Incremental Cost Effectiveness Ration Research Articles

Aligning opportunity cost and net benefit criteria: the health shadow price.

Given constrained healthcare budgets and many competing demands, public health decision-making requires comparing the expected cost and health outcomes of alternative strategies and associated adoption and financing actions. Opportunity cost (comparing outcomes from the best alternative use of budgets or actions in decision making) and more recently net benefit criteria (relative valuing of effects at a threshold value less costs) have been key concepts and metrics applied toward making such decisions. In an ideal world, opportunity cost and net benefit criteria should be mutually supportive and consistent. However, that requires a threshold value to align net benefit with opportunity cost assessment. This perspective piece shows that using the health shadow price as the ICER threshold aligns net benefit and opportunity cost criteria for joint adoption and financing actions that arise when reimbursing any new strategy or technology under a constrained budget. For an investment strategy with ICER at the health shadow price Bc = 1/(1/n + 1/d-1/m), net benefit of reimbursing (adopting and financing) that strategy given an incremental cost-effectiveness ration (ICER) of actual displacement, d, in financing, is shown to be equivalent to that of the best alternative actions, the most cost-effective expansion of existing programs (ICER = n) funded by the contraction of the least cost-effective programs (ICER = m). Net benefit is correspondingly positive or negative if it is below or above this threshold. Implications are discussed for creating pathways to optimal public health decision-making with appropriate incentives for efficient displacement as well as for adoption actions and related research.

Cost-utility analysis of hearing aid device for older adults in the community: a delayed start study

BackgroundHearing aids (HA) is the primary medical intervention aimed to reduce hearing handicap. This study assessed the cost-effectiveness of HA for older adults who were volunteered to be screened for hearing loss in a community-based mobile hearing clinic (MHC).MethodsParticipants with (1) at least moderate hearing loss (≥40 dB HL) in at least one ear, (2) no prior usage of HA, (3) no ear related medical complications, and (4) had a Mini-Mental State Examination score ≥ 18 were eligible for this study. Using a delayed-start study design, participants were randomized into the immediate-start (Fitted) group where HA was fitted immediately or the delayed-start (Not Fitted) group where HA fitting was delayed for three months. Cost utility analysis was used to compare the cost-effectiveness of being fitted with HA combined with short-term, aural rehabilitation with the routine care group who were not fitted with HA. Incremental cost effectiveness ration (ICER) was computed. Health Utility Index (HUI-3) was used to measure utility gain, a component required to derive the quality adjusted life years (QALY). Total costs included direct healthcare costs, direct non-healthcare costs and indirect costs (productivity loss of participant and caregiver). Demographic data was collected during the index visit to MHC. Cost and utility data were collected three months after index visit and projected to five years.ResultsThere were 264 participants in the Fitted group and 163 participants in the Not Fitted group. No between-group differences in age, gender, ethnicity, housing type and degree of hearing loss were observed at baseline. At 3 months, HA fitting led to a mean utility increase of 0.12 and an ICER gain of S$42,790/QALY (95% CI: S$32, 793/QALY to S$62,221/QALY). At five years, the ICER was estimated to be at S$11,964/QALY (95% CI: S$8996/QALY to S$17,080/QALY) assuming 70% of the participants continued using the HA. As fewer individuals continued using their fitted HA, the ICER increased.ConclusionsHA fitting can be cost-effective and could improve the quality of life of hearing-impaired older individuals within a brief period of device fitting. Long term cost-effectiveness of HA fitting is dependent on its continued usage.

Cost-effectiveness Analysis of Ankle-Brachial Index Screening in Patients With Coronary Artery Disease to Optimize Medical Management

Currently, screening for peripheral artery disease (PAD) with the ankle-brachial index (ABI) test is not recommended in the general population; however previous studies advocate screening in high risk populations. Although providers may be hesitant to prescribe patients low dose rivaroxaban in patients with coronary artery disease (CAD) we hypothesize that screening patients for PAD may provide additional evidence to prescribe rivaroxaban given the additional benefits of reducing cardiovascular events and death. We sought to describe the cost-effectiveness of screening for PAD in patients with CAD to optimizing medical management of these patients. We used a Markov model to evaluate the ABI test in patients with CAD. We assume that all patients screened would be candidates for low dose rivaroxaban. We assessed the cost of ABI screening at $100 per patient and added additional costs for physician visits ($100) and cost of rivaroxaban ($470). We used a 30-day cycle and performed analysis over 30 years. We evaluated quality-adjusted life-years (QALYs) from previous studies and determined the incremental cost effectiveness ration (ICER) according to our model. We performed sensitivity analysis of variables with uncertainty and report them in a Tornado diagram showing the variables with the greatest effect on the ICER. Our model estimates screening with ABI costs $109,382 compared with $99,607 without screening (difference $9775). The QALYs gained from screening was 0.075 generating an ICER of 130,897/QALY. Factors affecting the ICER was the cost of rivaroxaban and the reduction in cardiovascular events with rivaroxaban (Figure). If rivaroxaban cost less than $100 per 30 days this would reduce the ICER to $31,000/QALY and would make PAD screening with the ABI cost effective. According to our model, screening patients with CAD for PAD to start low dose rivaroxaban is not currently cost effective due to the cost of medication. However, vascular surgeons vascular surgeons have a unique opportunity to prescribe or advocate for low dose rivaroxaban in patients with PAD to help improve cardiovascular outcomes.

