Higher Quality-adjusted Life Years Research Articles

Cost-effectiveness analysis of anticoagulation options for non-valvular atrial fibrillation in Iran

BackgroundAtrial fibrillation (AF) imposes a substantial economic and clinical burden, particularly in developing countries like Iran. This study aimed to evaluate the cost-effectiveness of anticoagulation options for non-valvular atrial fibrillation (NVAF) in Iran.MethodsWe conducted a cost-effectiveness analysis comparing warfarin, apixaban, dabigatran 110 mg, dabigatran 150 mg, and rivaroxaban for NVAF patients from the Iranian payer’s perspective. A Markov model with a lifetime horizon was used to estimate costs and quality-adjusted life years (QALYs). The model incorporated clinical event rates, case-fatality rates, and utility values. Uncertainty was assessed using deterministic sensitivity analysis and probabilistic sensitivity analysis.ResultsAmong the interventions, warfarin had the lowest cost ($1,755) but apixaban resulted in the highest QALYs (7.33). Apixaban was the most cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $2,026 per QALY gained compared to warfarin. Apixaban dominated other treatments, with lower costs and higher QALYs. Probabilistic sensitivity analysis indicated that at Iran’s willingness-to-pay threshold of $4,387 per QALY gained, apixaban had a high probability of being cost-effective (88.2%).ConclusionOur study provides strong evidence for healthcare decision-makers in Iran, showing that apixaban is a cost-effective treatment for NVAF, potentially enhancing patient outcomes and optimizing healthcare expenditures.

Risk-stratified hepatocellular carcinoma screening according to the degree of obesity and progression to cirrhosis for diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD) in Japan: a cost-effectiveness study.

To evaluate the cost-effectiveness of risk-stratified hepatocellular carcinoma (HCC) screening in diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD). A state-transition model from a healthcare payer perspective on a lifetime horizon. Japan. A hypothetical cohort of 50-year-old diabetic patients with MASLD risk-stratified according to degree of obesity and progression to cirrhosis. Metabolic dysfunction-associated steatotic liver (MASL), metabolic dysfunction-associated steatohepatitis (MASH) and MASH cirrhosis are progressive manifestations of this specific type of liver disease. Abdominal ultrasound (US), US with alpha-fetoprotein (AFP), US with AFP and lectin-reactive alpha-fetoprotein (AFP-L3), CT, extracellular contrast-media-enhanced MRI (ECCM-MRI), gadoxetic acid-enhanced MRI (EOB-MRI) and no screening. Costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), early-stage HCC cases, advanced-stage HCC cases and HCC-related deaths. EOB-MRI is the most cost-effective screening method for non-obese diabetic patients with MASH cirrhosis and for obese diabetic patients with MASH and MASH cirrhosis. Cost-effectiveness was sensitive to HCC incidence in non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH, and the adherence rate of HCC screening in obese diabetic patients with MASH. When the semiannual HCC incidence was between 0.008 and 0.0138 in non-obese diabetic patients with MASH cirrhosis, US with AFP was more cost-effective than EOB-MRI. Cost-effectiveness acceptability curves showed that EOB-MRI was 50.7%, 96.0% and 99.9% cost-effective in obese diabetic patients with MASH and non-obese diabetic patients with MASH cirrhosis, and obese diabetic patients with MASH cirrhosis at a willingness-to-pay level of $50 000 per QALY gained. Compared with no screening in 100 000 non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH cirrhosis, EOB-MRI reduced total costs by US$69 million and by US$142 million, increased lifetime effectiveness by 12 546 QALYs and by 15 815 QALYs, detected 17 873 and 21 014 early-stage HCC cases, and averted 2068 and 2471 HCC-related deaths, respectively. Of all HCC screening methods for diabetic patients with MASH cirrhosis, EOB-MRI yields the greatest cost-saving with the highest QALYs, detects the greatest number of early-stage HCC cases and averts the greatest number of advanced-stage HCC cases and HCC-related deaths. The findings provide important insights for the precise implementation of risk-stratified HCC surveillance to reduce morbidity and mortality and improve the quality of life in diabetic patients with MASLD.

Cost-effectiveness of prophylactic ramosetron in the prevention of postoperative nausea and vomiting.

