Incremental Cost-effectiveness Ratio Analysis Research Articles

Abstract PO3-01-02: Real world outcomes of neoadjuvant therapy with Trastuzumab and Pertuzumab associated with carboplatin and docetaxel (TCHP) in HER2+ early breast cancer patients unfit for anthracyclines: a retrospective cohort comparative study

Abstract Backgound Neoadjuvant chemotherapy (CT) with anti-HER2 blockade using trastuzumab (H) and pertuzumab (P) is a standard of care for patients (pts) with HER2-positive early-stage Breast Cancer (eBC). Historically, taxanes (T) and anthracyclines (A) have been the mainstays of (neo)adjuvant CT in this setting, but the added benefit of A in the era of anti-HER2 therapy has been questioned. This study aimed to assess the effectiveness, cardiac safety, and cost-effectiveness of an anthracycline-free regimen (TCHP) in a real-world population of pts deemed unfit for A, compared to pts treated with the standard regimen of doxorubicin and cyclophosphamide plus dual-blockade associated with docetaxel (AC-DHP) at a single Portuguese Comprehensive Cancer Center. Methods This retrospective cohort study included a consecutive series of female eBC HER2+ pts who initiated primary treatment with TCHP between July 2018 and August 2022. The primary endpoint was pathological complete response (pCR), and secondary endpoints were cardiac safety and disease-free survival (DFS). The outcomes were compared with a historical database of eBC HER2+ pts who started primary treatment with AC-DHP between August 2015 and May 2021. Clinical data was collected from medical and administrative records. Descriptive statistics were used to describe categorical and continuous variables, and the Kaplan-Meier method was used for DFS analysis. Costs analysis employed the micro-costing technique, considering individual medical direct costs from diagnosis until surgery. Multivariate logistic regression models were used for effectiveness analysis and the gamma general model for costs analysis. The incremental cost-effectiveness ratio (ICER) was calculated using the pCR rate as a measure of effectiveness. Results A total of 233 and 23 pts were included in the TCHP and AC-DHP groups respectively. Reasons for choosing the anthracycline-free regimen in the TCHP group were primarily age-related frailty (52%), medical comorbidities (26%), and previous exposure to anthracyclines (22%). The TCHP pts were older (median age 71 years, range [45-77] vs. 47 years [24-70]) and had lower baseline Left Ventricular Ejection Fractions (LVEF) (median 65% [51-80] vs. 60% [56-73]), with a higher proportion of hormone receptor (HR) negative pts (78.3% vs. 33.0%). Clinical stages were balanced between groups, but the TCHP group had a higher nodal involvement (N+) (73.9% vs. 61.8%). The pCR rates were higher in the TCHP group (65.2% vs. 46.1%, HR 0.98 [95% CI 0.36 - 2.70]). Subgroup analysis by HR status showed comparable pCR rates: 77.1% vs. 74.1% in HR- pts and 40% vs. 39.7% in HR+ pts. Cardiac safety analysis indicated a median decrease in LVEF of 9% in both the TCHP and AC-DHP groups, with 43.5% of TCHP pts experiencing a decline of 10% or more, and 13.0% dropping below 50%. In comparison, these figures were 44.2% and 3.9%, respectively, in the AC-DHP group. At the end of the follow-up, only one patient in the TCHP group with a LVEF < 50% persisted with mild symptoms of chronic heart failure. The median follow-up time for DFS events, starting from surgery, was 31.1 months in the TCHP group and 45.7 months in the AC-DHP group, with 1-year DFS rates of 91.3% and 100%, respectively. The ICER analysis indicated that TCHP was cost-effective, as the incremental cost for achieving an additional pCR in similar subgroups can be outweighed by later cost savings, mainly due to further adjuvant treatment with trastuzumab instead of TDM-1. Conclusions In a real-world population of HER2+ eBC patients unfit for anthracyclines, the TCHP regimen demonstrated a higher overall pCR rate compared to a historical control treated with the AC-DHP regimen, along with an acceptable cardiac safety profile. These results support the broader use of the TCHP regimen in HER2+ eBC pts, as recommended by current NCCN guidelines. However, larger studies involving similar populations are needed to provide higher levels of evidence. Citation Format: Ricardo Pinto, Rita Calisto, Patrícia Redondo, Ana Silva, Pedro Castro, Rute Fernandes, Raquel Teixeira, Diana Mata, Ana Ferreira, Maria Bento, Cláudia Vieira. Real world outcomes of neoadjuvant therapy with Trastuzumab and Pertuzumab associated with carboplatin and docetaxel (TCHP) in HER2+ early breast cancer patients unfit for anthracyclines: a retrospective cohort comparative study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-01-02.

Cost-Effectiveness Analysis of 68Ga-DOTATATE PET/MRI in Radiotherapy Planning in Patients with Intermediate-Risk Meningioma.

While contrast-enhanced MR imaging is the criterion standard in meningioma diagnosis and treatment response assessment, gallium 68Ga-DOTATATE PET/MR imaging has increasingly demonstrated utility in meningioma diagnosis and management. Integrating 68Ga-DOTATATE PET/MR imaging in postsurgical radiation planning reduces the planning target volume and organ-at-risk dose. However, 68Ga-DOTATATE PET/MR imaging is not widely implemented in clinical practice due to higher perceived costs. Our study analyzes the cost-effectiveness of 68Ga-DOTATATE PET/MR imaging for postresection radiation therapy planning in patients with intermediate-risk meningioma. We developed a decision-analytical model based on both recommended guidelines on meningioma management and our institutional experience. Markov models were implemented to estimate quality-adjusted life-years (QALY). Cost-effectiveness analyses with willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were performed from a societal perspective. Sensitivity analyses were conducted to validate the results. Model input values were based on published literature. The cost-effectiveness results demonstrated that 68Ga-DOTATATE PET/MR imaging yields higher QALY (5.47 versus 5.05) at a higher cost ($404,260 versus $395,535) compared with MR imaging alone. The incremental cost-effectiveness ratio analysis determined that 68Ga-DOTATATE PET/MR imaging is cost-effective at a willingness to pay of $50,000/QALY and $100,000/QALY. Furthermore, sensitivity analyses showed that 68Ga-DOTATATE PET/MR imaging is cost-effective at $50,000/QALY ($100,000/QALY) for specificity and sensitivity values above 76% (58%) and 53% (44%), respectively. 68Ga-DOTATATE PET/MR imaging as an adjunct imaging technique is cost-effective in postoperative treatment planning in patients with meningiomas. Most important, the model results show that the sensitivity and specificity cost-effective thresholds of 68Ga-DOTATATE PET/MR imaging could be attained in clinical practice.

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns. We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis. Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness. The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation. Economic/decision analysis II.

Thromboprophylaxis of Patients Submitted to Total Hip and Knee Arthroplasty: A Cost-Effectiveness Assessment From the Perspective of the Brazilian National Health System

ObjectivesVenous thromboembolism (VTE) is a serious national and international public health issue. Major orthopedic surgeries, such as a total hip (THA) and knee (TKA) arthroplasties, are associated with an increased risk of VTE, long-term complications, functional disability, and death resulting from hypercoagulability by surgical trauma. This pharmacoeconomic analysis aimed to identify the most cost-effective anticoagulant alternative in preventing VTE in patients undergoing THA and TKA. MethodsA decision tree model was developed, comparing direct oral anticoagulants (rivaroxaban, apixaban, and dabigatran) with enoxaparin, with separate THA and TKA models a 3-month time horizon from the perspective of the Brazilian National Health System. The results were presented as incremental cost-effectiveness ratio (ICER), and the outcomes analyzed were avoided complications (ACs) after thromboprophylaxis. Comparative effectiveness was obtained from a published meta-analysis. A willingness to pay value of approximately R$ 15 000.00 was used per AC, and a probabilistic sensitivity analysis with the Monte Carlo simulation was conducted. ResultsApixaban was the anticoagulant that presented the best ICER for patients undergoing THA (R$ 207.52/AC) and TKA (R$ 133.59/AC), followed by rivaroxaban (R$ 347.21/AC), dabigatran (R$ 372.56/AC), and enoxaparin (R$ 711.44/AC) for THA and by dabigatran (R$ 194.07/AC), rivaroxaban (R$ 221.12/AC), and enoxaparin (R$ 747.25/AC) for TKA. After ICER analysis, apixaban prevails over the other technologies analyzed for both surgical procedures, confirmed after sensitivity analysis. ConclusionOur model suggests that, in the Brazilian National Health System, apixaban is the most cost-effective alternative in preventing VTE after THA and TKA.

Universal Dental Adhesives: Cost-Effectiveness and Duration of Use

The purpose of this study was to conduct a cost-effectiveness analysis (CEA) of different brands of universal dental adhesives used for composite restorations. Four adhesive brands were included: Single-Bond Universal (SB), Tetric N-Bond Universal VivaPen (TN), OptiBond All-In-One (OB), and G-Premio Bond (GP). Adhesives were applied 5 times daily in a standardized class II cavity onto a plastic tooth. A precision-analysis scale was used to measure all of the following parameters before and after use: adhesive bottle, applicator, dosing plate, and plastic tooth. CEA was done by measuring the amount of material utilized/day, waste/day, efficacy, efficiency, average cost-effectiveness ratio (ACER), and incremental cost-effectiveness ratio (ICER). Data were analyzed using Kruskal–Wallis and Dunn’s tests with Bonferroni correction at 0.05 significance level. CEA tested parameters were significantly different between groups (p < 0.001) except for ICER (p = 0.112). GP was the least effective (median = 0.062), and SB was the least efficient (median = 0.366). The highest and lowest ACER values were associated with TN (median cost ≈ USD 317) and SB (median cost ≈ USD 317), respectively. ICER analysis reported an incremental cost for extra material utilized per milliliter of ≈USD 208 for TN, USD 3.8 for GP, and USD −38 for OB, compared to SB. TN seems to be the most efficient and cost-effective dental adhesive.

Outbreak and control of Foot and Mouth Disease within and across adjacent districts—A mathematical perspective

In this study, we formulate a mathematical model for Foot and Mouth Disease (FMD) within and across two adjacent districts and use it to calculate the impact and cost effectiveness of vaccination and/ or quarantine in controlling this infection. The basic properties of the model are established and reproduction numbers for single district and two adjacent districts obtained. Steady states are examined and found to be both locally and globally stable. The model is transformed into an optimal control problem by incorporating time dependent controls to obtain the best strategy in controlling FMD among the cattle population. From numerical simulations, simultaneous implementation of vaccination with movement restriction is the most effective strategy in control and eventual eradication of FMD from cattle population. Further more, sole implementation of movement restriction across two adjacent and simultaneously infected districts is found to be ineffective in controlling FMD. However, using Incremental Cost Effectiveness Ratio analysis, it was determined that sole implementation of vaccination in both district one and two upon an FMD outbreak is the most cost-effective strategy to control and eventually eradicate FMD.

Pharmacoeconomic Study on the Application of Magnetic Resonance Imaging with Gadoxetic Acid in Addition to Contrast-Enhanced Computed Tomography in Diagnosis of Hepatocellular Carcinoma

Objective: to evaluate pharmacoeconomic advantages of the application of magnetic resonance imaging (MRI) with hepatobiliary-specific contrast agent – gadoxetic acid in addition to contrast-enhanced computed tomography (CT) in the diagnosis of hepatocellular carcinoma (HCC).Material and methods. We performed the modeling and obtained the results of the pharmacoeconomic study: effectiveness analysis, cost analysis, and cost-effectiveness analysis. The cost analysis included only direct medical costs (the cost of contrast-enhanced CT, gadolinium-based contrast agent (GBCA) for MRI, and therapy per a patient with verified HCC diagnosis after diagnostic procedures). The financing was performed from the Compulsary Health Insurance Fund. The calculations were made per 1 patient.Results. The effectiveness analysis showed that the diagnostic scheme CT + MRI with gadoxetic acid was the most effective complex for the diagnosis of HCC because its application provided 50% of patients with 5-year overall survival (4.8 years), which was significantly higher than in patients who were diagnosed HCC with CT + MRI with extracellular GBCA (2.3 years) or CT (3.7 years). The cost-effectiveness analysis showed that the diagnostic scheme with gadoxetic acid was dominant because each disability-adjusted life year required fewer costs (14 862 rubles) in comparison with CT + MRI with extracellular GBCA (25 293 rubles) or CT (46 540 rubles). According to the results of the incremental cost-effectiveness ratio analysis, the application of the diagnostic complex with gadoxetic acid was characterized by the lowest rate of additional costs per 1 disability-adjusted life year.Conclusion. The pharmacoeconomic study showed that the application of MRI with a hepatospecific contrasting agent – gadoxetic acid in addition to contrast-enhanced CT was an effective and economically beneficial method of early HCC diagnosis.

Cost-effectiveness of three different concepts for the rehabilitation of edentulous mandibles: Overdentures with 1 or 2 implant attachments and hybrid prosthesis on four implants.

There are scarce data regarding the combined assessment of the costs and effects of implant treatments for edentulous patients when multiple options are available. This randomised clinical trial aimed to assess the cost-effectiveness of three different concepts for treatment: mandibular overdenture retained by a single (Group I; n=11) or two implants (Group II; n=13) and fixed hybrid prosthesis on four implants (Group III; n=13). Treatment effectiveness was measured as the 1-year before-after changes in patient satisfaction with the mandibular prosthesis. Costs were prospectively quantified from the perspective of the health provider, including all direct cost items attributed to the delivery of treatments and up to the 1-year follow-up, using a "bottom-up" costing estimation method. Patient satisfaction after treatment improved significantly for the three groups. The overall costs were R$ 2370.66, R$ 3185.21 and R$ 5739.52 for Groups I, II and III, respectively (P<.001). Analysis of incremental cost-effectiveness ratios suggested that the overdentures retained by one or two implants were more cost-effective than the fixed implant treatment, considering the mean cost and effectiveness values and the±20% one-way sensitivity analysis. This study suggests that the incremental costs for the fixed hybrid prosthesis, compared to the overdenture treatments, is not proportional to the respective gain in effectiveness. Therefore, although all treatment options had satisfactory outcomes, the use of implants to retain a mandibular overdenture, irrespective of the use of one or two implants, is more cost-effective than the fixed implant treatment for the edentulous mandible.

Pharmacoeconomic analysis of different therapeutic regimens prescribed to ACNE patients coming to out-patient department (OPD) of dermatology, venereology and leprosy in tertiary care hospital of northern India

Background: Acne is a cosmetic disease with long treatment duration and expenditure. Therefore, this study was performed to evaluate pharmaoeconomic analysis of different acne treatment in northern population. Materials and Methods: It was a prospective observational study for a period of nine months. A total of 60 patients suffering from mild to moderate acne were enrolled and randomly divided into three groups of 20 each categorized as treatment A, treatment B and treatment C. The study tool used were case record form, Dermatology Life Quality Index (DLQI), Cardiff Acne Disability Index (CADI). Results: In a total of 60 acne patients, 1:1 ratio of male to female was observed. Maximum number of patients (50%) fell in the age group 21-30 yrs. Improvement in severity of acne was highest in group B. The minimum cost per unit was observed in treatment A group (rupees 73 for 15 gm). Large cost variation was observed in treatment B (rupees 178.15, with a range 76-254.15). The Mean+SD of total cost of therapy for duration of three months was observed to be lowest for treatment B (526.57+223.32). For reduction in GAGS score the Mean+SD of treatment B was found to be the most effective (20.75+4.36). The Mean+SD scores for Average cost effectiveness ratio (ACER), was found to be lowest for treatment B (28.47+19.76). This ACER analysis reflected treatment B as most cost effective. Incremental cost effectiveness ratio (ICER) of treatment A as compared to treatment B was -1.67 while that of treatment C as compared to treatment B was -202.98. This ICER analysis also reflected treatment B as the most cost effective. Mean (DLQI) score and mean CADI score was lowest in treatment group B at third visit. Conclusion: Pharmacoeconomic analysis helps to find disease treatment that is cost economical and equally effective.

Economic evaluation of guideline implementation in primary care: a systematic review.

To review the economic evaluation of the guideline implementation in primary care. Medline and Embase. Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form. Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome. Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.

Effectiveness of a multimodal intervention in functionally impaired older people with type 2 diabetes mellitus.

BackgroundType 2 diabetes, a highly prevalent chronic disease, is associated with increasing frailty and functional decline in older people. We aimed to evaluate the effectiveness of a multimodal intervention on functional performance in frail and pre‐frail participants aged ≥70 years with type 2 diabetes mellitus.MethodsThe MID‐Frail study was a cluster‐randomized multicenter clinical trial conducted in 74 trial sites across seven European countries. The trial recruited 964 participants who were aged >70 years [mean age in intervention group, 78.4 (SD 5.6) years, 49.2% male and 77.6 (SD 5.29) years, 52.4% male in usual care group], with type diabetes mellitus and determined to be frail or pre‐frail using Fried's frailty phenotype. Participants were allocated by trial site to follow either usual care (UCG) or intervention procedures (IG). Intervention group participants received a multimodal intervention composed of (i) an individualized and progressive resistance exercise programme for 16 weeks; (ii) a structured diabetes and nutritional educational programme over seven sessions; and (iii) Investigator‐linked training to ensure optimal diabetes care. Short Physical Performance Battery (SPPB) scores were used to assess change in functional performance at 12 months between the groups. An analysis of the cost‐effectiveness of the intervention was undertaken using the incremental cost‐effectiveness ratio (ICER). Secondary outcomes included mortality, hospitalization, institutionalization, quality of life, burden on caregivers, the frequency and severity of hypoglycaemia episodes, and the cost‐effectiveness of the intervention.ResultsAfter 12 months, IG participants had mean SPPB scores 0.85 points higher than those in the UCG (95% CI, 0.44 to 1.26, P < 0.0001). Dropouts were higher in frail participants and in the intervention group, but significant differences in SPPB between treatment groups remained consistent after sensitivity analysis. Estimates suggest a mean saving following intervention of 428.02 EUR (2016) per patient per year, with ICER analysis indicating a consistent benefit of the described health care intervention over usual care. No statistically significant differences between groups were detected in any of the other secondary outcomes.ConclusionsWe have demonstrated that a 12 month structured multimodal intervention programme across several clinical settings in different European countries leads to a clinically relevant and cost‐effective improvement in the functional status of older frail and pre‐frail participants with type 2 diabetes mellitus.

Cost-effectiveness evaluation of glucosamine for osteoarthritis based on simulation of individual patient data obtained from aggregated data in published studies

BackgroundThe economic evaluation of treatments usually requires access to individual patient data, which is difficult to obtain. Moreover, in osteoarthritis, health utility scores are unavailable and can be assessed only using a validated equation model based on various clinical data. We aimed to develop and validate a methodology to simulate individual health utility scores from aggregated clinical data available in published studies to calculate the cost-effectiveness of different glucosamine preparations (i.e., crystalline glucosamine sulfate, glucosamine sulfate, and glucosamine hydrochloride) used for osteoarthritis.MethodsWe developed a method to simulate individual utility values and validated the model by comparing the results obtained with the simulation and the results of one trial where the utility scores are available. Then, we simulated the utility scores of 10 published trials that used different glucosamine preparations. The utility estimates were used to calculate the quality-adjusted life year (QALY) using the area-under-the-curve method. Costs were for the glucosamine product only. The incremental cost/effectiveness ratio (ICER) was then calculated.ResultsThe values of utility scores calculated from data sources and those simulated with the model were similar. From 10 studies where utility was simulated, four used crystalline glucosamine sulfate, and six used other formulations. The ICER revealed that compared to placebo, crystalline glucosamine sulfate only was cost-effective at all time points and up to 3 years with a median ICER of 5347.2 €/QALY at month 3, 4807.2 €/QALY at month 6 and 11535.5 €/QALY at year 3. The use of other formulations was not cost-effective.ConclusionUsing a new model to simulate individual health utility scores of patients included in ten published trials, ICER analysis showed that the use of crystalline glucosamine sulfate is cost-effective, while other formulations were not. The results confirm the importance of the formulation of glucosamine products.

Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery

Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting. We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception. A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primaryoutcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000. Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy. Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined.

Cost-effectiveness analysis of interventions for prevention of invasive aspergillosis among leukemia patients during hospital construction activities.

Invasive Aspergillosis (IA) is a serious problem among hematological patients and it is associated with high mortality. This situation can worsen at times of hospital construction, however there are several preventive measures available. This work aims to define the cost-effectiveness of some of these interventions. A decision tree model was used, it was divided into four arms according to each 1 of the interventions performed. A cost-effectiveness incremental analysis comparing environmental control measures, high efficiency particulate absorption (HEPA) filter installation and prophylaxis with posaconazole was done. Probabilistic and deterministic sensitivity analyses were also carried out. Among 86 patients with 175 hospitalization episodes, the incidence of IA with environmental protection measures, antifungal prophylaxis and hospitalization in rooms with HEPA filters was 14.4%, 6.3% and 0%, respectively. An Incremental Cost Effectiveness Ratio analysis was performed and it was found that HEPA filtered rooms and environmental protection measures are cost saving interventions when compared with posaconazole prophylaxis (-$2665 vs -$4073 vs $42531 US dollars, respectively) for IA episode prevented. The isolation of inpatients with acute leukemia during hospital construction periods in HEPA filtered rooms could reduce the incidence of IA and might be a cost-effective prevention strategy.

Amino acid formula as a new strategy for diagnosing cow’s milk allergy in infants: is it cost-effective?

Aims: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow’s milk allergy (CMA).Materials and methods: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed.Results: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation.Limitations: In the absence of information in the literature, some premises were defined by a panel of specialists.Conclusions: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

Surgical Management of the Elderly With Traumatic Cervical Spinal Cord Injury: A Cost-Utility Analysis.

Aging of the population has modified the epidemiology of traumatic spinal cord injury (SCI) as evidenced by the establishment of a bimodal distribution of injuries with increased frequency of fall-related injuries among the elderly. To assess the economic impact of older age (65 years of age and older), using a cost-utility analysis, in the context of acute surgical management and rehabilitation of traumatic cervical SCI, given the paucity of economic studies involving elderly individuals with SCI. The cost-utility analysis was performed from the perspective of a public health care insurer. A time horizon of 6 months from SCI onset was used. Costs were estimated in 2014 US dollars. Utilities were generated from the Surgical Timing in Acute Spinal Cord Injury study. The baseline analysis indicated that surgical and rehabilitative management of acute cervical SCI in the elderly (n = 17) is costlier, but similarly effective, than that in younger adults (n = 47). When considering acute spinal surgical management and rehabilitation of younger adults with SCI as the baseline, the incremental cost-effectiveness ratio analysis revealed an additional cost of $5 655 557 per quality-adjusted life-year gained when managing elderly patients with traumatic cervical SCI. The probabilistic analysis confirmed that spinal surgery in the elderly is costlier, but similarly effective, in younger adults after SCI, even though there is no definitive dominance. This economic analysis indicates that surgical management and rehabilitation of acute traumatic cervical SCI in the elderly are costlier but similarly effective compared with younger adults with similar impairment. AIS, ASIA (American Spinal Injury Association) Impairment Scale.

Cost-Utility Analysis of 1- and 2-Level Dorsal Lumbar Fusions With and Without Recombinant Human Bone Morphogenic Protein-2 at 1-Year Follow-Up.

A retrospective 1-year cost-utility analysis. To determine the cost-effectiveness of using recombinant human bone morphogenic protein (rhBMP-2) in addition to autograft for 1- and 2-level lumbar fusions. rhBMP-2 has been studied extensively to identify its benefits, risks, patient outcomes, and costs relative to autograft [local bone or iliac crest bone graft (ICBG)]. This study seeks to analyze the cost-effectiveness of adding rhBMP-2 to autograft versus without rhBMP-2 in lumbar fusions. Thirty-three patients receiving rhBMP-2 in addition to either local bone autograft or ICBG (rhBMP-2 cohort) and 42 patients receiving only local bone autograft or ICBG (control cohort) for 1- or 2-level dorsal lumbar fusion were analyzed. This included posterolateral fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. One-year postoperative health outcomes were assessed based on Visual Analogue Scale, Pain Disability Questionnaire, Patient Health Questionnaire, and EuroQol-5 Dimensions questionnaires. Direct medical costs were estimated using Medicare national payment amounts and indirect costs were based on patient missed work days and patient income. Postoperative 1-year cost-utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness using a threshold of $100,000/QALY gained. The 1-year cost-utility ratio (total cost/ΔQALY) for the control cohort was significantly lower ($143,251/QALY gained) than that of the rhBMP-2 cohort ($272,414/QALY gained) (P<0.01). At 1-year follow-up, the control group dominated the ICER compared with the rhBMP-2 group. Statistically significant and clinically relevant improvements (through minimum clinically important differences) were seen for both cohorts. In the ICER analysis, the control cohort dominated the rhBMP-2 group. Assuming durable per year gains in QALY, by 2 years fusion with autograft but without rhBMP-2 would be considered cost-effective ($71,625/QALY gained), whereas fusion with both autograft and rhBMP-2 would not be cost-effective ($136,207/QALY gained).

Early Versus Delayed Surgical Decompression of Spinal Cord after Traumatic Cervical Spinal Cord Injury: A Cost-Utility Analysis

This cost-utility analysis was undertaken to compare early (≤24 hours since trauma) versus delayed surgical decompression of spinal cord to determine which approach is more cost effective in the management of patients with acute traumatic cervical spinal cord injury (SCI). This study includes the patients enrolled into the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) and admitted at Toronto Western Hospital. Cases were grouped into patients with motor complete SCI and individuals with motor incomplete SCI. A cost-utility analysis was performed for each group of patients by the use of data for the first 6 months after SCI. The perspective of a public health care insurer was adopted. Costs were estimated in 2014 U.S. dollars. Utilities were estimated from the STASCIS. The baseline analysis indicates early spinal decompression is more cost-effective approach compared with the delayed spinal decompression. When we considered the delayed spinal decompression as the baseline strategy, the incremental cost-effectiveness ratio analysis revealed a saving of US$ 58,368,024.12 per quality-adjusted life years gained for patients with complete SCI and a saving of US$ 536,217.33 per quality-adjusted life years gained in patients with incomplete SCI for the early spinal decompression. The probabilistic analysis confirmed the early-decompression strategy as more cost effective than the delayed-decompression approach, even though there is no clearly dominant strategy. The results of this economic analysis suggests that early decompression of spinal cord was more cost effective than delayed surgical decompression in the management of patients with motor complete and incomplete SCI, even though no strategy was clearly dominant.

Cost-effectiveness analysis of oral anti-viral drugs used for treatment of chronic hepatitis B in Turkey.

BackgroundAll international guidelines suggested that Tenofovir and Entecavir are the primary drugs at the first line therapy for the treatment of chronic hepatitis B (CHB). However, in Turkey these medications reimbursed at the second line therapy according to the Healthcare Implementation Notification. The aim of this study is to compare the cost effectiveness of oral antiviral treatment strategies in CHB for Turkey using lamuvidine, telbuvidine, entecavir, and tenofovir as medications.MethodsThe analysis was conducted using Markov models. The analysis scenarios based on first line treatment options with Lamuvidine, Telbuvidine, Entecavir, and Tenofovir as the medications. In the analysis, inadequate response or resistance after receiving 12 months of the treatment with Entecavir and Telbivudine were compared to the results found from switching from Entecavir to Tenofovir or from switching from Telbuvidine to Tenofovir. In additional, inadequate response or resistance after receiving 6 months of the treatment for Lamivudine was compared to the results found from switching from Lamivudine to Tenofovir. The study population included men and women, who were 40 years of age. The patients` compliance was estimated 100 % for all of the therapy options. The model duration was constructed to evaluate, treatment strategy duration of 40 years. The cost of medications, examinations/follow-ups and complications were included in the model. Years of Potential Life Lost was used as the health outcome. An incremental cost-effectiveness ratio analysis has been conducted.Results and discussionWhile the minimum years of life lost was found as 0.22 with tenofovir treatment in 5 years, treatment cost was calculated as 12,169 TL. These values were detected as 0.56 years and 7727 TL, 0.37 years and 12,770 TL, respectively for lamuvidine and telbuvidine treatments. The maximum years of life lost and treatment cost was with lamuvidine treatment were detected as 1.60 years and 18,813 TL and, secondly 0.89 years and 24,007 TL for lamuvidine-tenofovir treatment during 10 years. The minimum years of life lost and cost are 0.54 year and 35,821 TL for tenofovir treatment during 10 years. The minimum years of life lost and cost were determined as 1.21 years and 52,839 TL for tenofovir treatment strategy during 20 years. During 30 years period, tenofovir treatment was found to have the minimum years of life lost (1.73 years) and minimum cost (84,149 TL). When the results of 40 years period were analyzed, years of life lost and costs are 2.06 years and 119,604 TL, 2.13 years and 162,115 TL, 2.13 years and 161,642 TL, 6.52 years and 147,245 TL, 3.20 years and 132,157 TL, 4.10 years and 151,059 TL and 3.05 years and 138,182 TL for tenofovir, entecavir, entecavir-tenofovir, lamuvidine, lamuvidine-tenofovir, telbivudine and telbivudine-tenofovir.ConclusionsIn the model presented in this study, in cost effectiveness analysis about CHB treatments, Tenofovir was found to be one of the cost effective methods in comparison with other treatment strategies different time intervals. Beyond this achievement Tenofovir has shown to reduce cumulative treatment cost in first line CHB treatment when compared with regard to 40 year cumulative treatment cost.

Cost-effectiveness analysis of antiretroviral therapy in a cohort of HIV-infected patients starting first-line highly active antiretroviral therapy during 6 years of observation.

ObjectivesCosts may play a role in deciding how and when to start highly active antiretroviral therapy (HAART) in a naïve patient. The aim of the present study was to assess the cost- effectiveness of treatment with HAART in a large clinical cohort of naïve adults to determine the potential role of single-tablet regimens in the management of patients with human immunodeficiency virus (HIV). An incremental cost-effectiveness ratio analysis was performed, including a quality-adjusted life year approach.ResultsIn total, 741 patients (females comprising 25.5%) were retrospectively included. The mean age was 39 years, the mean CD4 cell count was 266 cells/μL, and the mean viral load was 192,821 copies/mL. The most commonly used backbone was tenofovir + emtricitabine (77.6%); zidovudine + lamivudine was used in 10%, lamivudine + abacavir in 3%, and other nucleoside reverse transcriptase inhibitor (NRTI) or NRTI-free regimens in 9.4% of patients. NNRTIs were used in 52.8% of cases, boosted protease inhibitors in 44.1%, and unboosted protease inhibitors and integrase inhibitors in 0.7% and 2.4%, respectively. Starting therapy at CD4 >500 cells/μL and CD4 351–500 cells/μL rather than at <201 cells/μL was the more cost-effective approach. The same consideration was not true comparing current indications with the possibility to start HAART at any CD4 value (eg, >500 cells per μL); in this case, the incremental cost-effectiveness ratio value was €199,130 per quality-adjusted life year gained, a higher value than the one suggested in guidelines. The single-tablet regimen (STR) invariably dominated any other therapeutic approach. Sensitivity analysis was performed, and starting right away with an STR was cost-effective even when compared with therapeutic strategies contemplating STR as simplification.ConclusionBy integrating clinical data with economic variables, our study offers an estimate of the cost-effectiveness of the various first-line treatment strategies for patients infected with HIV and provides significant evidence to be used in future prospective pharmacoeconomic evaluations.