Increased Life Years Research Articles

Health impact of policies to reduce agriculture-related air pollutants in the UK: The relative contribution of change in PM2.5 exposure and diets to morbidity and mortality

Food systems can negatively impact health outcomes through unhealthy diets and indirectly through ammonia emissions originating from agricultural production, which contribute to air pollution and consequently cardiovascular and respiratory health outcomes. In the UK, ammonia emissions from agriculture have not declined in the same way as other air pollutants in recent years. We applied a novel integrated modelling framework to assess the health impacts from six ammonia reduction scenarios to 2030: two agriculture scenarios – a “Current trends” scenario projecting current mitigation measures to reflect a low ambition future, and “High ambition mitigation” based on measures included in the Climate Change Committee's Balanced Pathway to Net Zero; three dietary scenarios – a “Business as usual” based on past trajectories, “Fiscal” applying 20% tax on meat and dairy and 20% subsidy on fruit and vegetables, and “Innovation” applying a 30% switch to plant-based alternatives; one combination of “High ambition mitigation” and “Innovation”. Compared to “Current trends”, the “High ambition mitigation” scenario would result in a reduction in premature mortality of 13,000, increase life years by 90,000 and reduce incidence of respiratory diseases by 270,000 cases over a 30 year period. Compared to Business as Usual, the dietary scenarios would reduce the number of premature deaths by 65,000 and 550,000–600,000 life years gained over 30 years, with most of the benefits gained by reducing ischemic heart disease (incidence reduction: 190,000). The “High ambition combination” would lead to 67,000 deaths averted, 536,000 incidence reductions and 650,000 life-years gained. For all scenarios, older age groups and those living in lower income households would experience the greatest benefits, because of higher underlying mortality rates or higher levels of risk factors. Our study shows that combining mitigation policies targeting agricultural production systems with diet-related policies would lead to significant reductions in emissions and improvement in health outcomes.

Cost-effectiveness analysis of olaparib maintenance therapy for BRCA mutation ovarian cancer in the public sector in Malaysia.

Ovarian cancer is one of the most common cancer among women in Malaysia. Patients with ovarian cancer are often diagnosed at an advanced stage. Despite initial response to surgery and chemotherapy, most patients will experience a relapse. Olaparib has been reported have promising effects among BRCA mutated ovarian cancer patients. This study aimed to evaluate the cost-effectiveness of olaparib as a maintenance therapy for BRCA ovarian cancer in Malaysia. We developed a four-state partitioned survival model which compared treatment with olaparib versus routine surveillance (RS) from a Malaysian healthcare perspective. Mature overall survival (OS) data from the SOLO-1 study were used and extrapolated using parametric models. Medication costs and healthcare resource usage costs were derived from local inputs and publications. Deterministic and probabilistic sensitivity analyses (PSA) were performed to explore uncertainties. In Malaysia, treating patients with olaparib was found to be more costly compared to RS, with an incremental cost of RM149,858 (USD 33,213). Patients treated with olaparib increased life years by 3.05 years and increased quality adjusted life years (QALY) by 2.76 (9.45 years vs 6.40 years; 7.62 vs 4.86 QALY). This translated to an incremental cost-effectiveness ratio (ICER) of RM 49,159 (USD10,895) per life year gained and RM54,357 (USD 12,047) per QALY gained, respectively. ICERs were most sensitive to time horizon of treatment, discount rate for outcomes, cost of treatment and health state costs, but was above the RM53,770/QALY threshold. The use of olaparib is currently not a cost-effective strategy compared to routine surveillance based upon the current price in Malaysia for people with ovarian cancer with BRCA mutation, despite the improvement in overall survival.