This study was conducted to assess the cost-effectiveness of prophylactic use of ramosetron compared to no antiemetic medications for the prevention of postoperative nausea and vomiting (PONV) from the healthcare payer and societal perspectives in South Korea. A decision analytic model was constructed to assess the cost-effectiveness of prophylactic ramosetron use versus no antiemetic therapy at 24-hour and 48-hour periods post-surgery over a 5-day duration. The model was populated using costs and utility parameters from published studies as well as from surveys of an expert panel of physicians using structured questionnaires. The cost parameters included the costs of drugs, treatment, patient time, productivity loss, and transportation. Effectiveness was measured using quality adjusted life years (QALYs). The study outcome was the incremental cost-effectiveness ratio (ICER). The parameter uncertainties were addressed using deterministic and probabilistic scenario analyses. The base-case analysis showed that, on average, patients treated with prophylactic ramosetron had lower costs from both the healthcare payer (US$16.88 vs US$17.33) and societal (US$16.89 vs US$18.72) perspectives and higher QALYs (0.0121 vs 0.0114) over the 5-day study duration compared to patients without any antiemetic medications. Deterministic and probabilistic sensitivity analyses were conducted to examine the robustness of results for the parameters included in the model. The acceptability curve probability showed that treating patients with ramosetron compared to no antiemetic medications was more than 99% cost-effective at a willingness-to pay threshold of US$5,000/QALY from both payer and societal perspectives. The results demonstrated that prophylactic use of ramosetron compared to no antiemetic therapy is highly cost-effective to prevent PONV for patients undergoing surgery from both healthcare payer and societal perspectives. The cost effectiveness is the result of the decrease in the incidence of PONV and the direct treatment costs of severe PONV with improved patient quality of life.

Cost-effectiveness of universal esophageal cancer screening for newly diagnosed oral cancer patients.

Oral and esophageal cancers are globally prevalent, especially in East Asia. Over half of head and neck cancer patients developing second primary esophageal cancer (SPEC) were initially diagnosed with oral cavity cancer (OCC). This study assessed the cost-effectiveness of universal endoscopic screening for early SPEC prevention in newly diagnosed OCC patients at different stages. This study employed Markov cohort models to evaluate the cost-effectiveness of endoscopic SPEC screening post-OCC diagnosis (stages 0 to IV) between screened and non-screened groups. Four surveillance frequencies were assessed: (i) one time, (ii) annual for 3years, (iii) annual for 10years, and (iv) annual for life. A hypothetical cohort of 100000 cases across stages was compared for costs and quality-adjusted life-years (QALYs), discounted annually at 3%. All four screening strategies were beneficial for all OCC stages, especially for early-stage patients, resulting in higher QALYs. Lifetime/annual screening from the payer's perspective proved most favorable, with incremental QALYs of 1.23 at stage 0 and 0.06 at stage IV. Incremental costs for this strategy ranged from NTD 121331 (USD 4044) at stage 0 to NTD 13032 (USD 434) at stage IV. Both incremental costs and incremental cost-effectiveness ratio (ICER) values indicated cost savings from a societal perspective. The ICER values ranged from NTD -626440 (USD -20881) at stage 0 and NTD -475021 (USD -15834) at stage IV. Overall, our study provided cost-effectiveness evidences to understanding the cost-effectiveness of endoscopic screening in OCC patients, particularly emphasizing the benefits of early and consistent screening.

Cost-utility analysis and drug pricing of once-weekly insulin icodec versus once-daily insulin degludec for type 2 diabetes patients treated with basal insulin in China.

Insulin icodec is a first once-weekly administration basal insulin analogue for type 2 diabetes. This study aimed to investigate the price range of icodec for type 2 diabetes in the Chinese market, taking insulin degludec as reference. Long-term health outcomes and costs for icodec and degludec were simulated using the United Kingdom Prospective Diabetes Study Outcomes Model (version 2.1) over 40 years from the Chinese healthcare provider's perspective. The efficacy and safety data were obtained from the ONWARDS 2 trial (Switching to once-weekly insulin icodec versus once-daily insulin degludec in individuals with basal insulin-treated type 2 diabetes (ONWARDS 2): a phase 3a, randomised, open label, multicentre, treat-to-target trial). Cost-utility analysis and a binary search were used to investigate the price range of icodec. Sensitivity analyses were performed to verify the robustness of the base-case analysis results. After a 40-year simulation, the quality-adjusted life years (QALY) of icodec and degludec were 10.32 and 10.28 years, respectively. At the initial assumption of the same annual costs of icodec and degludec of $455.40, icodec was the dominant therapy compared with degludec, with higher QALYs and lower total cost. After the binary search, we observed that the annual cost range of icodec was $625.17-$855.25. This cost range was finally adjusted to be $597.66-$736.34 using one-way sensitivity analysis and confirmed using probabilistic sensitivity analysis and scenario analysis. The scenario analysis revealed that the annual cost range of icodec could be $506.70-$736.34 if the price of degludec decreased by 20% in the future. Insulin icodec appears to be more cost effective than degludec if the annual cost of icodec ranges from $597.66 to $736.34 for patients with type 2 diabetes in China.

