Health Economic Assessment Research Articles

No. 380-Investigation and Management of Prenatally Identified Microcephaly.

To update Canadian maternity care and reproductive health care providers on the diagnostic criteria of fetal microcephaly and provide information on the relevant investigations, prognosis, and pre- and perinatal management of this prenatal finding. All maternity care (most responsible health provider [MRHP]) and pediatric providers; genetic counsellors; maternity nurses; nurse practitioners; provincial maternity care administrators; medical students; postgraduate residents, and fellows. To provide better counselling and appropriate clinical management to women and families who have received a prenatal diagnosis of fetal microcephaly. Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018, using appropriate key words (prenatal ultrasound, prenatal imaging, fetal, antenatal, or prenatal microcephaly). Additional publications were identified from the bibliographies of these articles. Seven years (2010-2018); completed final search April 19, 2018. The primary author completed validation of the articles. This document educates readers about (1) the diagnostic criteria for fetal microcephaly, (2) its potential etiologies, (3) investigation and management options both pre- and postnatally. It proposes an evidence-based approach to the diagnosis and management of prenatally detected microcephaly. These recommendations are based on expert opinion and have not been subjected to a health economics assessment. Local or provincial implementation will be required. The authors recognize that there is variability across Canada in access to the cited services and resources. As such, these recommendations were developed in an attempt to promote access and to provide guidance for all provinces and territories across the country. The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

Molecular biomarkers and precision medicine in colorectal cancer: a systematic review of health economic analyses.

An increased understanding of the biology of colorectal cancer (CRC) has fuelled identification of biomarkers with potential to drive a stratified precision medicine care approach in this common malignancy.We conducted a systematic review of health economic assessments of molecular biomarkers (MBMs) and their employment in patient stratification in CRC. Our analysis revealed scenarios where health economic analyses have been applied to evaluate the cost effectiveness of MBM-guided clinical interventions: (i) evaluation of Dihydropyrimidine dehydrogenase gene (DPYD) status to identify patients susceptible to 5-Fluouracil toxicity; (ii) determination of Uridine 5′-diphospho- glucuronosyltransferase family 1 member A1 gene (UGT1A1) polymorphism status to help guide irinotecan treatment; (iii) assessment of RAS/RAF mutational status to stratify patients for chemotherapy or Epidermal Growth Factor Receptor (EGFR) therapy and (iv) multigene expression analysis (Oncotype Dx) to identify and spare non-responders the debilitating effects of particular chemotherapy interventions.Our findings indicate that Oncotype Dx is cost-effective in high income settings within specific price points, by limiting treatment toxicity in CRC patients. DPYD status testing may also be cost effective in certain settings to avoid specific 5-FU toxicities post treatment. In contrast, current research does not support UGT1A1 polymorphism status as a cost-effective guide to irinotecan dosing, while the health economic evidence to support testing of KRAS/NRAS mutational status and chemo/EGFR therapy choice was inconclusive, despite its widespread adoption in CRC treatment management. However, we also show that there is a paucity of high-quality cost-effectiveness studies to support clinical application of precision medicine approaches in CRC.

Exploring the health and spatial equity implications of the New York City Bike share system

IntroductionThis paper examines spatial equity and estimates the health impact of Citi Bike, New York City's (NYC) bike share system. We discuss how further system expansion and utilization by residents in high-poverty communities of color could affect the potential benefit of the largest bicycle share system in the United States. MethodsFirst, we compared the Citi Bike station distribution by census tract poverty during the system's 2013 launch and after the 2015 geographic expansion. Second, we applied the World Health Organization's Health Economic Assessment Tool (HEAT) to estimate the benefit of cycling associated with annual Citi Bike members for two 12-month time periods and analyzed change of the benefit over time. ResultsThe results showed that the greatest proportion of Citi Bike stations were located in low-poverty (wealthier) NYC census tracts (41% per period), and there were no significant changes in station distribution during expansion. HEAT estimated an increase from two to three premature deaths prevented and an increased annual economic benefit from $18,800,000 to $28,300,000 associated with Citi Bike use. ConclusionIn conclusion, although Citi Bike stations are not equitably located, the estimated annual health benefits are substantial and have increased over time. Our findings underscore the potential for even greater benefits with increased spatial access in higher-poverty neighborhoods and communities of color. Our findings highlight the importance of the built environment in shaping health and the need for a health equity lens to consider the social and political processes that perpetuate inequities.