Cost-Effectiveness Analysis of Frontline Treatment with Polatuzumab Vedotin in Diffuse Large B-Cell Lymphoma

Introduction: The POLARIX trial (NCT03274492) recently demonstrated that substituting polatuzumab vedotin (pola), a CD79b-targeted antibody-drug conjugate, for vincristine in standard R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemoimmunotherapy for first-line therapy can prolong progression-free survival in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). However, the medication cost of pola-R-CHP (pola, rituximab, cyclophosphamide, doxorubicin, and prednisolone) regimen is substantially higher than that of R-CHOP treatment. It remains unknown whether the lower rate of treatment failure with pola-R-CHP can be translated into reduced subsequent healthcare costs, increased life years (LYs), and improved quality of life, which may offset the higher medication cost. This study aimed to investigate the cost-effectiveness of substituting pola for vincristine in first-line therapy for patients with newly diagnosed DLBCL from a US payer perspective. Methods: We developed a decision analytic model to project lifetime quality-adjusted life years (QALYs) gained, LYs gained, and direct healthcare costs in newly diagnosed DLBCL patients. The model utilized a hypothetical cohort of patients at 65 years (the median age of disease onset). Direct healthcare costs were adjusted to 2021 US dollars, and an annual rate of 3% was used to discount future costs and benefits. Incremental cost-effectiveness ratios (ICERs) were calculated, and a willingness-to-pay (WTP) threshold of USD 150,000 per QALY gained was used as the acceptable level for determining cost-effectiveness. Sensitivity analyses and scenario analyses were conducted to assess the uncertainty of the base-case scenario and input parameters. Results: Pola-R-CHP, compared to standard R-CHOP, was associated with an incremental cost of USD 90,439, an improvement of 0.89 QALYs and 1.14 LYs, leading to an ICER of USD 101,510/QALY. The model was most sensitive to the survival benefit provided by pola-R-CHP, the age of the patients at initial treatment, and the price of pola. The ICER would increase significantly if pola-R-CHP is ineffective in providing long-term remissions. Furthermore, the ICER value increased as patients were older at the beginning of the treatment. When patients were older than 76.5 years at initial treatment, the ICER would exceed the WTP threshold of USD 150,000/QALY. To make the pola-R-CHP regimen cost-effective in all age groups (up to 80 years old), the current price of pola, which was estimated to be USD 19,307 for 170 mg per treatment cycle, needed to be reduced by 20%. In the probabilistic sensitivity analysis, 48% and 73% of the iterations produced ICERs below WTP thresholds of USD 100,000/ QALY and USD 150,000/ QALY, respectively. Conclusion: Our study findings suggest that pola-R-CHP, compared to the standard R-CHOP regimen, could be a cost-effective strategy in treatment-naïve DLBCL patients aged 65 years from a US payer perspective. However, several noticeable factors that could affect the cost-effectiveness profile of pola-R-CHP therapy should be considered in decision-making. The follow-up period of the POLARIX trial was relatively short, and mature survival data would be required to fully evaluate the value of pola in the treatment of newly diagnosed DLBCL.

Frailty Transitions in Older Persons With Lung Function Impairment: A Population-Based Study.

The aging population and its burden on health care systems warrant early detection of patients at risk of functional decline and mortality. We aimed to assess frailty transitions and its accuracy for mortality prediction in participants with impaired spirometry (Preserved Ratio Impaired Spirometry [PRISm] or chronic obstructive pulmonary disease [COPD]). In participants from the population-based Rotterdam Study (mean age 69.1 ± 8.9 years), we examined whether PRISm (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≥ 70% and FEV1 < 80%) or COPD (FEV1/FVC < 70%) affected frailty transitions (progression/recovery between frailty states [robust, prefrailty, and frailty], lost to follow-up, or death) using age-, sex- and smoking state-adjusted multinomial regression models yielding odds ratios (OR). Second, we assessed the diagnostic accuracy of frailty score for predicting mortality in participants with COPD using c-statistics. Compared to participants with normal spirometry, participants with PRISm were more likely to transit from robust (OR 2.2 [1.2-4.2], p < .05) or prefrailty (OR 2.6 [1.3-5.5], p < .01) toward frailty. Participants with PRISm (OR 0.4 [0.2-0.8], p < .05) and COPD (OR 0.6 [0.4-1.0], NS) were less likely to recover from their frail state, and were more likely to progress from any frailty state toward death (OR between 1.1 and 2.8, p < .01). Accuracy for predicting mortality in participants with COPD significantly improved when adding frailty score to age, sex, and smoking status (90.5 [82.3-89.8] vs 77.9 [67.2-88.6], p < .05). Participants with PRISm or COPD more often developed frailty with poor reversibility. Assessing physical frailty improved risk stratification for participants with impaired spirometry for predicting increased life years.

Breast cancer screening for carriers of ATM, CHEK2, and PALB2 pathogenic variants: A comparative modeling analysis.