Cost-Effectiveness of Empagliflozin in Chronic Kidney Disease with or without Albuminuria

Key Points Empagliflozin is cost-effective for the treatment of CKD in patients with an urine albumin-to-creatinine ratio of 30 mg/g or more.Empagliflozin is not cost-effective for the treatment of CKD in patients with an urine albumin-to-creatinine ratio <30 mg/g. Background The Study of Heart and Kidney Protection with Empagliflozin (EMPA-KIDNEY) expanded the CKD population that may benefit from sodium-glucose cotransporter 2 inhibitors in terms of eGFR and urine albumin-to-creatinine ratio. This enables a cost-effectiveness analysis of empagliflozin in subgroups stratified by these two parameters. Methods A cost–utility analysis using the Markov model was performed to evaluate the cost-effectiveness of adding empagliflozin to the standard treatment for CKD in Japan over 20 years of observation. Each cohort with the initial eGFR (≥45 but <60 ml/min per 1.73 m2, ≥30 but <45 ml/min per 1.73 m2, or ≥20 but <30 ml/min per 1.73 m2) and urine albumin-to-creatinine ratio (<30 mg/g, ≥30 but <300 mg/g, or ≥300 mg/g) within the defined ranges was analyzed. The changes in eGFR were determined on the basis of the EMPA-KIDNEY study. An incremental cost-effectiveness ratio of <¥5,000,000 (approximately $35,500) per quality-adjusted life-year (QALY) was considered cost-effective. One-way deterministic analyses, probabilistic sensitivity analyses, and scenario analyses were conducted to ensure the robustness of the results. Results The addition of empagliflozin to the standard treatment was associated with lower costs and higher QALYs in the macroalbuminuria or microalbuminuria cohorts while the incremental cost-effectiveness ratios in the negative albuminuria cohorts were >¥5,000,000 per QALY, regardless of the initial eGFR. The probabilities of empagliflozin being cost-effective were >84% in the macroalbuminuria or microalbuminuria cohorts but <30% in the negative albuminuria cohorts. Scenario analyses where empagliflozin suppressed the eGFR decline in the negative albuminuria cohorts showed that the drug was cost-effective in CKD stage G3b and G4 cohorts. Empagliflozin was not cost-effective in patients with CKD stage G3a and microalbuminuria with the observation period of 10 years. Conclusions In patients meeting the enrollment criteria for the EMPA-KIDNEY trial, the addition of empagliflozin to the standard treatment of CKD was judged as cost-effective for patients with albuminuria but not for those without albuminuria in the Japanese health care system.

Cost-effectiveness of ace inhibitors versus ARBs in heart failure management.

Heart failure is a chronic condition that imposes a significant burden on healthcare systems worldwide. Effective management is crucial for improving patient outcomes and reducing costs. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are widely used to manage heart failure by reducing cardiac strain and preventing disease progression. Despite their common use, ACE inhibitors and ARBs differ in mechanisms, cost, and potential side effects. ACE inhibitors have long been the standard treatment, while ARBs are often prescribed to patients intolerant to ACE inhibitors, particularly due to side effects like cough. Given these differences, evaluating the cost-effectiveness of these treatments is essential. This study compares the cost-effectiveness of ACE inhibitors and ARBs from a healthcare system perspective, considering both direct medical costs and health outcomes. A cost-effectiveness analysis was conducted using a decision-analytic Markov model to simulate heart failure progression in a hypothetical cohort. Data inputs included clinical trial outcomes, real-world effectiveness data, direct medical costs (medications, hospitalizations, monitoring), and utility values for quality of life. The primary outcome measures were the cost per quality-adjusted life year gained and the incremental cost-effectiveness ratio. Sensitivity analyses tested the robustness of results, and subgroup analyses were conducted based on age and disease severity. The base-case analysis showed that ACE inhibitors were associated with lower overall costs and slightly higher quality-adjusted life years than ARBs. Sensitivity analyses revealed that variations in key parameters, such as transition probabilities, mortality rates, and healthcare expenses, had limited impact on the overall cost-effectiveness conclusions. Subgroup analyses indicated that ACE inhibitors and ARBs exhibited similar cost-effectiveness profiles for patients aged <65 and ≥65 years. However, among patients with severe heart failure, ARBs demonstrated a higher incremental cost-effectiveness ratio compared with ACE inhibitors, suggesting reduced cost-effectiveness in this subgroup. ACE inhibitors are likely a more cost-effective option for managing heart failure than ARBs, particularly from a healthcare system perspective. The findings underscore the importance of tailoring treatment decisions to individual patient factors, preferences, and clinical conditions, providing valuable insights for healthcare policy and practice, particularly regarding cost-effectiveness across patient subgroups.

