Healthcare Payer Research Articles

Collaborative Ambulatory Orthopaedic Care in Patients with Hip and Knee Osteoarthritis: A Retrospective Comparative Cohort Study on Health Utilisation and Economic Outcomes.

To evaluate a novel healthcare programme for the treatment of patients with hip and knee osteoarthritis in southern Germany in terms of clinical and health economic outcomes. The study is based on claims data from 2014 to 2017. We conducted a retrospective comparative cohort study of 9768 patients with hip and knee osteoarthritis, of whom 9231 were enrolled in a collaborative ambulatory orthopaedic care programme (intervention group), and 537 patients received usual orthopaedic care (control group). Key features of the programme are coordinated care, morbidity-adapted reimbursement and extended consultation times. Multivariable analysis was performed to determine effects on health utilisation outcomes. The economic analysis considered annual costs per patient from a healthcare payer perspective, stratified by healthcare service sector. Besides multivariable regression analyses, bootstrapping was used to estimate confidence intervals for predicted mean costs by group. Musculoskeletal-disease-related hospitalisation was much less likely among intervention group patients than control group patients [odds ratio (OR): 0.079; 95% CI: 0.062-0.099]. The number of physiotherapy prescriptions per patient was significantly lower in the intervention group (RR: 0.814; 95% CI: 0.721-0.919), while the likelihood of participation in exercise programmes over one year was significantly higher (OR: 3.126; 95% CI: 1.604-6.094). Enrolment in the programme was associated with significantly higher ambulatory costs (€1048 vs. €925), but costs for inpatient care, including hospital stays, were significantly lower (€1003 vs. €1497 and €928 vs. €1300 respectively). Overall annual cost-savings were €195 per patient. Collaborative ambulatory orthopaedic care was associated with reduced hospitalisation in patients with hip and knee osteoarthritis. Health costs for programme participants were lower overall, despite higher costs for ambulatory care.

Distributional Cost-Effectiveness: Putting Money Where Your Mouth Is on Health Equity.

Editorials30 May 2023Distributional Cost-Effectiveness: Putting Money Where Your Mouth Is on Health EquityRichard Cookson, PhDRichard Cookson, PhDCentre for Health Economics, University of York, York, United KingdomSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-1145 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The COVID-19 pandemic sparked substantial talk about health equity (1) and the potential role of medical innovation in reducing health disparities (2). But talk is cheap. Health care payers, policymakers, and the life sciences industry must now put their money where their mouth is by investing more of the vast resources at their disposal into equity-enhancing technologies with measured impacts on reducing disparities in health between more and less socially advantaged groups.Primarily, this will require sustained political leadership and social solidarity. However, it will also require reliable quantification of the health equity impacts of interventions, of the kind that ...

Beyond transportation: Financial hardship, food insecurity, and care access barriers among US cancer survivors with transportation barriers to care.

