Highest Probability Of Cost-effectiveness Research Articles

The cost-effectiveness of providing antenatal lifestyle advice for women who are overweight or obese: the LIMIT randomised trial.

BackgroundOverweight and obesity during pregnancy is common, although robust evidence about the economic implications of providing an antenatal dietary and lifestyle intervention for women who are overweight or obese is lacking.We conducted a health economic evaluation in parallel with the LIMIT randomised trial. Women with a singleton pregnancy, between 10+0-20+0 weeks, and BMI ≥25 kg/m2 were randomised to Lifestyle Advice (a comprehensive antenatal dietary and lifestyle intervention) or Standard Care. The economic evaluation took the perspective of the health care system and its patients, and compared costs encountered from the additional use of resources from time of randomisation until six weeks postpartum. Increments in health outcomes for both the woman and infant were considered in the cost-effectiveness analysis. Mean costs and effects in the treatment groups allocated at randomisation were compared, and incremental cost effectiveness ratios (ICERs) and confidence intervals (95%) calculated. Bootstrapping was used to confirm the estimated confidence intervals, and to generate acceptability curves representing the probability of the intervention being cost-effective at alternative monetary equivalent values for the outcomes avoiding high infant birth weight, and respiratory distress syndrome. Analyses utilised intention to treat principles.ResultsOverall, the increase in mean costs associated with providing the intervention was offset by savings associated with improved immediate neonatal outcomes, rendering the intervention cost neutral (Lifestyle Advice Group $11261.19±$14573.97 versus Standard Care Group $11306.70±$14562.02; p=0.094). Using a monetary value of $20,000 as a threshold value for avoiding an additional infant with birth weight above 4 kg, the probability that the antenatal intervention is cost-effective is 0.85, which increases to 0.95 when the threshold monetary value increases to $45,000.ConclusionsProviding an antenatal dietary and lifestyle intervention for pregnant women who are overweight or obese is not associated with increased costs or cost savings, but is associated with a high probability of cost effectiveness. Ongoing participant follow-up into childhood is required to determine the medium to long-term impact of the observed, short-term endpoints, to more accurately estimate the value of the intervention on risk of obesity, and associated costs and health outcomes.Trials registrationAustralian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Serum Free Light Chain Assays in the Early Detection of Cast Nephropathy in Patients Presenting with Unexplained Acute Kidney Injury (AKI): Results from a Pharmacoeconomic Evaluation

International Kidney and Monoclonal research Group (IKMG) recommendations for screening for acute kidney injury (AKI) secondary to multiple myeloma (MM) include the assessment of patients with the serum free light chain test (sFLC). Here we compare the economic impact of following this recommendation compared to standard serum and urine electrophoretic techniques.An economic model was constructed using published UK data and centre specific clinician advice. The model compared the following scenarios: (i) serum protein electrophoresis (SPEP) + sFLC (IKMG recommendation), (ii) SPEP alone, (iii) SPEP + urine electrophoresis (SPEP + UPE), with a positive test in scenarios (i)—(iii) proceeding to immunofixation electrophoresis (IFE); (iv) all electrophoretic methods run in parallel (SPEP + UPE + sIFE + uIFE). The key economic drivers in the model were length of in-patient stay and dialysis costs. The incremental costs per QALY gained were modelled over a 365d time horizon.The economic model utilized a decision tree structure to the time of diagnosis and a Markov model including the health states: dialysis dependence, renal function recovery, other cause of AKI and death. The model structure and assumptions were validated through clinician consultation.Survival in the diagnostic pathway was estimated using hazard ratios applied to survival of MM based on the stage of AKI, obtained from a retrospective observational study (Han, et al., 2013). Survival within the Markov model post-diagnosis was based on UK data stratified for cast nephropathy patients who had or had not recovered renal function. Post-diagnosis, a probability of renal recovery based on the duration of AKI prior to diagnosis was applied.Utility values in the decision tree structure were estimated using the Modification of Diet in Renal Disease equation. The Markov model employed previously published utility values in MM with a decrement applied for dialysis dependence.Costs for medical resource use, medical management, dialysis, adverse events associated with dialysis and terminal care were derived from the 2012-2013 NHS Reference Cost and British National Formulary.Key user defined values for the comparison included a presenting patient distribution of 10% stage 2 AKI, 45% stage 3 AKI (dialysis independent) and 45% stage 3 AKI (dialysis dependent), 1% incidence of cast nephropathy as a cause of AKI, and a 20% incidence of renal biopsy following a positive diagnostic result.User amendable fields ensure the model is amenable to refinement as new data on assay performance and patient pathways become available.The incremental costs and QALYs for each comparator are shown in Table 1. The model predicts the pathway with SPEP + sFLC to be dominant; SPEP + sFLC accrues the most QALYs and the least costs. The savings in the diagnostic decision tree (£7, £31, -£5, respectively) are driven by reduced dialysis and in-patient bed stay costs. In the treatment pathway savings (£34, £37, £41, respectively) are driven by reduced dialysis costs. Probabilistic sensitivity analysis showed the model results to be robust - the probability of SPEP + sFLC being cost-effective at a £20,000 per QALY willingness to pay threshold was 98.6%, 93.8%, 92.6%, respectively.Table 1 -Base Case Cost-Effectiveness ResultsModel ResultsSPEP + sFLCSPEPDifferenceTotal Cost (GBP)£427£467-£40Total QALYs0.62450.62350.00099ICER=Incremental Cost/ Incremental QALYDominantModel ResultsSPEP + sFLCSPEPDifferenceTotal Cost (GBP)£427£495-£68Total QALYs0.62450.62310.00133ICER=Incremental Cost/ Incremental QALYDominantModel ResultsSPEP + sFLCSPEPDifferenceTotal Cost (GBP)£427£463-£36Total QALYs0.62450.62390.00055ICER=Incremental Cost/ Incremental QALYDominantThis model supports the recommended international guidelines for screening for AKI secondary to MM. Inclusion of the sFLC assay improves the probability of renal recovery and survival by reducing time to diagnosis and treatment.Cost savings and QALY gains are found in both the diagnostic stage and treatment stage of the patient pathway. The SPEP + sFLC pathway is therefore cost-effective at a willingness to pay threshold of £20,000 per QALY with a high probability of cost-effectiveness against all comparator pathways from probabilistic sensitivity analysis.The model template may be used in future health economic models to assess the contribution of new assays into diagnostic algorithms. DisclosuresNo relevant conflicts of interest to declare.