Cost-effectiveness of monitoring ocular hypertension based on a risk prediction tool

Background/AimsTo assess the cost-effectiveness of making treatment decisions for patients with ocular hypertension (OHT) based on a risk prediction (RP) tool in the United Kingdom.MethodsA discrete event simulation model was...

Comparing the effectiveness and cost-effectiveness of alternative type 2 diabetes monitoring intervals in resource limited settings.

Type 2 diabetes (T2D) represents a growing disease burden in South Africa. While glycated haemoglobin (HbA1c) testing is the gold standard for long-term blood glucose management, recommendations for HbA1c monitoring frequency are based on expert opinion. This study investigates the effectiveness and cost-effectiveness of alternative HbA1c monitoring intervals in the management of T2D. A Markov model with three health states (HbA1c <7%, HbA1c ≥ 7%, Dead) was used to estimate lifetime costs and quality-adjusted life years (QALYs) of alternative HbA1c monitoring intervals among patients with T2D, using a provider's perspective and a 3% discount rate. HbA1c monitoring strategies (three-monthly, four-monthly, six-monthly and annual tests) were evaluated with respect to the incremental cost-effectiveness ratio (ICER) assessing each comparator against a less costly, undominated alternative. The scope of costs included the direct medical costs of managing diabetes. Transition probabilities were obtained from routinely collected public sector HbA1c data, while health service utilization and health-related-quality-of-life (HRQoL) data were obtained from a local cluster randomized controlled trial. Other parameters were obtained from published studies. Robustness of findings was evaluated using one-way and probabilistic sensitivity analyses. A South African indicative cost-effectiveness threshold of USD2665 was adopted. Annual and lifetime costs of managing diabetes increased with HbA1c monitoring, while increased monitoring provides higher QALYs and life years. For the overall cohort, the ICER for six-monthly vs annual monitoring was cost-effective (USD23 22.37 per QALY gained), whereas the ICER of moving from six-monthly to three-monthly monitoring was not cost effective (USD6437.79 per QALY gained). The ICER for four-monthly vs six-monthly monitoring was extended dominated. The sensitivity analysis showed that the ICERs were most sensitive to health service utilization rates. While the factors influencing glycaemic control are multifactorial, six-monthly monitoring is potentially cost-effective while more frequent monitoring could further improve patient HrQoL.

Cost-Effectiveness of Varicella Vaccination for 1–4-Year-Olds in Shanghai, China

IntroductionVaricella has not yet been included in the National Immunization Program (NIP) in China, and varicella vaccination strategies vary by region. To determine the optimal varicella vaccination strategy in Shanghai, China, the cost-effectiveness and five-year costs of five immunization scenarios were analyzed. MethodsA static decision tree-Markov model was developed in 2022 to assess the cost-effectiveness and five-year costs of voluntary and routine varicella vaccination programs in the 2019 birth cohort in Shanghai from a societal perspective. Parameters were collected in 2022 from the varicella surveillance system, a questionnaire survey of 414 guardians of patients with childhood varicella, and semi-structured interviews with 20 experts on varicella outbreaks from different institutions in Shanghai. The outcomes included varicella cases avoided, quality-adjusted life year (QALY) loss, and incremental costs per QALY (ICER). The five-year costs were compared with local medical expenditures. ResultsAmong the five scenarios, one dose of routine varicella vaccination was the most cost-saving (USD 70.2) and cost-effective (Dominant) with a five-year immunization expenditure of USD 9.9 million. Two doses of routine varicella vaccination had the highest QALY (29.9), and its ICER (USD 791.9/QALY) was below the willingness-to-pay threshold (USD 5,203-23,767/QALY). The five-year immunization expenditure was USD 19.8 million. The effectiveness and price of vaccines, vaccination coverage, and per capita income are the four main factors that affect ICERs. ConclusionsIn Shanghai, the two doses of routine varicella vaccination strategy for 1- and 4-year-olds with a 95% coverage rate was found to be the optimal varicella immunization strategy.