Evaluating Augmented Depression Therapy (ADepT): study protocol for a pilot randomised controlled trial

BackgroundWhile existing psychological treatments for depression are effective for many, a significant proportion of depressed individuals do not respond to current approaches and few remain well over the long-term. Anhedonia (a loss of interest or pleasure) is a core symptom of depression which predicts a poor prognosis but has been neglected by existing treatments. Augmented Depression Therapy (ADepT) has been co-designed with service users to better target anhedonia alongside other features of depression. This mixed methods pilot trial aims to establish proof of concept for ADepT and to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost-effectiveness of ADepT, compared to an evidence-based mainstream therapy (Cognitive Behavioural Therapy; CBT) in the acute treatment of depression, the prevention of subsequent depressive relapse, and the enhancement of wellbeing.MethodsWe aim to recruit 80 depressed participants and randomise them 1:1 to receive ADepT (15 weekly acute and 5 booster sessions in following year) or CBT (20 weekly acute sessions). Clinical and health economic assessments will take place at intake and at 6-, 12-, and 18-month follow-up. Reductions in PHQ-9 depression severity and increases in WEMWBS wellbeing at 6-month assessment (when acute treatment should be completed) are the co-primary outcomes. Quantitative and qualitative process evaluation will assess mechanism of action, implementation issues, and contextual moderating factors. To evaluate proof of concept, intake-post effect sizes and the proportion of individuals showing reliable and clinically significant change on outcome measures in each arm at each follow-up will be reported. To evaluate feasibility and acceptability, we will examine recruitment, retention, treatment completion, and data completeness rates and feedback from patients and therapists about their experience of study participation and therapy. Additionally, we will establish the cost of delivery of ADepT.DiscussionWe will proceed to definitive trial if any concerns about the safety, acceptability, feasibility, and proof of concept of ADepT and trial procedures can be rectified, and we recruit, retain, and collect follow-up data on at least 60% of the target sample.Trial registrationISCRTN85278228, registered 27/03/2017

Application and significance of willingness-to-pay in measuring the burden of skin diseases

According to the new biopsychosocial medical model, status and burden of diseases should be evaluated comprehensively, and health-related quality of life can be an important measurement index of the burden of diseases. Conventional assessment methods for health-related quality of life include interval-based assessment methods and preference-based assessment methods (health utilities and willingness-to-pay) . This review introduces willingness-to-pay, and summarizes its applications in skin diseases. However, at present, only a small quantity of small-scale studies are available on willingness-to-pay, with only a few kinds of skin diseases involved. In the application of health-economic assessment of skin diseases, willingness-to-pay can serve as an approximate index of benefit gains, and be more valuable in practice than health utilities (the index of utility gains) . With the increase in health-economic researches on skin diseases, more attention is paid to the willingness-to-pay for skin diseases and other health-economic assessment methods, and large-scale health-economic assessment-related researches are expected to be conducted on more kinds of skin diseases. Key words: Skin diseases; Cost of illness; Quality of life; Willingness-to-pay; Health utilities

The need for comparative data in spondyloarthritis

Spondyloarthritis comprises a group of inflammatory diseases, characterised by inflammation within axial joints and/or peripheral arthritis, enthesitis and dactylitis. An increasing number of biologic treatments, including biosimilars, are available for the treatment of spondyloarthritis. Although there are a growing number of randomised controlled trials assessing treatments in spondyloarthritis, there is a paucity of data from head-to-head studies. Comparative data are required so that clinicians and payers have the level of evidence required to inform clinical decision-making and health economic assessments. In the absence of head-to-head studies, statistical methods such as network meta-analyses and matching-adjusted indirect comparisons (MAICs) are used for assessing comparative effectiveness.Network meta-analysis can be used to compare treatments for trials using a common comparator (e.g. placebo); however, for those without a common comparator or where considerable heterogeneity exists between the study populations, a MAIC that controls for differences in study design and baseline patient characteristics may be used. MAICs, unlike network meta-analyses, are of value for longer-term comparisons beyond the placebo-controlled phase of clinical trials, which is important for chronic diseases requiring long-term treatment, like spondyloarthritis. At present, there are a number of limitations that restrict the effectiveness of MAIC, such as the poor availability of individual patient-level data from trials, which results in patient-level data from one trial being compared with published whole-population data from another. Despite these limitations, drug reimbursement agencies are increasingly accepting MAIC as a means of comparative effectiveness and greater methodological guidance is needed.This report highlights a number of challenges that are specific to conducting comparative studies like MAIC in spondyloarthritis, including disease heterogeneity, the paucity of biomarkers and the duration of studies required for radiographic endpoints in this slow-progressing disease.