6534 Background: Health care payers and providers increasingly focus on addressing social determinants of health (SDoH) in order to reduce disparities in care and patient outcomes in the US. Transportation barriers to health care, a key SDoH, are associated with increased emergency department use and mortality risk among cancer survivors. Transportation barriers may also be associated with other potentially addressable aspects of SDoH and access barriers. To inform future interventions, we examined financial hardship and barriers to timely care among cancer survivors with transportation challenges in a nationally representative sample. Methods: We identified 18,140 adults with a history of cancer from the 2011-2018 National Health Interview Survey. Transportation barriers were defined as delay in care due to lack of transportation over the past 12 months. Primary outcomes included 1) medical financial hardship (FH) in any of the three following domains: material (problems paying medical bills), psychological (worrying about medical bills), and behavioral hardship (delaying/forgoing care due to cost); 2) food insecurity (worrying food would run out); and 3) delayed care due to other factors (long wait times, inability to get an appointment quickly). We estimated the proportion of survivors who report any financial hardship, food insecurity, or other factors that lead to care delays and compared the age-sex adjusted prevalence of these barriers among cancer survivors by whether or not they reported transportation barriers using logistics regression. Results: Of the 18,123 cancer survivors, 2.9% reported having transportation barriers to care. Survivors with transportation barriers experienced significantly higher financial hardship, food insecurity, or other factors that lead to care delays than survivors without transportation barriers (86.0% vs 45.3%, p<0.001). Additionally, survivors with transportation barriers were more likely to experience medical financial hardship (73.2% vs 38.3%, p<0.001), including material (50.3% vs 27.1%, p<0.001), behavior (57.5% vs 20.4%, p<0.001), and psychological (33.5% vs 15.4%, p<0.001) hardship than survivors without transportation barriers. Additionally, survivors with transportation barriers were more likely to experience food insecurity (43.9% vs 12.0%, p<0.001) and care delays due to other factors (45.6% vs. 11.6%, p<0.001). Conclusions: Most cancer survivors with transportation barriers to care also report struggling financially and experiencing additional barriers to timely care. Findings highlight the importance of screening and addressing social needs and comprehensive interventions to address barriers to care access in this vulnerable population.

EE377 Cost-Effectiveness Analysis of Annual Routine Cognitive Assessment in People Living with HIV (PLWH) Aged 50 in the US

Alzheimer's disease (AD) has a significant economic impact on patients, caregivers, and healthcare payers. Medicare and Medicaid were estimated to cover $205 billion for AD and other cognitive disorders in 2022. Patients' out-of-pocket expenditure was projected to be $81 billion. As for caregivers, the hours of unpaid care and the value of unpaid care reached 16,023 hours and $271,598 million in total in the US. The significant burden of illness for AD and cognitive disorders makes timely diagnosis crucial in disease management. It allows healthcare providers and patients to employ strategies earlier to slow disease progression and reduce disease burden. People living with HIV (PLWH) are at higher risk of developing AD earlier because of HIV infection. This study aimed to evaluate the cost-effectiveness of implementing annual routine cognitive assessment in PLWH aged 50.

An Economic Evaluation Estimating the Clinical and Economic Burden of Increased Vancomycin-Resistant Enterococcus faecium Infection Incidence in Japan.

While incidence rates of vancomycin-resistant Enterococcus faecium have remained comparatively low in Japan, there have been increasing reports of more vancomycin-resistant Enterococcus (VRE) outbreaks, requiring costly measures to contain. Increased incidence of VRE in Japan may lead to more frequent and harder to contain outbreaks with current control measures, causing a significant burden to the healthcare system in Japan. This study aimed to demonstrate the clinical and economic burden of vancomycin-resistant E. faecium infections to the Japanese healthcare system and the impact of increasing rates of vancomycin resistance. A de novo deterministic analytic model was developed to assess the health economic outcomes of treating hospital-acquired VRE infections; patients are treated according to a two-line treatment strategy, dependent on their resistance status. The model considers hospitalisation costs and the additional cost of infection control. Scenarios investigated the current burden of VRE infections and the additional burden of increased incidence of VRE. Outcomes were assessed over a 1-year and 10-year time horizon from a healthcare payer's perspective in a Japanese setting. Quality-adjusted life years (QALYs) were valued with a willingness-to-pay threshold of ¥5,000,000 ($38,023), and costs and benefits were discounted at a rate of 2%. Current VRE incidence levels in enterococcal infections in Japan equates to ¥130,209,933,636 ($996,204,669) in associated costs and a loss of 185,361 life years (LYs) and 165,934 QALYs over 10 years. A three-fold increase (1.83%) is associated with an additional ¥4,745,059,504 ($36,084,651) in total costs on top of the current cost burden as well as an additional loss of 683 LYs over a lifetime, corresponding to 616 QALYs lost. Despite low incidence rates, VRE infections already represent a substantial economic burden to the Japanese healthcare system. The substantial increase in costs associated with a higher incidence of VRE infections could result in a significant economic challenge for Japan.