Cost-utility Analysis of Navigate, a Treatment Decision Aid for Men with Prostate Cancer and Their Partners, in Comparison to Usual Care

Background and objectiveEvidence on the cost effectiveness of decision aids to guide management decisions for men with prostate cancer is limited. We examined the cost utility of the Navigate online decision aid for men with prostate cancer in comparison to usual care (no decision aid). MethodsA Markov model with a 10-yr time horizon was constructed from a government health care perspective. Data from the Navigate trial (n = 302) and relevant published studies were used for model inputs. Incremental costs and quality-adjusted life-years (QALYs) were calculated for the two strategies. One-way and probabilistic sensitivity analyses were undertaken to address model uncertainty. Key findings and limitationsOn average, the Navigate strategy was estimated to cost AU$8899 (95% uncertainty interval [UI] AU$7509–AU$10438) and produce 7.08 QALYs (95% UI 6.73–7.36) in comparison to AU$9559 (95% UI AU$8177–AU$11017) and 7.03 QALYs (95% UI 6.67–7.31) or usual care. The Navigate strategy dominated usual care as it produced cost-savings and higher QALYs, although differences for both outcomes were small over 10 yr. The likelihood of Navigate being cost effective at a conventionally acceptable threshold of AU$50000 per QALY gained was 99.7%. This study is limited by the availability, quality, and choice of the data used in the model. Conclusions and clinical implicationsUse of an online decision aid for men with prostate cancer appears to be cost effective relative to usual care in Australia, driven by the higher acceptance and uptake of active surveillance. Wider implementation of decision aids may better inform men diagnosed with prostate cancer about their management options. Patient summaryWe looked at the cost effectiveness of an online decision aid for guiding Australian men with prostate cancer in choosing a management option. We found that this decision aid was cost effective, mainly because more men chose active surveillance. Decision aids that inform patients about their management options should be more widely used in health care.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management. This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions. This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective. In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00. Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Polypill versus medication monotherapy in the prevention of cardiovascular diseases in Iran: An economic evaluation study.

Cardiovascular diseases (CVDs) are one of the major diseases in developing and developed countries and have high prevalence and mortality rates. Pharmacological interventions, especially the use of combination medications, can have preventive effects in patients with CVDs. Recently, in the PolyIran trial, a combination of atorvastatin, hydrochlorothiazide, aspirin, and valsartan or enalapril (Polypill) was shown to be effective in providing survival benefits as a primary prevention strategy. In the present study, we examine the cost-effectiveness of the use of polypill compared to its individual components (named as medication monotherapy) in the prevention of CVDs in Iran. This was an economic evaluation study conducted to compare the cost-utility of polypill with that of medication monotherapy for 10,000 hypothetical cohorts of people over 35 years of age using the Markov model and with a lifetime horizon. The study perspective was patient perspective and direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio were estimated. To deal with uncertaintysensitivity analyses were used. The results showed that polypill, with the lowest costs (871 USD) and highest QALYs (14.55), had the most cost-utility than medication monotherapy. Also, the results showed that the highest sensitivities were related to the utilities of angina and stroke states. At the 21,768 USD threshold, polypill had a 92% probability of being cost-effective versus other medications. Considering that polypill had the most cost-utility, it is suggested that health system policymakers pay special attention to polypill in designing clinical guidelines. Also, through covering this medication by health insurance organizations, it is possible to complete the country's medicine pharmacopeia in preventing CVDs.

Cost-effectiveness analysis of the pediatric 20-valent pneumococcal conjugate vaccine compared with lower-valent alternatives in Argentina

ObjectivesThe 13-valent pneumococcal conjugate vaccine (PCV13) has been recommended for infants in Argentina’s national immunization program (NIP) in a 2 + 1 schedule since 2012. Licensure of the 15-valent vaccine (PCV15) is anticipated soon, and the 20-valent vaccine (PCV20) recently received regulatory approval. This cost-effectiveness analysis examined the public health and economic implications of transitioning from PCV13 to either PCV15 or PCV20 in Argentina’s pediatric NIP. MethodsA decision-analytic Markov model was used with a 10-year time horizon and a 3.0% annual discount rate for costs and benefits. Vaccine effectiveness estimates were derived from Argentinian surveillance data, PCV13 clinical effectiveness and impact studies, and PCV7 efficacy studies. Population, epidemiologic, and economic inputs were obtained from literature and Argentinian-specific data. The study adopted a healthcare system perspective; sensitivity and scenario analyses were conducted to assess input parameters and structural uncertainty. ResultsCompared with PCV13, PCV20 was estimated to avert an additional 7,378, 42,884, and 172,389 cases of invasive pneumococcal disease (IPD), all-cause pneumonia, and all-cause otitis media (OM), respectively, as well as 3,308 deaths, resulting in savings of United States Dollars (USD) 50,973,962 in direct medical costs. Compared with PCV15, PCV20 was also estimated to have greater benefit, averting an additional 6,140, 35,258, and 142,366 cases of IPD, pneumonia, and OM, respectively, as well as 2,624 deaths, resulting in savings of USD 37,697,868 in direct medical costs. PCV20 was associated with a higher quality-adjusted life year gain and a lower cost (i.e., dominance) versus both PCV13 and PCV15. Results remained robust in sensitivity analyses and scenario assessments. ConclusionOver a 10-year horizon, vaccination with PCV20 was expected to be the dominant, cost-saving strategy versus PCV13 and PCV15 in children in Argentina. Policymakers should consider the PCV20 vaccination strategy to achieve the greatest clinical and economic benefit compared with lower-valent options.