10500 Background: Inherited pathogenic variants in ATM, CHEK2, and PALB2 confer moderate to high risks of breast cancer. The optimal approach to screening in these women has not been established. Methods: We used two simulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) and data from the Cancer Risk Estimates Related to Susceptibility consortium (CARRIERS) to project lifetime breast cancer incidence and mortality in ATM, CHEK2, and PALB2 carriers. We simulated screening with annual mammography from ages 40-74 alone and with annual magnetic resonance imaging (MRI) starting at ages 40, 35, 30, and 25. Joint and separate mammography and MRI screening performance was based on published literature. Lifetime outcomes per 1,000 women were reported as means and ranges across both models. Results: Estimated risk of breast cancer by age 80 was 22% (21-23%) for ATM, 28% (26-30%) for CHEK2, and 40% (38-42%) for PALB2. Screening with MRI and mammography reduced breast cancer mortality by 52-60% across variants (Table). Compared to no screening, starting MRI at age 30 increased life years (LY)/1000 women by 501 (478-523) in ATM, 620 (587-652) in CHEK2, and 1,025 (998-1,051) in PALB2. Starting MRI at age 25 versus 30 gained 9-12 LY/1000 women with 517-518 additional false positive screens and 197-198 benign biopsies. Conclusions: For women with ATM, CHEK2, and PALB2 pathogenic variants, breast cancer screening with MRI and mammography halves breast cancer mortality. These mortality benefits are similar to those for MRI screening for BRCA1/2 mutation carriers and should inform practice guidelines.[Table: see text]

THE COVID-19 PANDEMIC AND THE OPIOID CRISIS IN UNITED STATES OF AMERICA

Deaths from drug overdose have been on a&nbsp;stark&nbsp;rise.&nbsp;In 2019,&nbsp;72,000 people died&nbsp;from a drug&nbsp;overdose in the US,&nbsp;a 5% increase&nbsp;since 2018.1&nbsp;In New Jersey&nbsp;alone, the drug overdose-related deaths have increased by 17% in the first half of 2020.2&nbsp; It is speculated that&nbsp;opioid&nbsp;overdose deaths will be the highest&nbsp;this year, a new spike that we had never seen since 2016 when fentanyl came into&nbsp;the&nbsp;market.&nbsp;The&nbsp;pandemic has resulted in a shortage of available clinics, mental health workers,&nbsp;and social services that provided a safety net to the most&nbsp;vulnerable&nbsp;members of our communities. The data&nbsp;among&nbsp;different New Jersey communities show that the&nbsp;black community has been&nbsp;disproportionately&nbsp;affected, highlighting the racial inequalities,&nbsp;especially&nbsp;in our&nbsp;public&nbsp;healthcare system.&nbsp; There are three&nbsp;FDA-approved&nbsp;medications for managing&nbsp;opioid&nbsp;use disorder- methadone, suboxone, and naloxone.&nbsp;Although&nbsp;methadone and suboxone have been shown to reduce the risk of mortality,&nbsp;there is much stigma around using these drugs.&nbsp;Many patients&nbsp;view&nbsp;them as switching to another form of&nbsp;opioid&nbsp;or believe they are “lacking will or strength”&nbsp;if they continue taking these medications.&nbsp;Further complications arise as there are limitations and barriers for doctors allowing only limited or daily prescriptions.&nbsp;&nbsp;For&nbsp;instance,&nbsp;methadone can only be dispensed daily&nbsp;only&nbsp;at&nbsp;a limited number of specialized clinics.&nbsp;For Buprenorphine prescription, doctors require&nbsp;special certification to&nbsp;prescribe&nbsp;the drug, and there are stringent criteria for&nbsp;insurance&nbsp;reimbursement.&nbsp;None of these&nbsp;criteria&nbsp;are evidence-based&nbsp;and limiting access to the patient to these medications.&nbsp;With a rising eviction rate and an increase in homelessness,&nbsp;there is a need for a strong government response to tackle the crisis.&nbsp;&nbsp; &nbsp;The federal government has taken&nbsp;some&nbsp;critical steps allowing&nbsp;dispensing&nbsp;four weeks of these&nbsp;medications&nbsp;to&nbsp;stable patients&nbsp;without a face-to-face&nbsp;evaluation. Steps&nbsp;like this&nbsp;are being welcomed in the public health forums and provide medication access to thousands of&nbsp;patients&nbsp;practicing&nbsp;social isolation&nbsp;due to&nbsp;COVID 19.&nbsp;Another promising initiative&nbsp;was the distribution of free&nbsp;naloxone&nbsp;over&nbsp;selective&nbsp;pharmacies, which helps reverse the effects of an&nbsp;opioid&nbsp;overdose.&nbsp;American Journal of Public Health in 2018 published a study&nbsp;outlining 11&nbsp;policies to&nbsp;mitigate the impact of the&nbsp;opioid&nbsp;epidemic.3 The study found&nbsp;that naloxone&nbsp;distribution, expanding medication-assisted&nbsp;and psychosocial treatment,&nbsp;and&nbsp;promoting needle exchange&nbsp;helped reduce&nbsp;opioid-related deaths and increased life years.&nbsp;The government should implement these steps drastically on an emergency basis and educate the public through electronic and print media.&nbsp;Even though&nbsp;New Jersey has been&nbsp;the first state to offer buprenorphine treatment after reviving from an&nbsp;opioid&nbsp;overdose, there is a need to expand care and overcome barriers to&nbsp;follow-up&nbsp;treatment.4&nbsp;Especial efforts should help the homeless and&nbsp;individuals&nbsp;living in&nbsp;shelters&nbsp;as they receive minimal&nbsp;mental health&nbsp;support.&nbsp;Such policy interventions&nbsp;can help reduce the deaths during the pandemic and help save individuals, families, and&nbsp;the&nbsp;most&nbsp;underprivileged&nbsp;communities.&nbsp;&nbsp;

Evaluating the cost-effectiveness of universal hepatitis B virus vaccination in Iran: a Markov model analysis

ABSTRACT Vaccination is an essential way to prevent the transmission of hepatitis B virus (HBV). Various studies have been published on the cost-effectiveness of HBV vaccination, but since the results vary according to the target population and related health outcomes, this study examined the cost-effectiveness of the universal HBV vaccination in Iran. In this economic evaluation study, a decision tree with the Markov model was used to compare the universal HBV vaccination with a strategy of non-vaccination. Health states used in the model included healthy, chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and death. Analyses were performed from a payer’s perspective. Incremental cost-effectiveness ratio (ICER) per life-year gained, and quality-adjusted life-years (QALYs) gained were calculated at a 5% annual discount rate. The sensitivity analysis was conducted using Monte Carlo simulation. Analyses were performed using Microsoft Excel and TreeAge Pro 2011 software. In 2017, the estimated cost per dose for any HBV vaccine was $3.20 USD. The universal HBV vaccination was economically advantageous compared to non-vaccination, and the estimated cost of this program per life-year and QALY gained were $6,319 and negative (-) $1,183.85 USD, respectively. Given the uncertainty of all parameters, the model remained robust and reliable. In Iran, the universal HBV vaccination strategy for both health outcomes of QALY and life-years gained was cost-effective and advantageous. The vaccination strategy saved money, increased life years and improved quality of life. Therefore, it is recommended that this program continues to be provided.

Social inequalities in mild and severe myocardial infarction: how large is the gap in health expectancies?

BackgroundAcute myocardial infarction (MI) remains a frequent health event and a major contributor to long-term impairments globally. So far, research on social inequalities in MI incidence and mortality with respect to MI severity is limited. Furthermore, evidence is lacking on disparities in the length of life affected by MI. This study investigates social inequalities in MI incidence and mortality as well as in life years free of MI and affected by the consequences of mild or severe MI.MethodsThe study is based on data of a large German statutory health insurance provider covering the years 2008 to 2017 (N = 1,253,083). Income inequalities in MI incidence and mortality risks and in life years with mild or severe MI and without MI were analysed using multistate analyses. The assessment of MI severity is based on diagnosed heart failure causing physical limitations.ResultsDuring the study period a total of 39,832 mild MI, 22,844 severe MI, 276,582 deaths without MI, 15,120 deaths after mild MI and 16,495 deaths after severe MI occurred. Clear inequalities were found in MI incidence and mortality, which were strongest among men and in severe MI incidence. Moreover, substantial inequalities were found in life years free of MI in both genders to the disadvantage of those with low incomes and increased life years after mild MI in men with higher incomes. Life years after severe MI were similar across income groups.ConclusionsSocial inequalities in MI incidence and mortality risks led to clear disparities in the length of life free of MI with men with low incomes being most disadvantaged. Our findings stress the importance of primary and secondary prevention focusing especially on socially disadvantaged groups.

Assessing the Impact of a New Emergency Triage System on Head Injury Mortality: Tikur Anbessa Specialized Hospital Emergency Department in Addis Ababa, Ethiopia

Introduction:One of the improvements in Ethiopia’s emergency medical system was the introduction of a five-level Emergency Triage System (ETS) in January 2015 that was piloted in selected Addis Ababa hospitals.Aim:To assess the effect of this intervention on the head injury mortality in Tikur Anbessa Specialized Hospital (TASH) Emergency Department (ED).Methods:Data were retrospectively collected from all medical records of head injury patients seen in Adult TASH- ED over two 6 months periods, before and after the new Emergency Triage System implementation: 01/04/2014 – 30/09/2014 versus 01/04/2016 – 30/09/2016. An inclusion criterion was age above 13 for the records that could be retrieved. Exclusion criterion was “patient declared dead on arrival.” Mortality and patterns of head injury were compared pre- and post-intervention. Chi-square was used for the analysis using STATA 14.Results:A total of 522 Head injury patients were analyzed in the ED in both the pre- 258 and post-264 intervention study periods. Among head injury admission in the ED in both study periods, the highest number of patients were Road Traffic Accident/RTA/ victims, males and young age (&lt;30). Mortality rate among head injury patients decreased from a pre-intervention 44 (17.05%) to post-intervention 27 (10.2%) (OR=0.55 9. 5% CI (0.32, 0.95), p=0.02). The median age of death was 45 years in pre- and 40 years in the post-intervention period, with ages ranging from 13 to 85 and 13 to 96 years, respectively. The proportion of deaths from moderate head injury decreased significantly from 14.0% in pre-intervention to 6.3% in the post-intervention period, respectively (p&lt;0.001).Discussion:The Emergency Triage System at TASH-ED has decreased mortality caused by head injury. This could increase life years saved and productivity in a cost-effective and easily achievable way in resource-poor settings.

PCN137 - THE ECONOMIC EVALUATION OF IMATINIB COMBINED WITH CHEMOTHERAPY FOR PEDIATRIC PHILADELPHIA CHROMOSOME-POSITIVE ACUTE LYMPHOBLASTIC LEUKEMIA IN CHINA

Pediatric Philadelphia chromosome-positive Acute Lymphoblastic Leukemia (Ph+ ALL) is a very rare disease with poor prognosis. imatinib combined with chemotherapy is currently the first-line treatment. However, Ph+ ALL has long been unlisted as the relevant indication for imatinib in the national healthcare reimbursement system in China. To inform the relevant decision makers, we aimed to evaluate the cost-effectiveness of imatinib combined with conventional chemotherapy (imatinib+CC) as compared to conventional chemotherapy alone (CC) for this neglected and vulnerable population. We first conducted a systematic review to summarize literature evidence on clinical effectiveness and cost-effectiveness of imatinib+CC, and then developed a Markov model based on the best available published data and local expert opinions. From the perspective of the Chinese healthcare system, the model simulated the following health states over a life-time horizon for a hypothetical cohort of newly diagnosed 8-year old Ph+ ALL children: event-free survival, relapsed/resistant disease, cure, and death. A few of tunnel states were also built to reflect the treatment pathway according to the clinical guideline CCLG-ALL 2008 (HR protocol). In the absence of published cost data for Ph+ ALL patients, we sought expert opinions from an ongoing Chinese Childhood Cancer Group ALL-2015 trial consisting of 20 centers nationwide. The base case analysis showed quality-adjusted life-years (QALYs) increased by 1.25 QALYs with imatinib in addition to CC. The resulting mean Incremental Cost-Effectiveness Ratio (ICER) was CNY 32,725/QALY. At a willingness-to-pay threshold of CNY 53,935/QALY according to China’s GDP per capita in 2016, imatinib+CC was considered highly cost-effective. The decision outcomes were robust to the probabilistic and deterministic sensitivity analyses. For children with Ph+ ALL, imatinib+CC was found to be a cost-effective intervention, compared to CC alone. The addition of imatinib is associated with increased life years and increased QALYs at a reasonable incremental cost.

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic.

To estimate health outcomes of policies to mitigate the opioid epidemic. We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic. Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.

Socioeconomic status, non-communicable disease risk factors, and walking speed in older adults: multi-cohort population based study

ObjectiveTo assess the association of low socioeconomic status and risk factors for non-communicable diseases (diabetes, high alcohol intake, high blood pressure, obesity, physical inactivity, smoking) with loss of physical functioning...

Economic evaluation of rituximab in addition to standard of care chemotherapy for adult patients with acute lymphoblastic leukemia

Aims: Acute lymphoblastic leukemia (ALL) is an aggressive form of leukemia with a poor prognosis in adult patients. The addition of the monoclonal antibody rituximab to standard chemotherapy has been shown to improve survival in adults with ALL. However, it is unknown whether the addition of rituximab is cost-effective. The objective was to determine the economic impact of rituximab in addition to standard of care (SOC) chemotherapy vs SOC alone in newly-diagnosed Philadelphia chromosome-negative, CD20-positive, B-cell precursor ALL.Methods: A decision analytic model was constructed, based upon the Canadian healthcare system. It included the following health states over a lifetime horizon (max ≈60 years): event-free survival (EFS), relapsed/resistant disease, cure, and death. SOC was either hyper-CVAD or the Dana Farber Cancer Institute (DFCI) ALL consortium. EFS, overall survival, and serious adverse event (SAE) rates were derived from a large randomized controlled trial. Costs of the model included: first-line treatment and administration, disease management, second-line and third-line treatment and administration, palliative care, and SAE-related treatments. Inputs were sourced from provincial and national public data, the literature, and cancer agency input.Results: Quality-adjusted life-years (QALYs) increased by 2.20 QALYs with rituximab in addition to SOC. The resulting mean Incremental Cost-Effectiveness Ratio (ICER) was C$21,828/QALY. At a willingness-to-pay threshold of C$100,000/QALY, the probability of being cost-effective was 98%. Decision outcomes were robust to the probabilistic and deterministic sensitivity analyses, including the SOC backbone as either hyper-CVAD or DFCI.Limitations: The results of this analysis are limited by generalizability of the chemotherapy backbone to Canadian practice.Conclusions: For adults with ALL, rituximab in addition to SOC was found to be a cost-effective intervention, compared to SOC alone. The addition of rituximab is associated with increased life years and increased QALYs at a reasonable incremental cost.

Expansion or compression of multimorbidity? 10-year development of life years spent in multimorbidity based on health insurance claims data of Lower Saxony, Germany.

Our study examined how life years spent in multimorbidity changed over a period of 10years (2005-2014) and whether morbidity expansion or compression has taken place. There is a little evidence on whether life years gained due to increasing life expectancy are spent in good health, or if they are accompanied by morbidity expansion. The analyses are based on German administrative claims data. Multimorbidity was defined as a combination of at least six chronic conditions and polypharmacy. After having estimated age-standardized prevalence, time trends for life years with and without multimorbidity, and the proportion of life years spent in multimorbidity (morbidity ratio) were estimated. Prevalence proportions of multimorbidity rose continuously. Increasing life expectancies were accompanied by increasing life years with multimorbidity, decreasing multimorbidity-free life years, and by an increasing morbidity ratio. The lifespan spent in multimorbidity was increasing over time. Our findings indicate a growing burden of multimorbidity and an increasing proportion of life years with multiple chronic conditions. It can be concluded that an expansion of morbidity in absolute and in relative terms has occurred. The findings stress the importance of prevention, healthy lifestyles, and improved medical care strategies meeting the specific requirements of patients with multimorbidity.