HPR107 Landscape of Value-Based Contracting in Oncology

Increasing approvals and rising budget impact of cancer treatments over the past few decades have raised the need for value-based contracting – arrangements between healthcare payers and biopharmaceutical companies that allow coverage of new medicines while accommodating uncertainties around their performance and financial impact. The objective of this study was to identify and analyze publicly available value-based contracts (VBCs) for oncology drugs.

Evaluating patient adherence and persistence to first-line tyrosine-kinase inhibitors for metastatic renal cell carcinoma.

e18856 Background: Tyrosine kinase inhibitors (TKIs) have been approved in treating advanced renal cell carcinoma (RCC) since 2005. More recently, combination therapy with an immune checkpoint inhibitor (ICI) and a kinase inhibitor (TKI) is considered standard of care in the first-line setting of metastatic RCC. While oral neoplastic therapies such as TKIs promote patient autonomy, these therapies pose unique challenges including ensuring patients take medications as indicated (i.e., adherence) and for the recommended duration (i.e., persistence). Persistence and adherence data from prescription dispensing and refill patterns are important to health care providers, systems, and payers in order to assess and/or optimize the therapeutic goal(s) of anticancer treatment. Therefore, we sought to explore adherence and persistence of first-line TKIs when used in combination with ICIs for treating metastatic RCC. Methods: Adults with metastatic RCC who received at least two prescriptions for FDA-approved TKIs used in combination with ICIs between April 29, 2019 and August 29,2022 were identified at University of California Irvine Medical Center. Adherence was determined by calculating the Medication Possession Ratio (MPR) and the Proportion of Days Covered (PDC). TKI persistence was evaluated using the Kaplan-Meier method. Also evaluated was the average length of therapy. We examined additional dispensing and refill pattern indicators, including the monthly total number of prescriptions filled. Results: A total of 66 individuals and 849 prescriptions were discovered. The mean duration of treatment for all patients was 237 days, and the median duration was 201 days (Table 1). The mean persistence was 303 days, whereas the median persistence was 233 days. Over 180 days, the median MPR was 83%, whereas the median PDC was 72%. The median variable PDC was 86%, while the median variable MPR was 105%. September was historically the month with the lowest prescription counts (16 +/- 2). Conclusions: We observed a significantly longer median duration of oral TKIs therapy (201 days) in an academic medical center than the national average ( < 100 days). This analysis of real-world data reveals that lengthier treatment durations for TKI+ICI combinations are feasible. Further research is warranted to identify possible factors such as clinical monitoring or adverse effect management that may prolong adherence and persistence. [Table: see text]

HPR19 Variation in Medicaid and Commercial Coverage of Cell and Gene Therapies

Cell and gene therapies (CGTs) are potentially curative treatments for a growing array of diseases. CGTs pose a particular challenge to health care payers due to their one-time administration, high costs and uncertain long-term benefits. Most patients who are eligible for CGTs are covered by Medicaid or Commercial health plans. In this study we assessed variation in Medicaid and Commercial coverage for 11 CGTs.

Cost-Effectiveness of Screening to Identify Patients With Atrial Fibrillation: ASystematic Review.