Human Papillomavirus Infection and Transmission Among Couples Through Heterosexual Activity (HITCH) Cohort Study: Protocol Describing Design, Methods, and Research Goals.

BackgroundHuman papillomavirus (HPV) epidemiological research has generally been individual based, typically focusing on women, with couple-based research mostly consisting of cross-sectional assessment of prevalent HPV infection in both partners.ObjectiveThe HPV Infection and Transmission among Couples through Heterosexual activity (HITCH) study was set up to investigate the transmissibility of HPV among young, recently formed couples in Montreal, Canada. This paper provides an overview of the HITCH cohort study design and procedures as well as a narrative summary of the most important findings.MethodsHITCH is a longitudinal investigation of HPV transmission in recently formed heterosexual partnerships initiated within 6-month pre-enrollment, a time at which considerable transmission is believed to occur. A total of 549 newly formed dyads were recruited (2005-2011) from postsecondary institutions, including 502 young women and their male partners. An additional 46 males were enrolled at follow-up, as some women enrolled a subsequent partner at follow-up. Women aged 18-24 years were followed for 24 months for acquisition of HPV types not present at enrollment, whereas men returned for a single follow-up visit at month 4, for a sum total of 3361 clinic visits. The last follow-up visit occurred in January 2014. Extensive sociodemographic, sexual behavioral, and medical history data were collected every 2-4 months using computer-assisted, self-administered questionnaires. Furthermore, participants provided genital, blood, oral, and hand specimens for HPV assessment.ResultsAlthough in its early analysis stage, HITCH has produced important publications. Findings from HITCH have increased the available knowledge about the natural history of HPV transmission and its determinants, provided further evidence regarding oral-oral and oral-genital routes of HPV transmission, and supplied empirically valid epidemiological parameters of HPV transmission to assist mathematical modelers in health economic assessments. In addition, HITCH data were made available to several multistudy collaborations evaluating new HPV detection assays and evidence for-or-against HPV type replacement following the introduction of HPV vaccination.ConclusionsHITCH will continue to offer a unique resource for research on HPV transmission.International Registered Report Identifier (IRRID)RR1-10.2196/11284

The Cost-effectiveness of Analogue Insulin Pens in Comparison with Human Insulin Pens for Controlling Type 1, Type 2, and Gestational Diabetes: A Systematic Review Article

Context: For many years, the classical (traditional) insulin injection methods have been used. The first insulin pen was made in the 1980s. These types of pens are divided into two categories, namely analogue and vial-human. Analogue insulin pens are similar to human insulin pens in molecular structure and can lead to differences in pharmacokinetic and pharmacodynamic properties.Methods: This was a systematic review conducted by searching Web of Science PubMed, SID, Embase, Scopus, and Magiran databases for articles published from the beginning of 2007 to June 2017. The related studies in the field of health technology and economic assessment were investigated.Results: Twenty studies were included; these studies indicated that there is no reason for the higher risk of rapid-acting insulin analogue pens in comparison with vial (human) and that analogue insulin pens significantly reduce the risk of hypoglycemia. Analogue insulin was compared to other existing insulins and was not found cost effectiveness (ICER: 642994$QALY), (ICER: 130865 $ QALY), (ICER: 87932$ QALY), but due to the increased quality of life and patient satisfaction compared to vial insulin pens, this type of pen has been used. Some studies have shown that aspart 30 insulin pens are more cost-effective than other analogues (ICER: 22488$QALY).Conclusions: Although the use of analogue insulin is more expensive for diabetic patients, it is more effective than vial insulin. Thus, insurance companies are recommended to develop special plans for the three vulnerable groups of seniors, children, and pregnant women to provide them with analogue insulin.