Cost-effectiveness analysis of ibrutinib in patients with Waldenström macroglobulinemia in Italy

ABSTRACTBackground and Objective: Ibrutinib has recently been approved in Europe for Waldenström Macroglobulinemia (WM) in symptomatic patients who have received at least one prior therapy, or in first-line treatment for patients unsuitable for chemo-immunotherapy. The aim of the study is to estimate the incremental cost-effectiveness ratio (ICER) of ibrutinib in relapse/refractory WM, compared with the Italian current therapeutic pathways (CTP).Methods: A Markov model was adapted for Italy considering the National Health System perspective. Input data from literature as well as global trials were used. The percentage use of therapies, and healthcare resources consumption were estimated according to expert panel advice. Drugs ex-factory prices and national tariffs were used for estimating costs. The model had a 15-year time horizon, with a 3.0% discount rate for both clinical and economic data. Deterministic and probabilistic sensitivity analyses were performed to test the results strength.Results: Ibrutinib resulted in increased Life Years Gained (LYGs) and increased costs compared to CTP, with an ICER of €52,698/LYG. Sensitivity analyses confirmed the results of the BaseCase. Specifically, in the probabilistic analysis, at a willingness to pay threshold of €60,000/LYG ibrutinib was cost-effective in 84% of simulations.Conclusions: Ibrutinib has demonstrated a positive cost-effectiveness profile in Italy.

Health Losses at The End of Life: A Bayesian Mixed Beta Regression Approach

Summary The relationship between aging, health and healthcare expenditures is of central importance to academics and public policy makers. Generally, it is observed that, with advancing age, health deteriorates and healthcare expenditures increase. This seems to imply that increases in life expectancy would strongly increase both the demand for healthcare expenditures and the number of years lived in poor health. Previous research has shown that such straightforward conclusions may be flawed. For example, it has been established that not age but ‘time to death’ is the main driver of increased healthcare expenditures at advanced ages. The paper extends this line of research by investigating the relationship between age, time to death and health, the last being longitudinally measured via a health-related quality-of-life questionnaire. We propose an approach for modelling the health-related quality-of-life outcome that accounts for both the non-standard nature of this response variable (e.g. bounded, left skewed or heteroscedastic) and the panel structure of the data. Analyses were performed within a Bayesian framework. We found that health losses are centred in the final phase of life, which indicates that future increases in longevity will not necessarily increase life years spent in poor health. This may alleviate the consequences of population aging.

Use of PET/CT instead of CT-only when planning for radiation therapy does not notably increase life years lost in children being treated for cancer.

PET/CT may be more helpful than CT alone for radiation therapy planning, but the added risk due to higher doses of ionizing radiation is unknown. To estimate the risk of cancer induction and mortality attributable to the [F-18]2-fluoro-2-deoxyglucose (FDG) PET and CT scans used for radiation therapy planning in children with cancer, and compare to the risks attributable to the cancer treatment. Organ doses and effective doses were estimated for 40 children (2-18years old) who had been scanned using PET/CT as part of radiation therapy planning. The risk of inducing secondary cancer was estimated using the models in BEIR VII. The prognosis of an induced cancer was taken into account and the reduction in life expectancy, in terms of life years lost, was estimated for the diagnostics and compared to the life years lost attributable to the therapy. Multivariate linear regression was performed to find predictors for a high contribution to life years lost from the radiation therapy planning diagnostics. The mean contribution from PET to the effective dose from one PET/CT scan was 24% (range: 7-64%). The average proportion of life years lost attributable to the nuclear medicine dose component from one PET/CT scan was 15% (range: 3-41%). The ratio of life years lost from the radiation therapy planning PET/CT scans and that of the cancer treatment was on average 0.02 (range: 0.01-0.09). Female gender was associated with increased life years lost from the scans (P < 0.001). Using FDG-PET/CT instead of CT only when defining the target volumes for radiation therapy of children with cancer does not notably increase the number of life years lost attributable to diagnostic examinations.

Cost-Effectiveness of Ventricular Assist Device Therapy as a Bridge to Transplantation Compared With Nonbridged Cardiac Recipients