Screening for Atrial Fibrillation (AF) is recommended for people aged above 65 years. Screening for AF in asymptomatic individuals can be beneficial by enabling earlier diagnosis and the commencement of interventions to reduce the risk of early events, thus improving patient outcomes. This study systematically reviews the literature about the cost-effectiveness of various screening methods for previously undiagnosed AF. Four databases were searched to identify articles that are cost-effectiveness studies conducted on screening for AF published from January 2000 to August 2022. The Consolidated Health Economic Evaluation Reporting Standards 2022 checklist was used to assess the quality of the selected studies. A previously published approach was used to assess the usefulness of each study for health policy makers. The database search yielded 799 results, with 26 articles meeting the inclusion criteria. Articles were categorised into four subgroups: (i) population screening, (ii) opportunistic screening, (iii) targeted, and (iv) mixed methods of screening. Most of the studies screened adults ≥65 years of age. Most studies were performed from a 'health care payer perspective' and almost all studies used 'not screening' as a comparator. Almost all screening methods assessed were found to be cost-effective in comparison to 'not screening'. The reporting quality varied between 58% to 89%. The majority of the studies were found to be of limited usefulness for health policy makers, as none of the studies made any clear statements about policy change or implementation direction. All approaches of AF screening were found to be cost-effective compared with no screening, while opportunistic screening was found to be the optimal approach in some studies. However, screening for AF in asymptomatic individuals is context specific and likely to be cost-effective depending on the population screened, screening approach, frequency, and the duration of screening.

Developing and evaluating a formal care decision‐making intervention for African American parent‐adult daughter dementia dyads: A mixed‐methods study

AbstractBackgroundAfrican American older adults are suggested to be two times more likely to develop Alzheimer’s disease and related dementias (ADRD) compared to non‐Latinx White older adults. As a result, there is a need for more African American caregivers. The largest group of caregivers of African American persons living with ADRD, African American adult daughters, must navigate decision making related to formal care. Formal care—paid health care services for older adults usually associated with an institution— is important in the treatment of ADRD and maintaining quality of life.MethodGuided by the NIA Health Disparities Research Framework, Black Family Social‐Ecological Context Model, and Superwoman Schema, this presentation will describe a clinical trial that is designing a culturally tailored prototype intervention to support the formal care decision‐making process for African American persons living with ADRD and evaluating the feasibility and efficacy of the prototype intervention. The prototype intervention focuses on both members of the dyad’s quality of life as well as formal care utilization by the African American person living with ADRD. The design process will recruit 76 African American dementia dyads (70 dyads for quantitative and qualitative data collection to aid in the development of the prototype intervention and 6 dyads to use design thinking approaches to develop the prototype intervention) and will be tested with 20 African American dementia dyads using a pretest posttest design with two follow ups at 1 month and 3 months post intervention.ResultData will be presented regarding factors influencing the feasibility of implementing a dyadic intervention as an early‐stage investigator. We will focus on the planning process (e.g., IRB approval, study setup, and project management), recruitment strategies (e.g., recruitment videos), recruitment challenges (e.g., consent and eligibility), and mutual engagement of both members of the dyad.ConclusionIn the early stages of planning and recruitment of dementia dyads, there are challenges and key strategies to consider when conducting a dyadic clinical trial as an early‐stage investigator.

EE349 A Systematic Literature Review, Network Meta-Analysis, and Cost-Effectiveness Analysis of Resmetirom for the Treatment of Nonalcoholic Steatohepatitis

Resmetirom is an orally-administered, liver-targeted, thyroid hormone receptor-beta selective agonist which has shown promising results in Phase 2/3 trials for nonalcoholic steatohepatitis (NASH). A systematic literature review (SLR) and network meta-analysis (NMA) were conducted to assess the efficacy of resmetirom compared with obeticholic acid (OCA) and placebo. An economic evaluation was subsequently performed to explore the cost-effectiveness of resmetirom versus OCA and placebo from a US healthcare payer perspective.

MT45 Cost-Effectiveness Analysis of Left Atrial Appendage Closure (LAAC) Device Vesus Warfarin and New Oral Anticoagulants (NOACS) in Patients with Atrial Fibrillation (AF) - Large Brazilian Healthcare Payer Perspective

Atrial fibrillation (AF) is associated with increasing risk for stroke. Strokes are related to a large economic burden such as increased health expenditures, high and prolonged rates of hospitalization. Left atrial appendage closure (LAAC) emerged as viable treatment alternative for stroke risk reduction. The objective of the study was to evaluate the cost-effectiveness of LAAC with WATCHMAN device in the perspective of a large Brazilian healthcare payer with more than 18 million patients.