Cost-effectiveness of the RefluxStop device for management of refractory gastroesophageal reflux disease in Switzerland

Background One of the most prevalent conditions in Western societies is gastroesophageal reflux disease (GERD). In Switzerland, the standard treatment for GERD is proton pump inhibitor (PPI)-based medical management, but surgical options such as Nissen fundoplication and magnetic sphincter augmentation (MSA) are available. RefluxStop is a novel device that offers an alternative solution. The purpose of this report is to evaluate the cost-effectiveness of RefluxStop compared to PPIs and existing surgical treatments. Methods A model (Markov) was developed using the Swiss healthcare payer perspective with a lifetime horizon, 1-month cycle length, and a 3% annual discount rate for costs and benefits. Adverse events specific to treatment arms were incorporated, and benefits were measured in quality-adjusted life-years (QALYs). Clinical efficacy data for RefluxStop was obtained from its CE mark study, and comparator treatments were based on published literature. Deterministic and probabilistic sensitivity analyses were used to explore uncertainty. Since there are no head-to-head studies between RefluxStop and PPI therapy, Nissen fundoplication, or MSA, a limitation of this study is the use of naïve, indirect comparison of clinical effectiveness between the studied treatment options. Results Higher QALYs and lower costs were provided by RefluxStop compared to Nissen fundoplication and the MSA system. The incremental cost-effectiveness ratio (ICER) for RefluxStop was CHF 2,116 in comparison to PPI-based medical management. At a cost-effectiveness threshold of CHF 100,000 per QALY gained, the probability of RefluxStop being cost-effective was high, with probabilities of 100%, 97%, and 100% against PPI-based medical management, Nissen fundoplication, and MSA, respectively. The robustness of the analysis was provided by deterministic and probabilistic sensitivity analyses. Conclusion This cost-effectiveness analysis demonstrates that there is a high likelihood of RefluxStop being a cost-effective treatment modality in adults with GERD when compared with other treatment options available in Switzerland.

The Cost-Effectiveness of Computer-Assisted Compared with Conventional Total Knee Arthroplasty: A Payer's Perspective.

Recent evidence showing that computer-assisted total knee arthroplasty (TKA) is associated with better outcomes compared with conventional TKA for patients with end-stage knee osteoarthritis has not been included in economic evaluations of computer-assisted TKA, which are needed to support coverage decisions. This study evaluated the cost-effectiveness of computer-assisted TKA from a payer's perspective, incorporating recent evidence. We compared computer-assisted TKA with conventional TKA with regard to costs (in 2022 U.S. dollars) and quality-adjusted life-years (QALYs) using Markov models for elderly patients (≥65 years of age) and patients who were not elderly (55 to 64 years of age). Costs and QALYs were estimated in the lifetime for elderly patients and in the short term for patients who were not elderly, under a bundled payment program and a Fee-for-Service program. Transition probabilities, costs, and QALYs were retrieved from the literature, a national knee arthroplasty registry, and the National Center for Health Statistics. Threshold and probabilistic sensitivity analyses were conducted to examine the robustness of key estimates used in the base-case analysis. Using projected estimates of TKA utilization, the total cost savings of performing computer-assisted TKA rather than conventional TKA were estimated. Compared with conventional TKA, computer-assisted TKA was associated with higher QALYs and lower costs for both elderly patients and patients who were not elderly, regardless of payment programs, making computer-assisted TKA a favorable treatment option. Widespread adoption of computer-assisted TKA in all U.S. patients would result in an estimated total cost saving of $1 billion for payers. Compared with conventional TKA, computer-assisted TKA reduces costs to payers while providing favorable outcomes. Payers may consider providing additional payment incentives to providers for performing computer-assisted TKA, to achieve outcome improvement and cost control by facilitating widespread adoption of computer-assisted TKA. Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness of romosozumab for the treatment of postmenopausal women with osteoporosis at high risk of fracture in Belgium