Current available treatment options for advanced heart failure include heart transplantation and ventricular assist device (VAD) therapy. This project aimed to evaluate the cost-effectiveness of a bridge-to-transplantation (BTT)-VAD approach relative to direct heart transplantation in transplant-eligible patients. A Markov model was used to evaluate survival benefits and costs for BTT-VAD versus nonbridged heart transplant recipients. Three different scenarios were considered according to severity of patients' baseline hemodynamic status (high, medium, and low risk). Results are presented in terms of survival, costs, and cost-effectiveness ratio. Sensitivity analyses were used to analyze uncertainty in model estimates. Over a 20-year time horizon, BTT-VAD therapy increased survival at an increased cost relative to nonbridged heart transplant recipients: $100 841more in costs and 1.19 increased life years (LYs) in high-risk patients ($84 964/LY), $112 779 more in costs and 1.14 more LYs ($99 039/LY) in medium-risk patients, and an additional cost of $144 334 and incremental clinical benefit of 1.21 more LYs ($119 574/LY) in low-risk patients. The sensitivity analysis estimated a 59%, 54%, and 43% chance of BTT-VAD therapy being cost-effective for high-, medium-, and low-risk patients at a willingness-to-pay level of $100 000/LY. Subgroup analyses indicated that risk of post-VAD and transplantation complications, waiting time, renal dysfunction, and patient age substantially affected the cost-effectiveness ratio. BTT-VAD therapy is associated with improved survival and increased costs. On the basis of commonly accepted willingness-to-pay thresholds, BTT-VAD therapy is likely to be cost-effective relative to nonbridged heart transplantation in specific circumstances.

Impact and cost-effectiveness of a universal strategy to promote physical activity in primary care: population-based Cohort study and Markov model

BackgroundThis study aimed to estimate the cost-effectiveness of a universal strategy to promote physical activity in primary care.MethodsData were analysed for a cohort of participants from the general practice research database. Empirical estimates informed a Markov model that included five long-term conditions (diabetes, coronary heart disease, stroke, colorectal cancer and depression). Simulations compared an intervention promoting physical activity in healthy adults with standard care. The intervention effect on physical activity was from a meta-analysis of randomised trials. The annual cost of intervention, in the base case, was one family practice consultation per participant year. The primary outcome was net health benefit in quality adjusted life years (QALYs).ResultsA cohort of 262,704 healthy participants entered the model. Intervention was associated with an increase in life years lived free from physical disease. With 5 years intervention the increase was 52 (95 % interval −11 to 115) per 1,000 participants entering the model (probability increased 91.9 %); with 10 years intervention the increase was 102 (42–164) per 1,000 (probability 99.7 %). Net health benefits at a threshold of £30,000 per QALY were 3.2 (−11.1 to 16.9) QALYs per 1,000 participants with 5 years intervention (probability cost-effective 64.7 %) and 5.0 (−9.5 to 19.3) with 10 years intervention (probability cost-effective 72.4 %).ConclusionsA universal strategy to promote physical activity in primary care has the potential to increase life years lived free from physical disease. There is only weak evidence that a universal intervention strategy might prove cost-effective.

Cost-Effectiveness of Ventricular Assist Device Therapy as a Bridge to Transplant in Comparison to Non-Bridged Cardiac Recipients

Purpose The available treatment options for advanced heart failure are heart transplantation (HTx) and ventricular assist device (VAD) therapy. This project aimed to evaluate the cost-effectiveness of bridge to transplant (BTT)-VAD relative to direct to HTx in transplant eligible patients. Methods and Materials A Markov model was used to evaluate survival benefits and costs for BTT-VAD versus unbridged HTx recipients. We divided simulated base cases in three different scenarios according to the severity of patients’ baseline hemodynamic status (high, medium and low risk). Results were presented in terms of survival, costs and cost-effectiveness ratio (CER). We conducted sensitivity analyses to analyze uncertainty in model estimates. Results Over a 20-year time horizon, BTT-VAD therapy increased survival at increased cost relative to non-bridged cardiac transplant recipients: $100,841more and 1.19 increased life years (LY) in high risk patients ($84,964/LY), $112,779 more and 1.14 more life years ($99,039/LY) in medium risk patients BTT-VAD therapy, and an additional cost of $144,334 and incremental clinical benefit of 1.21 more life years ($119,574/LY) in low risk patients. The sensitivity analysis estimated a 59%, 54% and 43% chance of BTT-VAD therapy being cost-effective for high, medium and low risk patients at a willingness to pay of $100,000/LY. Subgroup analyses identified that risk of post-VAD and transplant complications, waiting time, renal dysfunction and patient age substantially affect CER. Conclusions BTT-VAD therapy is associated with improved survival and increased costs. Based on commonly accepted willingness to pay thresholds, BTT-VAD therapy is likely to be cost-effective relative to unbridged HTx in special circumstances.