Using state claims data to explore first-line antibiotic prescribing for acute respiratory conditions—Minnesota, 2018–2019

Background: Nationally, >30% of all outpatient antibiotics are unnecessary or inappropriate, and only 52% of outpatients with sinusitis, otitis media, or pharyngitis receive recommended first-line antibiotics. The Minnesota All Payer Claims Database (MN APCD) collects medical claims, pharmacy claims, and eligibility files from private and public healthcare payers. We analyzed claims to describe overall and firstline antibiotic prescribing for acute bronchitis, adult acute sinusitis, and pediatric patients. Results: We analyzed 3,502,013 respiratory events from 1,612,501 members. Acute bronchitis accounted for 179,723 events (5.1%), acute sinusitis accounted for 236,901 adult events (10%), and otitis media accounted for 232,226 pediatric events (19%). Also, 73,385 bronchitis diagnoses (~40%) had no associated antibiotic. Antibiotics were associated with 199,445 adult sinusitis events (84.2%), of which 89,386 (44.8%) were firstline antibiotics, and 190,962 pediatric otitis media events (82.2%), of which 126,859 (66.4%) were firstline antibiotics. Common antibiotic classes used when a firstline drug was not selected were macrolides (28.9%) and tetracyclines (26.8%) for adult acute sinusitis and cephalosporins (61.4%) and macrolides (30.6%) for pediatric otitis media. Compared to the least vulnerable quartile, the most vulnerable social vulnerability index (SVI) quartile had lower odds of receiving firstline antibiotics for adult acute sinusitis if antibiotics were prescribed (OR, 0.90; 95% CI, 0.87–0.94) and higher odds of receiving firstline antibiotics for pediatric otitis media if antibiotics were prescribed (OR, 1.16; 95% CI, 1.12–1.21). Conclusions: Improvement is needed in avoiding antibiotics for acute bronchitis and selecting firstline drugs for sinusitis and otitis media. Additional analyses adjusting for demographic, geographic, and prescriber factors are planned to better understand differences in prescribing appropriateness among Minnesotans.Disclosures: None

EE227 The Impact of Treatment-Related Changes in Lipids on the Cost-Effectiveness of Resmetirom and Obeticholic Acid for Treatment of Nonalcoholic Steatohepatitis

Lipid levels impact cardiovascular disease (CVD) risk, including stroke and myocardial infarction. This analysis assessed the impact of treatment-related changes in lipid levels resulting from two potential treatments for nonalcoholic steatohepatitis (NASH), resmetirom and obeticholic acid (OCA), on costs and health outcomes versus placebo from a U.S. healthcare payer perspective over a lifetime horizon.

Cost-effectiveness of trastuzumab deruxtecan in HER2 low metastatic breast cancer.