SummaryThis study evaluated the cost-effectiveness of sequential treatment with romosozumab-to-alendronate compared to alendronate monotherapy and teriparatide-to-alendronate, in postmenopausal osteoporotic women from a Belgian healthcare perspective. Romosozumab-to-alendronate was found to be cost-effective compared to alendronate monotherapy and dominant compared to teriparatide-to-alendronate for osteoporotic women at high risk of fracture in Belgium.PurposeThis study aimed to evaluate the cost-effectiveness of sequential treatment with romosozumab followed by alendronate compared to alendronate monotherapy and teriparatide followed by alendronate, in postmenopausal osteoporotic women at high risk of fracture, from a Belgian healthcare perspective. Romosozumab is reimbursed in Belgium since December 2021.MethodsA Markov microsimulation model was used to evaluate the cost-effectiveness of romosozumab-to-alendronate compared to alendronate monotherapy and to teriparatide-to-alendronate over a lifetime horizon. Patients transition between five different health states every 6 months based on fracture risks or death. The model was populated with Belgium-specific epidemiological and cost data, where available. The fracture risk reduction of romosozumab treatment was collated from the ARCH study, and from a published network meta-analysis. Costs were included from a healthcare perspective (NIHDI). Cost-effectiveness was reported in terms of costs per quality-adjusted life year (QALY), reported in Euro (€) 2022. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were performed.ResultsRomosozumab-to-alendronate was associated with 0.12 additional QALYs at an additional cost of €2314 compared to alendronate monotherapy, resulting in an ICER of €19,978. Compared to teriparatide-to-alendronate, romosozumab-to-alendronate was found to be dominant, with higher QALYs and lower costs. The base-case results were robust to uncertainty in the input parameters when conducting the sensitivity analysis.ConclusionSequential treatment with romosozumab followed by alendronate was found to be cost-effective compared to alendronate monotherapy and dominant compared to teriparatide followed by alendronate for postmenopausal women with osteoporosis at high risk of fracture in Belgium.

Cost-Effectiveness of CT, CTA, MRI, and Specialized MRI for Evaluation of Patients Presenting to the Emergency Department With Dizziness.

BACKGROUND. Underlying stroke is often misdiagnosed in patients presenting with dizziness. Although such patients are usually ineligible for acute stroke treatment, accurate diagnosis may still improve outcomes through selection of patients for secondary prevention measures. OBJECTIVE. The purpose of our study was to investigate the cost-effectiveness of differing neuroimaging approaches in the evaluation of patients presenting to the emergency department (ED) with dizziness who are not candidates for acute intervention. METHODS. A Markov decision-analytic model was constructed from a health care system perspective for the evaluation of a patient presenting to the ED with dizziness. Four diagnostic strategies were compared: noncontrast head CT, head and neck CTA, conventional brain MRI, and specialized brain MRI (including multiplanar high-resolution DWI). Differing long-term costs and outcomes related to stroke detection and secondary prevention measures were compared. Cost-effectiveness was calculated in terms of lifetime expenditures in 2022 U.S. dollars for each quality-adjusted life year (QALY); deterministic and probabilistic sensitivity analyses were performed. RESULTS. Specialized MRI resulted in the highest QALYs and was the most cost-effective strategy with US$13,477 greater cost and 0.48 greater QALYs compared with noncontrast head CT. Conventional MRI had the next-highest health benefit, although was dominated by extension with incremental cost of US$6757 and 0.25 QALY; CTA was also dominated by extension, with incremental cost of US$3952 for 0.13 QALY. Non-contrast CT alone had the lowest utility among the four imaging choices. In the deterministic sensitivity analyses, specialized MRI remained the most cost-effective strategy. Conventional MRI was more cost-effective than CTA across a wide range of model parameters, with incremental cost-effectiveness remaining less than US$30,000/QALY. Probabilistic sensitivity analysis yielded similar results as found in the base-case analysis, with specialized MRI being more cost-effective than conventional MRI, which in turn was more cost-effective than CTA. CONCLUSION. The use of MRI in patients presenting to the ED with dizziness improves stroke detection and selection for subsequent preventive measures. MRI-based evaluation leads to lower long-term costs and higher cumulative QALYs. CLINICAL IMPACT. MRI, incorporating specialized protocols when available, is the preferred approach for evaluation of patients presenting to the ED with dizziness, to establish a stroke diagnosis and to select patients for secondary prevention measures.

Cost-effectiveness of triplet therapies in metastatic hormone-sensitive prostate cancer used in PEACE-1 and ARASENS.

