBlended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI −0.05 to 0.19), response to treatment (RD 0.03, 95% CI −0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI −0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI −399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI −659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects.ConclusionsThis pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted.Trial RegistrationNetherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408International Registered Report Identifier (IRRID)RR2-10.1186/s12888-014-0290-z

Cost-effectiveness of pharmaceutical care on patients undergoing maintenance hemodialysis – a multicenter randomized controlled study

ABSTRACTObjectives: The aim of the study is to assess the cost-effectiveness of pharmaceutical care versus usual care on the treatment costs in patients undergoing maintenance hemodialysis (HD) in the outpatient HD centers of academic, government, and corporate hospitals.Methods: An open-labeled randomized controlled study was registered under clinical trial registry of India (Ref. no. CTRI/2014/004900). The study was conducted for a period of 12-month follow-up in patients undergoing maintenance HD. The patients were randomized into Usual Care (UC) group and Pharmaceutical Care (PC) group by the block design method. The UC group received the usual care provided by the hospital staff like physicians, nurses, and technicians whereas, the PC group received the usual care along with the pharmaceutical care delivered by a qualified registered pharmacist. The patient perspective ‘out-of-pocket expenditures’ was considered for calculating the annual cost incurred for the treatment of HD patients.Results: Out of 153 patients, academic hospital (n = 83), government hospital (n = 18), and corporate hospital (n = 52). The incremental cost-effectiveness ratio for academic, government, and corporate hospitals HD patients of PC group compared with UC group were 86,230 Indian Rupee (INR)/Quality-adjusted life year (QALY), 231,016.66 INR/QALY, and 87,430 INR/QALY, respectively. Our study results revealed that PC group was costlier and more effective compared to the UC group.Conclusions: It depends upon the policymakers and regulators to take the decision, if they believe that the extra cost is worth the extra QALY.

Cost-effectiveness of a follow-up program for older patients with heart failure: a randomized controlled trial.

To assess the cost-utility of adding a disease management program (DMP) delivered by geriatric day hospital (GDH) for older patients with heart failure (HF) after hospital discharge. 117 older HF patients discharged by a geriatric service were randomly assigned to DMP (n = 59) and usual care (UC) (n = 58) groups. The DMP group received health education, therapeutic control and monitoring through both telephone contacts and face-to-face visits at the GDH for 12 months. The UC group received standard health care. The main outcome measures were the costs from the health-care system and societal perspectives and quality-adjusted life-years (QALYs) using EuroQol (EQ-5D-3L). The cost-effectiveness analysis used the package ICEinfer in R 2.13.0. The mean age was 85years, and 73% of the patients were women. The mean values of QALYs after 12months were - 0.083 in DMP and - 0.154 in UC. Each extra QALY gained by the DMP relative to usual care cost was €38,274 and €25,390 from health-care or societal perspective, respectively. An investment of €44,000/QALY (Spanish Health System Threshold) showed a 91 and 85% of probability to be cost-effective from health-care and societal perspectives. The intervention was moderately cost-effective in delaying deaths and preserving the loss of health-related quality of life in older patients with HF. The study was internationally registered with the ISRCTN10823032.

Harms, benefits and costs of fecal immunochemical testing versus guaiac fecal occult blood testing for colorectal cancer screening.

BackgroundThe ColonCancerCheck screening program for colorectal cancer (CRC) in Ontario, Canada, is considering switching from biennial guaiac fecal occult blood test (gFOBT) screening between age 50–74 years to the more sensitive, but also less specific fecal immunochemical test (FIT). The aim of this study is to estimate whether the additional benefits of FIT screening compared to gFOBT outweigh the additional costs and harms.MethodsWe used microsimulation modeling to estimate quality adjusted life years (QALYs) gained and costs of gFOBT and FIT, compared to no screening, in a cohort of screening participants. We compared strategies with various age ranges, screening intervals, and cut-off levels for FIT. Cost-efficient strategies were determined for various levels of available colonoscopy capacity.ResultsCompared to no screening, biennial gFOBT screening between age 50–74 years provided 20 QALYs at a cost of CAN$200,900 per 1,000 participants, and required 17 colonoscopies per 1,000 participants per year. FIT screening was more effective and less costly. For the same level of colonoscopy requirement, biennial FIT (with a high cut-off level of 200 ng Hb/ml) between age 50–74 years provided 11 extra QALYs gained while saving CAN$333,300 per 1000 participants, compared to gFOBT. Without restrictions in colonoscopy capacity, FIT (with a low cut-off level of 50 ng Hb/ml) every year between age 45–80 years was the most cost-effective strategy providing 27 extra QALYs gained per 1000 participants, while saving CAN$448,300.InterpretationCompared to gFOBT screening, switching to FIT at a high cut-off level could increase the health benefits of a CRC screening program without considerably increasing colonoscopy demand.