1593 Background: In recent years, metastatic breast cancer treatment has been revolutionized by new therapies that improve overall survival in phase three randomized clinical trials. These drugs are often more expensive than traditional cytotoxics. In 2022, the Destiny-Breast04 trial results showed that trastuzumab deruxtecan (T-DXd) improved survival in HER2 low metastatic breast cancer patients; FDA approval shortly thereafter greatly expanded the potential market capitalization of T-DXd. While the trial demonstrated T-DXd’s clinical efficacy, its cost-effectiveness remains unknown. Methods: We developed a decision-analytic state transition Markov model to simulate a hypothetical cohort of HER2 low metastatic breast cancer patients to assess the cost-effectiveness of T-DXd compared to a physician's choice chemotherapy from a US healthcare payer perspective over a lifetime horizon. Each month, simulated patients could remain progression-free, progress, have a non-interstitial lung disease (ILD) treatment-related adverse event leading to drug discontinuation (TRAE), have ILD leading to drug discontinuation, progress after either a TRAE or ILD, or die. Patients with either a TRAE or ILD were presumed to be progression free directly after discontinuation of the offending agent, and hence eligible for a different therapy. We calibrated the model to outcome data from the Destiny-Breast04 trial, supplemented with data from other relevant metastatic breast cancer clinical trials. Health-related quality-of-life weights were derived from studies of metastatic breast cancer patients. Drug prices (2020 USD) were extracted from the Federal Supply Schedule. Outcomes included discounted (3% annual) quality-adjusted life years (QALYs), life years, lifetime costs, and incremental cost-effectiveness ratios (ICER). We varied T-DXd price and efficacy in a two-way sensitivity analysis to assess our findings’ robustness. Results: Modeled life expectancies with T-DXd and chemotherapy were 26.5 and 21.5 months, respectively (T-DXd: 1.19 QALYs; chemotherapy: 0.93 QALYs). Discounted lifetime costs were 315,000 for T-DXd and 203,000 for chemotherapy; T-DXd cost 431,000 per QALY gained, surpassing a cost effectiveness threshold of 150,000 per QALY gained. The two-way sensitivity analysis showed that, across a range of plausible efficacies, T-DXd would need a price reduction of approximately 50% to be cost-effective at the $150,000 threshold. Conclusions: While providing clinical benefits, our model-based analysis finds that at current prices, T-DXd for HER2 low metastatic breast cancer is not cost-effective at traditional thresholds. Substantial price reduction for T-DXd to a level much closer to prices of comparator cytotoxics could greatly increase the value for money T-DXd provides patients.

Optimal Contracting with Altruistic Agents: Medicare Payments for Dialysis Drugs

We study health-care provider agency and optimal payments, considering an expensive medication for dialysis patients. Using Medicare claims data we estimate a structural model of treatment decisions, in which providers differ in their altruism and marginal costs, and this heterogeneity is unobservable to the government. In a novel application of nonlinear pricing methods, we empirically characterize the optimal contracts in this environment. The optimal contracts eliminate medically excessive dosages and reduce expenditures, resulting in approximately $300 million in annual gains from better contracting. This approach could be applied to a broad class of problems in health-care payment policy. (JEL D64, D86, H51, I11, I13, J33, L21)

Real-world treatment patterns of non-small cell lung cancer in an Indian hospital.

e18604 Background: The circumstances regarding lung cancer in India are similar to many countries around the world – it is one of the most commonly diagnosed cancers with many treatment options available. India, however, relies heavily on an out-of-pocket healthcare payment model in which patients are often directly responsible for the majority of these treatment costs. This paradigm makes many of the newer generation of medications financially inaccessible for most Indians. In this research, we aimed to understand the current treatment patterns of non-small cell lung cancer (NSCLC) from an analysis of Indian hospital data, as a way to contextualize the real-world treatment situation. Methods: Electronic Medical Record (EMR) data was sourced from a major cancer hospital located in India’s national capital region. Using the Querent health analytics platform, EMR data across 5 years (2017-2022) were analyzed. Demographics, disease characteristics, and treatment patterns were identified through a combination of structured and unstructured data including data from registration, laboratory, radiology, diagnosis, procedure, pharmacy, and clinical notes. Results: 1,227 unique patients with NSCLC were observed in the hospital over five years, with an average (SD) duration of observation time of 12.1 (15.4) months. The patients were, on average (SD), 59.0 (11.2) years old and were more likely to be male (69.4%). Most patients were in later cancer stages, with a distribution of I (3%), II (2%), III (13%), and IV (82%). Among those with metastatic NSCLC, 773 (76%) received cancer treatment at the hospital, with 52% receiving surgery, 5% radiotherapy, and 88% anti-cancer medication. The most commonly administered medications were chemotherapies (carboplatin (52%) and pemetrexed (38%)). Targeted therapies were administered in 55% of patients. Conclusions: Only about half of all metastatic NSCLC patients received targeted cancer therapy. This proportion pales in comparison to targeted therapy utilization rates observed in the US and Europe, indicating the need to address the affordability issues that hamper patient access to these medications. Increased adoption of advanced therapeutics could lead to improved outcomes for many patients in India.