Symptom- and fraction of exhaled nitric oxide–driven strategies for asthma control: A cluster-randomized trial in primary care

Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment. We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa). In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate. Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate. A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.

Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial

Objective To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone.Design Cost effectiveness analysis nested within a pragmatic...

Probability of Cost-Effective Management of Soybean Aphid (Hemiptera: Aphididae) in North America

Soybean aphid, Aphis glycines Matsumura (Hemiptera: Aphididae), is one of the most damaging pests of soybean, Glycine max (L.) Merrill, in the midwestern United States and Canada. We compared three soybean aphid management techniques in three midwestern states (Iowa, Michigan, and Minnesota) for a 3-yr period (2005-2007). Management techniques included an untreated control, an insecticidal seed treatment, an insecticide fungicide tank-mix applied at flowering (i.e., a prophylactic treatment), and an integrated pest management (IPM) treatment (i.e., an insecticide applied based on a weekly scouting and an economic threshold). In 2005 and 2007, multiple locations experienced aphid population levels that exceeded the economic threshold, resulting in the application of the IPM treatment. Regardless of the timing of the application, all insecticide treatments reduced aphid populations compared with the untreated, and all treatments protected yield as compared with the untreated. Treatment efficacy and cost data were combined to compute the probability of a positive economic return. The IPM treatment had the highest probability of cost effectiveness, compared with the prophylactic tank-mix of fungicide and insecticide. The probability of surpassing the gain threshold was highest in the IPM treatment, regardless of the scouting cost assigned to the treatment (ranging from $0.00 to $19.76/ha). Our study further confirms that a single insecticide application can enhance the profitability of soybean production at risk of a soybean aphid outbreak if used within an IPM based system.

Cost-utility analysis for advanced breast cancer therapy in Germany: results of the fulvestrant sequencing model

Therapy decisions in advanced breast cancer (ABC) increasingly require assessment not only of treatment efficacy but also of cost-effectiveness. To this end, we performed a cost-utility analysis by comparing treatment sequences including/omitting fulvestrant in a hypothetical population of hormone receptor-positive (HR+) postmenopausal women with ABC. The analysis was performed from the German health care perspective. Using a first-order sequential Markov model, expected costs and utilities were calculated over a time horizon of 10 years for cohorts of patients with HR+ ABC, previously treated for at least 5 years using adjuvant endocrine therapies. Utilities were primarily quantified in terms of quality adjusted life years (QALY). "Base-case" estimates of state transition rates, resource utilization, and other model parameters were derived from published evidence and expert assessment. The impacts of uncertainties in all key model parameters were evaluated by sensitivity analysis. Costs and benefits were discounted at 3% annually. Including second-line fulvestrant in the treatment sequence led to greater estimated health gains (0.021 QALY) and cost savings of 564 euros ($745, 380 pounds) per patient, i.e. the fulvestrant-containing sequence was "dominant". The prediction of a cost savings was robust with respect to variations in all key parameters. The probability of acceptable cost-effectiveness for the fulvestrant sequence was 72% at a willingness to pay (WTP) of 30,000 euros/QALY ($39,621/QALY, 20,198 pounds/QALY); the probability was even higher at lower WTP and substantially exceeded 50% for any realistic WTP. In a representative population of women with HR+ advanced breast cancer, inclusion of fulvestrant in the treatment sequence provides a cost-effective alternative from the German health care perspective. A high probability of cost-effectiveness is maintained under variations in all key parameters. The results reflect a tendency for patients receiving fulvestrant at an early stage to maintain high quality of life for a longer interval.