VP08 Can Health-Economic Evaluation Provide a Representation of ‘Value For Money’ For HTA?

IntroductionHealth technology assessment (HTA) processes typically combine both evidence and values in order to inform decisions about relative value. Health-economic evaluation and other economic evidence are thought by many to be important for such processes, but there is typically tension between the information offered by health-economic assessment, and the context-specific interpretation of such information. This study reviews the meaning, and interpretation, of ‘health-economic evaluation’ aimed at informing HTA processes. One central aim is to answer the question: “Can health-economic evaluation provide a representation of ‘value for money’ for HTA?”MethodsA seminal article was used as a starting point and then a variety of search techniques, including bi-directional citation searching, were used to obtain evidence relating to the study objective. A critical review is undertaken spanning the last fifty years of health-economic evaluation, which provides perspective on the balance between more context-independent assessments and the context-specific interpretation of those assessments.ResultsAlthough health-economic evaluation can legitimately be undertaken in a variety of ways, we find that processes of ‘valuation’ are fundamental to all approaches to economic evaluation in practice. Values influence how these economic value frameworks tend to be operationalized, promoted and understood. Our critical review provides those interested in prioritization with a timely reminder that health-economic evaluation should be thought of as largely context- and content -specific.ConclusionsHealth-economic evaluation can typically only offer a truncated representation of ‘value for money’ to HTA processes. In answer to the question posed above, this study finds that health-economic evaluation will typically not provide a full assessment of ‘value for money’. Therefore, it should always be accompanied by an assessment of its qualities: what is covered in the analysis, how well what is covered is measured or analysed, and what is left out. Humility about what health-economic evaluation can offer would seem useful, especially given that other elements of value exist, such as the potential harms and benefits of medical-industry profits and environmental sustainability.

Health Impact Assessment Study On Active Travel In Large Urban Areas

Abstract The paper intends to present the advantages and the disadvantages of the non-motorized movements (cycling and walking) in large urban areas compared to motorized modes using as a case study the application of an instrument called Health Economic Assessment Tool (HEAT) for walking and cycling. The case study is based upon the analogy between these aspects for a town which is friendly to walking and cycling (Barcelona - Spain) and a town less friendly with these types of movements (Bucharest - Romania). Health impact assessment is a combination of procedures, methods and tools used to evaluate the potential health effects of a policy, programme or project. Using a combination of qualitative, quantitative and participatory techniques, health impact assessment aims to produce recommendations that will help decision-makers and other stakeholders make choices about alternatives and improvements to prevent disease/injury and to actively promote health (more on health impact assessment).

OP98 Limitations In Health-Economic Guidance For Medical Devices

IntroductionHealth technology assessment (HTA) includes consideration of health and economic factors, playing a key role in optimizing healthcare provision in Europe. Medical devices are an important contributor to both health outcomes and the cost of healthcare provision, yet they are rarely addressed in current guidance for health-economic evaluation. Our aim is to help improve assessment of medical devices via review of European health-economic guidelines and recent research.MethodsSearches for European HTA guidelines were performed and where available were reviewed by two researchers working independently. Additionally, a systematic review of published literature focused on assessment of medical devices was conducted. English, German, or French literature published between 2000 and 2017 was analyzed. The status of HTA guidance to date was subsequently reviewed in light of current research findings and suggestions made to help improve standardization.ResultsOf the 41 investigated European countries, 22 had official HTA guidance. Only four of 22 (18 percent) dedicated documentation to guidance specific to medical devices. Where differences between pharmaceuticals and medical devices were highlighted, specifics for health-economic assessment of medical devices were generally absent. The systematic review yielded 472 unique articles, 28 of which underwent full-text review. Issues surrounding medical device value assessment that commonly emerged were: limited evidence base, learning curve effects, organizational impact, incremental innovation, diversity of devices, dynamic pricing, and transferability. While identification of issues was ubiquitous, actionable suggestions on how to overcome them were less common. The most frequent recommendations were use of Bayesian methods, inclusion of real-world data, and modelling the learning curve. Key to implementation is determination of the medical device type and its impact duration.ConclusionsCurrent guidelines rarely address the needs of medical devices. Practical recommendations for improvements exist and provide opportunity to start discussion on how best to serve the medical devices field and improve the HTA process.