Cost-effectiveness analysis of pembrolizumab in patients with treatment-refractory metastatic colorectal cancer in Japan.

The immune checkpoint inhibitor pembrolizumab has recently been recognized as a standard treatment regimen for patients with metastatic colorectal cancer and the microsatellite-instability-high/mismatch repair-deficient mutation. However, its cost-effectiveness in late-line treatment remains unclear. The aim of this study was to assess the cost-effectiveness of pembrolizumab for patients with microsatellite-instability-high/mismatch repair-deficient metastatic colorectal cancer. Markov decision modeling using treatment costs, disease-free survival and overall survival was performed to examine the cost-effectiveness of pembrolizumab monotherapy compared with chemotherapy, and best supportive care. The Japanese healthcare payer's perspective was adopted. The outcomes were modeled on the basis of published literature. The primary outcome was the incremental cost-effectiveness ratio between the strategies. Sensitivity analyses were performed and the effects of uncertainty on the model parameters were investigated. Pembrolizumab monotherapy had incremental cost-effectiveness ratios of $408204.3 per quality-adjusted life-year gained compared with best supportive care and $489123.4 per quality-adjusted life-year gained compared with chemotherapy. Given a Japanese willingness-to-pay threshold of $69560.38 per quality-adjusted life-year, the base case results suggested that pembrolizumab monotherapy was not cost-effective. The sensitivity analysis results were in line with the base case results. Pembrolizumab monotherapy is not a cost-effective option in late-line treatment for patients with metastatic colorectal cancer and microsatellite-instability-high/mismatch repair-deficient mutation in the Japanese healthcare system. Further studies on its cost-effectiveness in first-line treatment are warranted.

Methods of payment for oral health care in Yaoundé.

Payment for dental services is one of the key determinants of treatment options, access to health care, and treatment decisions. The ability to pay for services directly affects the quality of life of an individual and also their accessibility to oral health services. The aim of the present study was to identify the different methods of payment used to obtain oral health care in Yaoundé, Cameroon This was a cross-sectional descriptive study carried out in selected dental clinics in Yaoundé using convenient sampling between January 2021 and June 2021. Data was collected using a structured questionnaire. A total of 377 patients aged 8 to 83 years made up of 194 (51.46%) females and 183 (48.54%) males participated in the study. There is no government-assisted package for oral health care in Cameroon and more than two-thirds (66.84%) made direct payments or paid out of pocket without a refund from any insurance company. More than half 147 (58.33%) of the study population did not complete the planned dental care due to insufficient funds. Direct payments covered treatments such as scaling, restorations, root canal therapy, and dental extractions while prostheses (dentures, crowns, bridges, and implants) were only afforded by very few patients. The reasons for the inability to pay for dental services included financial difficulties 107 (72.97%) and lack of time 36 (24.49%). Only half 36 (50%) of the participants employed in the formal sector had access to health insurance and treatments like scaling, dental prosthesis, orthodontics, and dental implants were rarely provided by an insurance company. These procedures were considered to be very expensive with fluctuating prices and were viewed as being for aesthetic purposes. The majority 67 (93.06%) of payments through insurance reported being reimbursed aftercare. Two-thirds of 48 (71.64%) of the insured participants said it was difficult to get reimbursed due to the administrative bottlenecks and as such some preferred to pay out of pocket despite being insured. Late consultations encountered led to caries complications with 105 (52.24%) pulpitis. In general, financial difficulty was reported by 97 (48.26%) as the main reason for not being able to afford dental care. Oral diseases present a huge burden for children and adults due to the high cost of treatment limiting their accessibility and treatment options. There is a need to create compulsory health insurance to enhance greater access to oral health services to encourage the population to seek dental care timeously.

Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke.

Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.