Is screening of Staghorn Stones cost-effective?

Staghorn stones can cause damage to the kidneys and are considered as the one of the main cause of renal failure. If they are identified during the initial stages of diagnosis, kidney damage can be prevented. Screening can lead to a better diagnosis. Before the screening, it is necessary to calculate the cost-effectiveness of screening. Using the possibility calculations of staghorn stones in the society and different age groups as well as a decision tree model, the screening costs and effectiveness were calculated against no screening. Effectiveness was determined based on the number of prevented cases of renal failure. Ultimately, the incremental cost-effectiveness ration (ICER) was calculated and compared with the World Health Organization (WHO) method based on the gross domestic product (GDP) per capita and subgroup analysis was done for different age groups. In addition, the robustness of results was examined by sensitivity analysis. The results of decision tree showed that in the screening group, the expected cost was 8815997 USD and the expected effectiveness was 358 and in the no-screening group, the expected cost was 3954214 USD and the expected effectiveness was 258. Based on the results of the study, screening compared with no screening would increase the cost by 4861783 USD and effectiveness would increase by 100 people. The incremental cost-effectiveness ratio (ICER) showed that for each unit of increase in effectiveness of screening compared with no screening, would lead to an increase the cost by 48618 USD. The results also indicated that screening 30-70-year-old people compared with other age groups (20-70 and 25-70) if done every two years, could reduce the mean costs per preventing each case of renal failure.Conclusion: If screening staghorn stones are done every two years for 30-70-year-old individuals, it would be cost effective considering WHO method and 3026 USD could be saved in the health care system per each person.

Maternal depression treatment in HIV (M-DEPTH): Study protocol for a cluster randomized controlled trial.

Introduction:Over one-third of human immunodeficiency virus (HIV)-infected pregnant women are clinically depressed, increasing the risk of mother-to-child transmission (MTCT) of HIV, as well as negative birth and child development outcomes. This study will evaluate the efficacy and cost-effectiveness of an evidence-based stepped care treatment model for perinatal depression (maternal depression treatment in HIV [M-DEPTH]) to improve adherence to prevention of MTCT care among HIV+ women in Uganda.Methods:Eight antenatal care (ANC) clinics in Uganda will be randomized to implement either M-DEPTH (n=4) or usual care (n=4) for perinatal depression among 400 pregnant women (n=50 per clinic) between June 2019 and August 2022. At each site, women who screen positive for potential depression will be enrolled and followed for 18 months post-delivery, assessed in 6-month intervals: baseline, within 1 month of child delivery or pregnancy termination, and months 6, 12, and 18 following delivery. Primary outcomes include adherence to the prevention of mother-to-child transmission (PMTCT) care continuum—including maternal antiretroviral therapy and infant antiretrovial prophylaxis, and maternal virologic suppression; while secondary outcomes will include infant HIV status, post-natal maternal and child health outcomes, and depression treatment uptake and response. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between M-DEPTH and usual care, using 2-tailed tests and an alpha cut-off of P <.05. Using a micro-costing approach, the research team will relate costs to outcomes, examining the incremental cost-effectiveness ration (ICER) of M-DEPTH relative to care as usual.Discussion:This cluster randomized controlled trial will be one of the first to compare the effects of an evidence-based depression care model versus usual care on adherence to each step of the PMTCT care continuum. If determined to be efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics and promoting adherence to PMTCT.Trial Registration:NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