Cost-effectiveness analysis of budesonide/formoterol maintenance and reliever therapy versus fixed combination treatments for asthma in Finland

ABSTRACTBackground: Budesonide/formoterol maintenance and reliever therapy has shown its effectiveness as a treatment for moderate-to-severe asthma.Objective: To explore the cost-effectiveness of budesonide/formoterol maintenance and reliever therapy as compared to fixed combination therapies (budesonide/formoterol and salmeterol/fluticasone) with terbutaline as needed in the treatment of asthma in Finland.Methods: Patients without asthma exacerbations during a 6-month period were used as the effectiveness variable in the within-trial economic analysis. Finnish unit costs were applied to pooled resource use data, and multinomial cost-effectiveness plane and acceptability curves were formed based on bootstrapping.Results: Use of budesonide/formoterol maintenance and reliever therapy significantly reduced the rate of severe asthma exacerbations as compared with a fixed dose of budesonide/formoterol or salmeterol/fluticasone and terbutaline as needed. Total costs over 6 months were €496 per patient for those who used the budesonide/formoterol maintenance and reliever therapy treatment model, which was €78–101 lower than the cost of fixed combinations of salmeterol/fluticasone or budesonide/formoterol with terbutaline as needed. The results indicate that the budesonide/formoterol maintenance and reliever therapy achieves a high probability (> 93%) of cost effectiveness irrespective of willingness to pay level.Conclusions: Budesonide/formoterol maintenance and reliever therapy may be considered in the treatment of moderate-to-severe asthma instead of conventional treatment with combination products in view of its good clinical efficacy and a high probability of cost-effectiveness in the Finnish setting. However, a cost-effectiveness analysis with a longer time horizon, more Finnish-specific data, and ICS + short/long-acting inhaled β2-agonist as an additional comparator is still warranted.

Cost-Effectiveness of Palliation of Unresectable Esophageal Cancer

Different modalities of palliation for obstructive symptoms in patients with unresectable esophageal cancer (EC) exist. However, these therapeutic alternatives have significant differences in costs and effectiveness. A Markov model was designed to compare the cost-effectiveness (CE) of self-expandable stent (SES), brachytherapy and laser in the palliation of unresectable EC. Patients were assigned to one of the strategies, and the improvement in swallowing function was compared given the treatment efficacy, probability of survival, and risks of complications associated to each strategy. Probabilities and parameters for distribution were based on a 9-month time frame. Under the base-case scenario, laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $4,400.00, and SES is a dominated strategy. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for willingness to pay (WTP) values lower than $3,201 and brachytherapy for all WTP yielding a positive net health benefit (NHB) (threshold $4,440). The highest probability of cost-effectiveness for brachytherapy is 96%, and consequently, selection of suboptimal strategies can lead to opportunity losses for the US health system, ranging from US$ 4.32 to US$ 38.09 million dollars over the next 5-20 years. Conditional to the WTP and current US Medicare costs, palliation of unresectable esophageal cancers with brachytherapy provides the largest amount of NHB and is the strategy with the highest probability of CE. However, some level of uncertainly remains, and wrong decisions will be made until further knowledge is acquired.

Prevalence of Patients Using Drugs Metabolized by Cytochrome P450 2D6 in Different Populations: a Cross-Sectional Study

Despite a large number of studies investigating the potential clinical relevance of CYP2D6 genotyping in preventing treatment failure (eg, insufficient efficacy and/or unacceptable adverse effects), the prevalence of patients using drugs metabolized by that isoenzyme is relatively unknown. To investigate the prevalence of patients in different populations using drugs metabolized by CYP2D6. In this cross-sectional study, 6 different patient populations were investigated: general, general hospital, geriatric, psychogeriatric, psychiatric, and mentally retarded. From every population, 150 adults using at least one drug were randomly selected. Primary outcome was the prevalence of patients using at least one drug metabolized by CYP2D6. The prevalence of patients using at least one CYP2D6 substrate in different populations was compared with the general population using chi(2) statistics. Data were expressed as a relative risk with a 95% confidence interval. Patients from the general hospital (RR 1.81; 95% CI 1.26 to 2.62), geriatric patients (RR 2.16; 95% CI 1.26 to 2.62), psychogeriatric patients (RR 2.31; 95% CI 1.63 to 3.27), and psychiatric patients (RR 2.44; 95% CI 1.73 to 3.44) were treated more frequently with at least one drug metabolized by CYP2D6 compared with patients in the general population. Approximately 50% of psychiatric (52%), psychogeriatric (49%), and geriatric (46%) patients used at least one drug metabolized by CYP2D6. In total, 416 drugs metabolized by CYP2D6 were prescribed, with 257 (62%) of these classified as an antidepressant (Anatomical and Therapeutic Chemical [ATC] category N06A) or antipsychotic (ATC N05A). Several patient populations (eg, psychiatric, psychogeriatric, geriatric) have a high prevalence of patients treated with at least one drug metabolized by CYP2D6. This study does not provide evidence regarding the clinical evidence of CYP2D6 genotyping, but shows that, if CYP2D6 genotyping is relevant for patient care, the highest probability of cost-effectiveness will, most likely, be in specific populations.