Latin American Clinical Epidemiology Network Series – Paper 4: Economic evaluation of Kangaroo Mother Care: cost utility analysis of results from a randomized controlled trial conducted in Bogotá

Background and ObjectiveAlthough kangaroo mother care (KMC) has been shown to be safe and effective in randomized controlled trials (RCTs), there are no published complete economic evaluations including the three components of the full intervention. MethodsA cost utility analysis performed on the results of an RCT conducted in Bogotá, Colombia between 1993 and 1996. Hospital and ambulatory costs were estimated by microcosting in a sample of preterm infants from a University Hospital in Bogotá in 2011 and at a KMC clinic in the same period. Utility scores were assigned by experts by means of (1) direct ordering and scoring discrete health states and (2) constructing a multi-attribute utility function. Ninety-five percent confidence intervals (CIs) for the incremental cost–utility ratios (ICURs) were computed by the Fiellers theorem method. One-way sensitivity analysis on price estimates for valuing costs was performed. ResultsICUR at 1 year of corrected age was $ −1,546 per extra quality-adjusted life year gained using the KMC method (95% CI $ −7,963 to $ 4,910). ConclusionIn Bogotá, the use of KMC is dominant: more effective and cost-saving. Although results from an economic analysis should not be extrapolated to different systems and communities, this dominant result suggests that KMC could be cost-effective in similar low and middle income countries settings.

Economic evaluation of Internet-based problem-solving guided self-help treatment in comparison with enhanced usual care for depressed outpatients waiting for face-to-face treatment: A randomized controlled trial

BackgroundPrevious studies have demonstrated the effectiveness of Internet-based interventions for depression in comparison with usual care. However, evidence on the cost-effectiveness of these interventions when delivered in outpatient clinics is lacking. The aim of this study was to estimate the cost-effectiveness of an Internet-based problem-solving guided self-help intervention in comparison with enhanced usual care for outpatients on a waiting list for face-to-face treatment for major depression. After the waiting list period, participants from both groups received the same treatment at outpatient clinics. MethodsAn economic evaluation was performed alongside a randomized controlled trial with 12 months follow-up. Outcomes were improvement in depressive symptom severity (measured by CES-D), response to treatment and Quality-Adjusted Life-Years (QALYs). Statistical uncertainty around cost differences and incremental cost-effectiveness ratios were estimated using bootstrapping. ResultsMean societal costs for the intervention group were €1579 higher than in usual care, but this was not statistically significant (95% CI - 1395 to 4382). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective in comparison with usual care was 0.57 at a ceiling ratio of €15,000/additional point of improvement in CES-D, and 0.25 and 0.30 for an additional response to treatment and an extra QALY respectively, at a ceiling ratio of €30,000. Sensitivity analysis showed that from a mental healthcare provider perspective the probability of the intervention being cost-effective was 0.68 for a ceiling ratio of 0 €/additional unit of effect for the CES-D score, response to treatment and QALYs. As the ceiling ratio increased this probability decreased, because the mean costs in the intervention group were lower than the mean costs in the usual care group. LimitationsThe patients in the intervention group showed low adherence to the Internet-based treatment. It is possible that greater adherence would have led to larger clinical effects. ConclusionsOffering an Internet-based intervention to depressed outpatients on waiting list for face-to-face treatment was not considered cost-effective in comparison with enhanced usual care from a societal perspective. There was a high probability of the intervention being cost-effective in comparison with enhanced usual care from the perspective of the mental healthcare provider.