Health Economic Evaluation Modeling Shows Potential Health Care Cost Savings with Increased Conformance with Healthy Dietary Patterns among Adults in the United States

BackgroundMany American adults have one or more chronic diseases related to a poor diet, resulting in significant direct and indirect economic impacts. The 2015-2020 Dietary Guidelines for Americans (DGA) recognized that dietary patterns may be more relevant for predicting health outcomes compared with individual diet elements and recommended three healthy patterns based on evidence of favorable associations with many chronic disease risk factors and outcomes. Health economic assessments provide a model to estimate the potential influence on costs associated with changes in chronic disease risk resulting from improved diet quality in the US adult population. ObjectiveTo estimate the impact on health care costs associated with increased conformance with the three healthy patterns recommended in the 2015-2020 DGA, including the Healthy US-Style, the Healthy Mediterranean-Style, and the Healthy Vegetarian eating patterns. MethodsRecent moderate- to high-quality meta-analyses of health outcomes associated with increased conformance with the Healthy US-Style eating pattern as measured by the Healthy Eating Index (HEI) or the Healthy Mediterranean-Style eating pattern measured by a Mediterranean diet score (MED) were identified. Given the lack of quantification of the association between an increased conformance with a vegetarian pattern and health outcomes, the analysis was limited to studies that evaluated Healthy US-style and Healthy Mediterranean-style eating patterns. The 2013-2014 What We Eat in America data provided estimates of conformance with these two eating patterns using the HEI-2015 and the 9-point MED among the US adult population. Risk estimates quantifying the association between eating patterns and health outcomes were combined with the eating pattern score increase under two conformance scenarios: increasing the average HEI-2015 and MED by 20% and increasing the average HEI-2015 and MED to achieve 80% of complete conformance. The resulting change in risk was combined with published data on annual health care and indirect costs, inflated to 2017 US dollars to estimate cost. To address double counting, costs were adjusted to minimize potential overlap of comorbidities. ResultsOverall modeled cost savings were $16.7 billion (range=$6.7 billion to $25.4 billion) to $31.5 billion (range=$23.9 billion to $38.9 billion) based on a 20% increase in the MED and HEI-2015, respectively, resulting from reductions in cardiovascular disease, cancer, and type 2 diabetes for both patterns and including Alzheimer’s disease and hip fractures for the MED. In the case that diet quality of US adults were to improve to achieve 80% of the maximum MED and HEI-2015, cost savings were estimated at $88.2 billion (range=$35.7 billion to $133 billion) and $55.1 billion (range=$41.8 billion to $68.2 billion), respectively. ConclusionsThis is the first study quantifying savings from all health outcomes identified to be associated with the HEI and the MED to assess conformance with two eating patterns recommended as part of the 2015-2020 DGA. Findings from this study suggest that increasing conformance with healthy eating patterns among US adults could reduce costs, with billions of dollars in potential savings.

The health economics of infertility treatment

The health economics of infertility raises a number of issues that are not generally considered in the standard canon for health economic assessment of health technology assessments. Six issues stand out, which are briefly considered in turn.

Study protocol: Care of Late-Stage Parkinsonism (CLaSP): a longitudinal cohort study

BackgroundParkinson’s disease (PD) is a chronic progressive disorder leading to increasing disability. While the symptoms and needs of patients in the early stages of their disease are well characterized, little information is available on patients in the late stage of the disease.Methods/designThe Care of Late-Stage Parkinsonism (CLaSP) study is a longitudinal, multicenter, prospective cohort study to assess the needs and provision of care for patients with late stage Parkinsonism and their carers in six European countries (UK, France, Germany, Netherlands, Portugal, Sweden). In addition, it will compare the effectiveness of different health and social care systems. Patients with Parkinsonism with Hoehn and Yahr stage ≥IV in the “On”-state or Schwab and England stage 50% or less are evaluated at baseline and three follow-up time-points. Standardised questionnaires and tests are applied for detailed clinical, neuropsychological, behavioural and health-economic assessments. A qualitative study explores the health care needs and experiences of patients and carers, and an interventional sub-study evaluates the impact of specialist recommendations on their outcomes.DiscussionThrough the combined assessment of a range of quantitative measures and qualitative assessments of patients with late stage parkinsonism, this study will provide for the first time comprehensive and in-depth information on the clinical presentation, needs and health care provision in this population in Europe, and lay the foundation for improved outcomes in these patients.Trial registrationThe protocol was registered at ClinicalTrials.gov as NCT02333175 on 07/01/2015.

Time lapse imaging of embryos is useful in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment: AGAINST: The jury is still out.

Time-lapse imaging (TLI) systems for incubation and assessment of embryos are hypothesised to improve success of in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Undisturbed embryo culture and improved embryo selection using the extra information from the time-lapse videos are postulated to achieve this. A medical intervention may be considered useful if it improves outcomes. In this sense it is too early to justify the motion of this debate. History has taught us that interventions that may seem logical are not always useful and may even be harmful. In spite of an attractive and theoretically plausible biological hypothesis, current best evidence has not shown the benefit of TLI (PLoS One 2017;12:e0178720, J Assist Reprod Genet 2015;32:1025–30). Improvement in clinical pregnancy/live birth or reduction in miscarriage/stillbirth has not been reported by either systematic review. The results of these reviews were dominated by a single large trial (Fertil Steril 2014;102:1287–94) deemed to be at a high risk of bias, thus providing only moderate-to-low-quality evidence. The encouraging results from this trial have not yet been replicated. In spite of the lack of evidence supporting its use, TLI is being offered by several fertility clinics to couples seeking treatment, often with an additional charge. This is highlighted in a recent publication (BMJ 2016;6:e013940) detailing add-on treatments in IVF/ICSI. The HFEA has reiterated the inconclusive evidence in its information for patients (www.HFEA.gov.uk). Possible arguments for its use include the immediate needs of patients seeking treatment, patient preference, personal experience of benefit, and a very reassuring safety profile. It may also be argued that the time, resources and funding to run an ideal trial providing high-quality evidence may be difficult and hence patients should be given a choice of the intervention after access to adequate information. We should support new technology that improves patient outcomes. However, reproductive medicine must be treated like any other medical speciality where it is unethical and unscientific to offer a treatment without robust evidence of its effectiveness, clinical or financial. TLI is expensive in terms of capital cost, running and maintenance cost, staff training and time. Although TLI may be cost-effective in theory, health-economic assessment of the intervention has never been reported. Patients are not trained medical professionals and hence are unable critically to appraise the evidence presented to them to reach valid conclusions. It remains the responsibility of healthcare professionals not to exploit this vulnerable group, who may be willing to go to any lengths to achieve a pregnancy. Protagonists of TLI would also argue that this technology allows insight into early embryonic development with the possibility to generate knowledge which could be useful to future patients. Although this statement is valid it would support the use of TLI only in a research setting. With opportunities for research funding, and over 685000 annual IVF/ICSI treatments in Europe and 231000 in the USA, is it not ironic that we are still unable to provide a definitive answer to this question? Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

2261 - Estimating the Health Benefits of a Proposed Regional Transportation Plan

The population of the Greater Toronto-Hamilton Area (GTHA) is projected to grow from 6.2 million people in 2001 to 9.6 million in 2031. Existing commute times are the country's highest with annual costs of congestion to reach $15 billion. A proposed 25-year, $50 billion Regional Transportation Plan (RTP) would build a regional rapid transit network, expand active transportation (AT), and build communities that are AT- and transit-supportive. Medical Officers of Health of GTHA communities issued a call to action for government investment based on the estimated health-related benefits of implementing the RTP. To calculate increases in transport physical activity, the RTP's projected increase in public transit use was combined with conservative estimates of increases in AT to work and school by adults (5%), as well as a substitution of 5% of local vehicle trips ≤7 km with AT. The associated number of prevented deaths and incident cases of diabetes were calculated using the Health Economic Assessment Tool and the Diabetes Population Risk Tool, respectively. Data inputs included regional travel data from transportation and census surveys, crude mortality rates, and literature-based walking estimates with transit use. Adjustments were included for the duration of the academic year and seasons. A value of a statistical life (VSL) was $6.5 million and the lifetime excess medical costs of a diabetes case of $24,500. Previous Toronto-based estimates for annual premature deaths and hospitalizations attributed to traffic-related emissions were extrapolated to the GTHA based on population. Full implementation of the RTP would prevent 338 deaths per year in the current population with a VSL-based cost of $2.2 billion. The number of projected prevented deaths due to increased physical activity (184) and reduced vehicle emissions (154) were similar. The annual number of prevented cases of diabetes due to an increase in physical activity was 1,061 with a projected lifetime excess healthcare costs of almost $26 million. The projected health impacts of the RTP are substantial, yet conservative since they consider only mortality and diabetes incidence. The results provided an additional health-based argument for government investment, as well as signaled public health's interest in building healthier communities. In addition to initial media coverage, the report has been repeatedly cited at local, provincial and national levels. While impossible to directly attribute causality, subsequent government policies have included strengthening the accountability for integrated land use and transportation planning, as well as substantial investment in the RTP.

2261 - Estimating the Health Benefits of a Proposed Regional Transportation Plan

Highest Scoring Abstract: Practitioner Background The population of the Greater Toronto-Hamilton Area (GTHA) is projected to grow from 6.2 million people in 2001 to 9.6 million in 2031. Existing commute times are the country's highest with annual costs of congestion to reach $15 billion. A proposed 25-year, $50 billion Regional Transportation Plan (RTP) would build a regional rapid transit network, expand active transportation (AT), and build communities that are AT- and transit-supportive. Medical Officers of Health of GTHA communities issued a call to action for government investment based on the estimated health-related benefits of implementing the RTP. Methods To calculate increases in transport physical activity, the RTP's projected increase in public transit use was combined with conservative estimates of increases in AT to work and school by adults (5%), as well as a substitution of 5% of local vehicle trips ≤7 km with AT. The associated number of prevented deaths and incident cases of diabetes were calculated using the Health Economic Assessment Tool and the Diabetes Population Risk Tool, respectively. Data inputs included regional travel data from transportation and census surveys, crude mortality rates, and literature-based walking estimates with transit use. Adjustments were included for the duration of the academic year and seasons. A value of a statistical life (VSL) was $6.5 million and the lifetime excess medical costs of a diabetes case of $24,500. Previous Toronto-based estimates for annual premature deaths and hospitalizations attributed to traffic-related emissions were extrapolated to the GTHA based on population. Results Full implementation of the RTP would prevent 338 deaths per year in the current population with a VSL-based cost of $2.2 billion. The number of projected prevented deaths due to increased physical activity (184) and reduced vehicle emissions (154) were similar. The annual number of prevented cases of diabetes due to an increase in physical activity was 1,061 with a projected lifetime excess healthcare costs of almost $26 million. Conclusions The projected health impacts of the RTP are substantial, yet conservative since they consider only mortality and diabetes incidence. The results provided an additional health-based argument for government investment, as well as signalled public health's interest in building healthier communities. In addition to initial media coverage, the report has been repeatedly cited at local, provincial and national levels. While impossible to directly attribute causality, subsequent government policies have included strengthening the accountability for integrated land use and transportation planning, as well as substantial investment in the RTP.

Elicitation of health state utilities associated with the mode of administration of drugs acting on the prostacyclin pathway in pulmonary arterial hypertension

IntroductionPulmonary arterial hypertension (PAH) is a rare, incurable disease associated with decreased life expectancy and a marked impact on quality of life (QoL). There are three classes of drugs available for treatment: endothelin receptor antagonists (ERA), drugs acting on nitric oxide pathway (riociguat and phosphodiesterase type 5 inhibitors [PDE5i]), and drugs acting on prostacyclin pathway. The latter have widely different modes of administration – continuous intravenous infusion, continuous subcutaneous infusion, inhaled, and oral – each associated with variable treatment burden, and implications for health economic assessment. This study aimed to establish utility values associated with different modes of administration of drugs acting on the prostacyclin pathway for use in economic evaluations of PAH treatments.MethodsA UK general public sample completed the EQ-5D-5L and valued four health states in time trade-off interviews. The health states drafted from literature and interviews with PAH experts (n=3) contained identical descriptions of PAH and ERA/PDE5i treatment, but differed in description of administration including oral (tablets), inhaled (nebulizer), continuous subcutaneous infusion, and continuous intravenous infusion.ResultsA total of 150 participants (63% female; mean age 37 years) completed interviews. Utilities are presented as values between 0 and 1, with 0 representing the state of being dead and 1 representing being in full health. The mean (SD) utility for oral health state was 0.85 (0.16), while all other health states were significantly lower at 0.74 (0.27) for inhaled (p=0.001), 0.59 (0.31) for subcutaneous (p<0.001) and 0.54 (0.32) for intravenous (p<0.001), indicating that there are disutilities (negative differences) associated with non-oral health states. Disutilities were −0.11 for inhaled, −0.26 for subcutaneous, and −0.31 for intravenous administration.ConclusionThe results demonstrate quantifiable QoL differences between modes of administration of drugs acting on the prostacyclin pathway. QoL burden should be considered for economic evaluation of drugs for PAH treatment.

2458 - Assessment of Advantages of Transit-oriented Developments over Traditional Auto-oriented Land Development: A Case Study

Background Transit oriented developments (TOD's) are a type of urban development that emphasize diversity in land use and concurrence of more sustainable modes of transport. Particular emphasis in TOD is given to active (Waling and Cycling) and semi-active (Transit) transport modes. The aim of the study is two-fold: demonstrates the advantages of transit-oriented developments including benefits to public health, and demonstrate a suitable analysis framework and structure for conducting similar studies. Methods A residential area at the outskirts of Dubai is used as a case study. Travel demand forecasting models were used to estimate changes in trip generation, distribution, mode choice, and route assignment brought about by the relocation of destinations. To account for normal variation and uncertainty, three travel mode choice shift scenarios and corresponding changes in distances walked and cycled were estimated based on published rates, local conditions and culture. Changes were mapped to health, environmental, energy, and economic benefits. On health, reductions in obesity, high blood pressure and high blood cholesterol, and heart attach were estimated based on published rates. Economic benefits (reduced mortality) were evaluated using HEAT (Health Economic Assessment Tool). Aggregate reductions in energy consumption, carbon dioxide emissions, travel time and operating costs (of private vehicles) were all estimated. Health benefits due to reductions in pollution were not estimated. Results A framework quantifying the health benefits of TOD was proposed and implemented. Travel demand changes were mapped to health benefits. The walk/cycle plus transit (to reach destination) scenario and yearly benefits due to reduced mortality was $1,797 and $8,343 for the conservative and optimistic scenarios, respectively; for the Walk/Cycle the values are $10,973 and $50,941. That a specific amount of health-induced economic gain may be estimated in conjunction with TOD's using the proposed framework is the more relevant outcome. Conclusions Estimating health gains, environmental improvements, and economic benefits of TOD implementation were possible using standard travel demand forecasting models. Mapping travel changes to health and other benefits is key to quantifying different benefits of TOD's. Normal variation and uncertainty precipitated by variations in policies, local environments and cultures may be accounted for by considering a range of scenarios.

Quality of life and quality-adjusted life years of chronic schistosomiasis mansoni patients in Brazil in 2015

Measures of health-related quality of life (HRQoL) have been used to express the impact of neglected diseases and to generate indicators for health economic assessments. Schistosomiasis mansoni is a neglected disease with various clinical manifestations, including severe repercussions, caused by parasitic worms. Here we describe the quality of life of chronic schistosomiasis mansoni patients and estimate the quality-adjusted life years (QALYs) associated with chronic schistosomiasis mansoni in Brazil in 2015. A HRQoL study was carried out using the three-level European Quality of Life 5-Dimensions (EQ-5D-3L) questionnaire in 147 chronic schistosomiasis mansoni patients at an outpatient monitoring facility of an endemic state for schistosomiasis. Losses in HRQoL were observed in all five dimensions of the EQ-5D-3L. Patients >60 y and 40-49 y of age reported the highest frequencies of problems. The average utility index was 0.71, and the median index was significantly lower among female patients and patients with comorbidities (0.68; p<0.05) compared with the entire sample. Approximately 26.7 QALYs were estimated for the study population and 31.2 QALYs for the chronic schistosomiasis mansoni patients in Brazil. The advanced forms of schistosomiasis mansoni, even during treatment, contribute to important health losses in the population dealing with the disease.