PMS52 - COST-EFFECTIVENESS ANALYSIS OF TELEREHABILITATION FOR POST-ACUTE HIP ARTHROPLASTY: A DECISION MODEL

To assess CEA of TR post-THA compared to standard of care Data Source Peer-reviewed published literature Design A decision model mapping out rehabilitation services each patient that enters will either receive SR or TR. Model assumed a societal perspective taking into account costs of THA, comparing SR services within the post-acute period. Willingness to pay was set to zero. Time horizon: 90 days to capture adverse events within post-acute time frame. Measures Inputs include costs of emergency room, average medication costs, travel costs to outpatient clinic, mortality rate after THA and adherence to physical therapy as prescribed Adherence in this model is a proxy to demonstrate patient preference and therefore utility for the patient Statistical Analysis All analyses were done using the TreeAge 2017 (TreeAge Pro v17.2.1.0 Mac) Initial results based on a one-way sensitivity analysis demonstrates probability of adherence has large effect on outcomes, patient going to ER has the most influence on model outputs. Point estimate or estimated incremental cost effectiveness ration when comparing TR to SR at $14,875 over a 90 day time horizon. This model demonstrates TR has potential to improve patient outcomes and reduce costs by increasing adherence and satisfaction. Value demonstrated with this model focuses on effectiveness or adherence, and as telerehabilitation becomes similar to the more expensive treatment option, then how can we leverage this lower cost of delivery and improve implementation.

Quality of Life and Cost Study of Rheumatoid Arthritis Therapy With Biological Medicines.

Biological medicines are considered as a cornerstone in the therapy of rheumatoid arthritis (RA). They change the course of the disease and improve the quality of life of patients. To this date there has been no study comparing the quality of life of and cost of RA therapy in Bulgaria. This fact is what provoked our interest toward this research. The aim of this study is to analyse the cost and quality of life of patients with RA threated with biological medicines in Bulgaria. This is an observational, real life study of 124 patients treated with biological medicines during 2012–2016 at the University hospital “St. Ivan Riskli” in Sofia, specialized in rheumatology disease therapy. Patients were recruited after their consecutive transfer from non-biological to biological medicines. The yearly pharmacotherapy cost was calculated with tocilizumab (n = 30), cetrolizmab (n = 16), golimumab (n = 22), etanercept (n = 20), adalimumab (n = 20), rituximab (n = 16). Three measurements of the quality of life (QoL) were performed with EQ5D—at the beginning of the therapy, after 6 months and after 1 year of therapy. Both section of EQ5D were used—VAS and EQ5D questionnaire. Cost—effectiveness was calculated for unit of improvement in EQ5D score for a one year period and decision model was built with TreeAgePro software. The observed cost of therapy varied between 12 thousand Euros for tocilizumab to 6 thousand Euros for rituximab. All biological medicines let to substantial increase in the quality of life of the patients. Patients on tocilizumab increased their QoL from 0.43 to 0.63 after 1 year; on cetrolizumab from 0.32 to 0.56; on golimumab from 0.41 to 0.67; on etanercept from 0.45 to 0.62; on adalimumab from 0.43 to 0.57; on rhituximab from 0.46 to 0.66. The cost-effectiveness estimates of different biological therapies also varied between 66 to 30 thousand Euros for unit of improvement in the EQ5D during one the course of the year. Therapy with biological medicines improves statistically significant the quality of life of patients, measured through VAS and EQ5D scales. Despite the improvement in the quality of life all biological medicines appears not to be note cost-effective due to their high incremental cost-effectiveness ration (ICER). Rituximab's incremental ratio has (ICER) falls closer to the three times gross domestic product per capita threshold and should be considered as preferred alternatives for RA therapy. In general we can conclude that the treatment of rheumatoid arthritis with biologicals improves quality of life significantly. Only rituximab was cost-effective.

MA03.06 Cost Effectiveness of Chest Scan Screeing for Lung Cancer in Abestos Occupational Exposure Subjects: A Model Based Study

The National Lung Screening trial (NLST) showed that screening with low-dose computed tomography (CT) compared with chest radiography reduced lung-cancer mortality. There is very few data's on subjects with occupational asbestos exposure. We examined the cost-effectiveness of CT lung cancer screening in a French cohort of asbestos post professional exposure subjects (APEXS cohort). We estimated mean lif-years, costs and incremental cost-effectiveness ration (ICER) for screening with low-dose CT compare to no screening in this population of asbestos exposed subjects. Estimations of life-years gained were based on the efficacy of NLST trial applied to APEXS cohort, adjusted to sex and age. Costs were limited to direct costs, from the payer perspective. We also performed sensitivity analysis based on several assumptions of screening program efficacy. Compared with no screening, screening with low-dose CT, over a period of 2 years, will cost, for 1000 subjects of APEXS cohort 312 645 €, will provide 9.4 additional life-years. The corresponding ICER was 33 102 € per life-gained. Sensitivity analysis showed that this result is sensitive to screening program efficacy (number, stage, and survival diagnosed by the program). ICER of low-dose CT lung cancer program in a cohort of asbestos post occupational exposure population appears as acceptable from the French health system.