222 Background: Recent findings from the PEACE-1 and ARASENS trials have demonstrated survival benefits in men with newly diagnosed metastatic hormone-sensitive prostate cancer using different triplet therapies, including Abiraterone and Darolutamide added to Androgen Deprivation Therapy and Docetaxel. Given the rising costs of cancer care, this study aimed to assess the cost-effectiveness of these treatment regimens. Methods: Drug prices were obtained from drugs.com and assurance-maladie.ameli.fr at wholesale prices to evaluate both United States (US) and France payer perspectives. Survival and progression data were sourced from Kaplan-Meier curves of the PEACE-1 and ARASENS trials and fitted to Weibull distribution models in R. The parameters were imported into TreeAge Pro 2023 for partitioned survival analysis. Health states were classified as "Pre-Progression," "Post-Progression," and "Death," each assigned specific health utility values and costs. Outcomes including total costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. Uncertainty was addressed through one-way and probabilistic sensitivity analyses. The baseline willingness-to-pay (WTP) threshold was $100,000 per QALY. Euros were converted to US Dollars. Results: At the baseline WTP of 100,000, generic Abiraterone (US, France) in PEACE-1 and Darolutamide in ARASENS from the French perspective were cost-effective. Generic Abiraterone was dominant, associated with lower net costs (-1,347 to -333) and higher QALYs (0.16) and Darolutamide had an ICER of .7,001 per QALY. In contrast, other triplet therapies increased both net costs and QALYs. Abiraterone yielded ICERs of 408,074 (US) and 114,995 (France) per QALY. Darolutamide in the US had an ICER of $383,732 per QALY. On one-way sensitivity analyses, most drugs would need to be priced at less than ~4,000 a month to be cost-effective at WTP of 100,000 per QALY. On probabilistic sensitivity analyses, with WTP of 100,000 per QALY, generic Abiraterone (US) was the cost-effective drug (88% of simulations), while brand Abiraterone and Darolutamide (US) were the least cost-effective (0% of simulations). Conclusions: Cost-effectiveness of therapies in metastatic hormone-sensitive prostate cancer vary significantly based on pricing and country payer perspective. At a WTP threshold of $100,000, only generic Abiraterone (US, FRA) and Darolutamide (France) were cost-effective. [Table: see text]

COST-EFFECTIVENESS ANALYSIS OF MIRIKIZUMAB VERSUS USTEKINUMAB IN ADVANCED THERAPY EXPERIENCED PATIENTS WITH MODERATELY TO SEVERELY ACTIVE ULCERATIVE COLITIS IN THE US

Abstract BACKGROUND Mirikizumab, an interleukin (IL)-23p19 inhibitor, demonstrated efficacy compared to placebo in clinical trials in adult patients with moderately to severely active ulcerative colitis (UC). Mirikizumab is expected to receive approval from the United States (US) Food and Drug Administration in 2023. Ustekinumab, an IL12/23 antagonist, is the preferred option in advanced therapy (AT; biologics, novel targeted systemics) experienced patients. OBJECTIVES To evaluate the cost effectiveness of mirikizumab compared to ustekinumab in the US among patients diagnosed with moderately to severely active UC who have been previously treated with AT. METHODS A Markov model was developed in MS Excel, comprising an AT layer, a second line (2L) AT layer, a conventional treatment (CT) layer, and a surgery layer. Following initial induction (2-week cycle length), responders transition to maintenance, while non-responders transition to induction in 2L, consisting of a weighted mix of ATs used in clinical practice according to market shares, or CT. During the maintenance phase (12-week cycle length), the AT layers include remission and non-remission response health states; patients who lose response transition to the 2L, CT or surgery layer, comprising surgery and post-surgery health states. Death is possible from all health states, as per US 2020 national life tables. Probabilities for remission, non-remission response at the end of induction, and transition probabilities during maintenance were derived from a network meta-analysis and published literature, as were health state utilities. The analysis from a US payer's perspective over a lifetime horizon considered only direct medical costs in 2023 US dollars (USD). Costs and outcomes were discounted at 3%. Sensitivity analyses were performed; scenario analyses explored the impact of re-induction, dose escalation, and including societal costs. RESULTS Mirikizumab resulted in lower total costs (USD 1,232,582) and more quality-adjusted life-years (QALYs) (10.352) when compared to ustekinumab at standard doses (USD 1,279,620; 10.247 QALYs). Key drivers of cost savings (USD -47,038) and higher QALYs (0.105) for mirikizumab were assumptions on loss of response, the efficacy of mirikizumab at induction and the price of mirikizumab. The probability that mirikizumab is cost-effective at a willingness to pay threshold of USD 100,000 per QALY gained was 74.9%. Adopting an escalated dose for ustekinumab and re-induction for mirikizumab considerably increased savings. CONCLUSIONS The analyses provided insights into the cost-effectiveness of mirikizumab compared to ustekinumab in the US for patients with moderately to severely active UC previously treated with AT. Results demonstrated that adopting mirikizumab can be considered cost-effective compared to ustekinumab, contributing to decision-making in healthcare management.