Thalidomide Consolidation Post Autologous Stem Cell Transplant (ASCT) For Multiple Myeloma (MM) Is Cost-Effective With Durable Survival Benefit At 5 Years Post Randomisation: Final Analysis Of The ALLG MM6 Study

BackgroundStudies investigating thalidomide consolidation/maintenance strategies post ASCT in patients with MM have consistently demonstrated improvement in duration of myeloma control, however not consistently shown improvements in overall survival. Cost effectiveness of thalidomide in the post-ASCT consolidation/maintenance setting in Australian clinical practice has not been previously established AimTo determine whether progression free survival (PFS) and overall survival (OS) advantages for thalidomide consolidation post ASCT at 3 years post randomisation in the ALLG MM6 study are durable at later follow-up. To compare overall response rate (ORR) to salvage therapy and incidence of second primary malignancy (SPM). To investigate the cost-effectiveness of thalidomide in the post-ASCT consolidation setting. MethodsPhase III, randomised, multi-centre, open label study. 243 newly diagnosed MM patients 6 weeks following a single MEL200 ASCT as part of their first-line therapy were randomly assigned to receive indefinite prednisolone maintenance (50mg alternate days) alone (CA = 129 patients, 1 patient withdrew consent) or in combination with 12 months of thalidomide consolidation (100mg/d increasing to 200mg/d after 2/52) (TA = 114 patients). This was a post hoc analysis, PFS and OS were measured from date of randomization; these endpoints were compared using intention-to-treat analyses. Data for ORR to salvage therapy was collected retrospectively for 96 of 187 relapsed/progressed patients only (TA = 42/81 relapsed, CA = 54/109 relapsed), as was data for SPM (207/238 patients, TA = 104/112, CA = 103/126). All statistical analyses were performed using SPSS version 19.Economic analysis incorporated treatment exposure (primary drug and co-therapies), the use of ongoing medical and diagnostic services, occurrence of SAEs and use of therapies to treat those events, post progression therapy and duration of survival, and was represented as incremental cost per discounted mean life year gained (LYG) – incremental cost effectiveness ration (ICER). All costs and outcomes beyond 12 months were discounted at 5% per annum, and were calculated in Australian dollars. ResultsAfter a median follow-up of 5.4 years post randomization, 2 patients per arm were lost to follow-up (TA = 112, CA = 126). Post randomization estimated 5 year PFS rates were 27% versus 15% (p=0.005; hazard ratio [HR] 0.16: 95% CI 0.044 to 0.582) and OS rates were 66% versus 47% (p=0.007; HR 0.12: 95% CI 0.028 to 0.558) in TA and CA respectively. Thalidomide remained beneficial irrespective of pre-ASCT B2m level <4mg/L (p=0.002) and ≥4mg/L (p=0.049), however TA patients who achieved VGPR/CR post ASCT no longer had a PFS advantage over CA patients who achieved VGPR/CR. Patients required at least 8 months of thalidomide exposure to gain a PFS and OS advantage (p<0.001). Landmark analysis confirmed that PFS/OS benefit was gained within the first 8-12m of therapy. There was no difference in ORR to salvage therapy (62% versus 69%, p=0.5), survival post-progression or incidence of SPM for TA versus CA.Discounted mean LYG for TA patients was 0.92 years (95%CI 0.32 to 1.52), and estimated treatment for TA patients cost $67,911 compared to $42,999 for CA patients, with a resultant incremental cost of $24,912 for TA compared with CA. ICER was $26,996 per mean LYG for TA versus CA. Cost of thalidomide accounted for 56% of the overall incremental cost difference between TA and CA, post-progression therapy 21%, and SAEs contributed the least to estimated difference in costs (3%). ConclusionPFS and OS advantages ascribed to thalidomide consolidation post ASCT remain highly significant at 5 years. At least 8 months of thalidomide exposure was required to attain the PFS/OS benefit. Further recapitulating previous findings, thalidomide did not impact on ORR to salvage therapy or survival following relapse in the context of salvage with alternate novel therapies. Thalidomide consolidation is cost effective in terms of ICER, with cost of thalidomide the key contributor to the cost difference. Disclosures:Spencer:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees.