Insurance Perspective Research Articles

Cost-effectiveness of lung cancer screening with low-dose computed tomography in heavy smokers: a microsimulation modelling study

BackgroundLung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality. The aim of this study was to evaluate the cost-effectiveness of lung cancer screening with LDCT in a high-risk population. MethodsThe study used an adapted microsimulation model in a cohort of Dutch heavy smokers for a lifetime horizon from a health insurance perspective. The main outcomes included average cost-effectiveness ratio (ACER), incremental cost-effectiveness ratio (ICER) and lung cancer mortality reduction. The comparator was no screening. Scenarios with different screening intervals and starting and stopping ages were evaluated for 100,000 male heavy smokers and 100,000 female heavy smokers. A cost-effectiveness threshold of 60 k€ per life year gained (LYG) was assumed acceptable. ResultsThe evaluated screening scenarios yielded ACERs ranging from 17.7 to 32.4 k€/LYG for men and from 17.8 to 32.1 k€/LYG for women. The lung cancer mortality reduction ranged from 9.3% to 16.8% for men and from 7.8% to 13.7% for women. The optimal screening scenario was annual screening from 55 to 80 years for men and biennial screening from 50 to 80 years for women, with an ICER of 51.6 and 45.8 k€ per LYG compared with its previous efficient alternative, respectively. Compared with no screening, the optimal screening scenario yielded an ICER of 27.6 k€/LYG for men and 21.1 k€/LYG for women. The mortality reduction of lung cancer was 15.9% for men and 10.6% for women. ConclusionsLung cancer LDCT screening is cost-effective in a high-risk population. The optimal screening scenario is dependent on sex.

Budget impact analysis for dapagliflozin in type 2 diabetes in Egypt

Introduction: Type 2 diabetes mellitus (T2DM) is a major health problem in Egypt with a high impact on morbidity, mortality, and healthcare resources. This study evaluated the budget impact and the long-term consequences of dapagliflozin versus other conventional medications, as monotherapy, from both the societal and health insurance perspectives in Egypt.Methods: A static budget impact model was developed to estimate the financial consequences of adopting dapagliflozin on the healthcare payer budget. We measured the direct medical costs of dapagliflozin (new scenario) as monotherapy, compared to metformin, insulin, sulphonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinedione, and repaglinide (old scenarios) over a time horizon of 3 years. Myocardial infarction (MI), ischemic stroke, hospitalization for heart failure (HHF), and initiation of renal replacement therapy (RRT) rates were captured from DECLARE TIMI 58 trial. One-way sensitivity analyses were conducted.Results: The budget impact model estimated 2,053,908 patients eligible for treatment with dapagliflozin from a societal perspective and 1,207,698 patients from the health insurance (HI) perspective. The new scenario allows for an initial savings of EGP121 million in the first year, which increased to EGP243 and EGP365 million in the second and third years, respectively. The total cumulative savings from a societal perspective were estimated at EGP731 million. Dapagliflozin allows for savings of EGP71, EGP143, and EGP215 million in the first, second and third years respectively, from the HI perspective, with total cumulative savings of EGP430 million over the 3 years.Conclusion: Treating T2DM patients using dapagliflozin instead of conventional medications, maximizes patients’ benefits and decreases total costs due to drug cost offsets from fewer cardiovascular and renal events. The adoption of dapagliflozin is a budget-saving treatment option, resulting in substantial population-level health gains due to reduced event rate and cost savings from the perspective of the national healthcare system.

Cost-effectiveness of preoperative magnetic resonance imaging to optimize surgery in ductal carcinoma in situ of the breast

PurposeComplete surgical excision is the main factor for successful breast-conserving surgery in patients with ductal carcinoma in situ (DCIS) of the breast. Preoperative magnetic resonance imaging (MRI) may allow surgery optimization in this indication. From an economic standpoint, systematic preoperative MRI is associated with an extra cost, which may be offset by a decrease in the number of re-interventions. We performed an economic evaluation alongside IRCIS randomised controlled trial (NCT01112254) to determine whether systematic preoperative MRI in DCIS is a cost-effective strategy. Methods360 patients were included in IRCIS trial. Costs were assessed from the French national health insurance perspective. Resource use was prospectively collected during a 6-month period after randomisation. We estimated the mean cost per averted re-intervention. ResultsDespite extra costs due to MRI and additional biopsies, difference in total costs between arms was not statistically significant (mean cost of €9980 in MRI arm and €9682 in no MRI arm, cost difference: €298 [CI95% : −470; 1063]). There was a non-significant decrease in the rate of re-hospitalisations for positive or close margins (20% in MRI arm versus 27% in No MRI arm, difference −7% [CI95% : −17; 3]). At a willingness to pay of €500 to avert a re-intervention, the probability that MRI strategy is cost-effective was 93%. ConclusionSystematic preoperative MRI in patients with DCIS of the breast may be a cost-effective strategy. However, the modest clinical benefit associated with such a strategy limits the interest for this procedure in routine practice given the current MRI techniques.

PCN173 HEALTHCARE COSTS OF BREAST CANCER BY MAMMOGRAPHY SCREENING BEHAVIOR AMONG COMMERCIALLY INSURED WOMEN AGED 40-64

Mammography screening saves lives, but the appropriate screening interval for younger women remains controversial. Little is known about the financial burden borne by health plan payers and women with breast cancer. The objective of this study was to estimate the per patient healthcare costs in the initial treatment phase of incident breast cancer associated with different mammography screening intervals, from a large U.S. commercial insurance claims database. From the perspective of insurers and patients, our study provides dollar estimates of healthcare costs from patients with different screening behavior (annual, biennial and none) identified 33 months before cancer diagnosis based on the MarketScan commercial claims database in the years 1999-2014. A generalized linear model was used to adjust for potential confounders. The first-year healthcare costs from insurance payer’s perspective for no screening, annual screening and biennial screening were $168,786, $165,814, and $157,950, respectively. And the out-of-pocket costs paid by patients were $7,101, $6,687, and $6,178. For health plan payers, there are cost savings associated with regular and more frequent screening. For patients, regular screening reduces out-of-pocket costs but the difference under different screening intervals is minimal. While regular mammography screening substantially reduces healthcare costs, the decision of annual versus biennial screening should be based on individual weighing of the benefits and harms.

Successful Strategies to Address Disparities: Insurer and Employer Perspectives.

Disparities in cancer have been documented for decades and continue to persist despite clinical advancements in cancer prevention, detection, and treatment. Disparate cancer outcomes continue to affect many populations in the United States and globally, including racial and ethnic minorities, populations with low income and education, and residents of rural areas or low socioeconomic neighborhoods, among others. Addressing cancer disparities requires approaches that are multilevel. Addressing social determinants of health, such as removing obstacles to health (e.g., poverty, discrimination, access to housing and education, jobs with fair pay, and health care) can reduce cancer disparities. However, to achieve cancer health equity, multilevel approaches are required to ensure that access to high-quality cancer care and equitable receipt of evidence-based services can reduce cancer disparities. Policy, health system interventions, and innovative delivery and health care coverage approaches by private and public payers, employer-based payers, and labor union organizations can assist in ensuring access to and receipt of high-quality cancer care while addressing the high costs of care delivery. Partnerships among patients, caregivers, employers, health care providers, and health care payers can make impactful changes in the way in which cancer care is delivered and, in turn, can assist in reducing cancer disparities.

PIH46 COSTS AND OUTCOMES ASSOCIATED TO POTENTIALLY INAPPROPRIATE DRUG PRESCRIBING DETECTED BY ALGORITHM: PRELIMINARY RESULTS FROM THE MAPT STUDY

Drug prescribing is an essential component in the management of pathologies and functional capacity of older patients. However, some medicines may be dangerous for patients. The potentially inappropriate drug prescribing (PIDP) among older patients represents a significant cause of morbidity. The aim of this study was to compare the clinical characteristics and the healthcare costs of elderly patients according to potentially inappropriate drug prescribing. Analyses were conducted using data from the MAPT (Multidomain Alzheimer Preventive Trial) study. An algorithm was constructed to detect potentially inappropriate drug prescribing and was based on different explicit criteria: the European List of potentially inappropriate medications, the STOPP and START tools version 2, Alert and Mastering of Iatrogenesis indicators (AMI) of the French High Authority for Health (HAS), the market withdrawals and the Summary of Product Characteristics (SPC) for contraindications. We performed the cost analysis from the French national health insurance perspective. The costs are reported as means and bootstrap 95% confidence intervals. At baseline, the algorithm analysed prescriptions from included patients (N=1525 aged 75.3±4.4 years; 64% women (N=978)). Among the included patients, 80.4% had PIDP (N=1226). The patients with PIDP (versus without PIDP) didn’t differ regarding sex, education levels, Fried frailty phenotype, intrinsic capacity domains (cognitive, psychological, locomotion and vitality). The patients with PIDP were slightly older (75.3 vs 74.8, p=0.028), had more prescribed drugs (5.4 vs 2.0, p<0.001), and more comorbidities (p= 0.029) (Charlson index) than those without PIDP. The average healthcare costs per patient over 6 months were 723€ [636€; 831€] for patients with PIDP and 658€ [540€; 788€] for patients without PIDP. Participants did not differ, as a function of PIDP, in terms of functional capacity and frailty, but differed regarding co-morbidities. These results have to be confirmed by a multivariate analysis on longitudinal data.

PND85 OUTPATIENT TRANSIENT ISCHEMIC ATTACK MANAGEMENT : HOW MUCH DO WE SAVE ?

Transient ischemic attack (TIA) is an excellent opportunity to prevent stroke. Thus, urgent management of TIA in a specialized center is associated with a reduction from 50 to 80% of recurrence risk. The aim of this study was to determine the hospital costs saving impact of an outpatient TIA Clinic located at Toulouse University Hospital (TUH) in south of France. This study was conducted from the French Healthcare insurance perspective. This is a retrospective analysis from the diagnosis related group (DRG) data base before (Phase I) and after (Phase II) the opening of an outpatient TIA Clinic Unit in TUH. All patients with TIA who were admitted in 2008 (Phase I) or in 2015 (Phase II) in TUH Neurovascular unit were included. Unit costs for DRG were based on reference prices from the French Healthcare insurance boards and tariffs. 549 hospital stays were analyzed in 2008 and 535 in 2015. Outpatient management (hospitalization duration<24hours) increased in phase II as compared to phase I (34%, n=180) vs 12%, n=68) (P<0,005) and was associated with a reduction of 1,64 days of lenght of stay per patient.Total costs for TIA care, whether in outpatient or patient facilities, decreased from1 511 186€ (2 223 107$) (phase I) to 896 767€ (989 223$) (phase II) corresponding to a 614 419€ (1 233 884$) saving as total and 1 148€ (2306$) saving per patient.Average costs per stay decreased from 2 753€ (3 276$) in Phase I to 1 676€ (1 973$) in phase II. This first study in french context corroborates English and Dutch studies and shows that TIA Clinic model is associated with a cost reduction, which is of particular interest in the current context of expanding health expenses.

PND44 EVALUATION OF THE EFFICIENCY OF FOUR PREVENTION STRATEGIES IN ALZHEIMER'S DISEASE: RESULTS FROM THE MULTIDOMAIN ALZHEIMER PREVENTIVE TRIAL (MAPT) STUDY

According to the WHO, Alzheimer Disease represents approximately 50 million of demented people with a societal cost estimated to US$ 818 billion worldwide. Nevertheless, no curative treatment is available putting forward the need to develop prevention strategies. Current evidences suggest that nutrition, physical exercise, cognitive activity and social stimulation may improve cognitive health. We aim to assess the efficiency of an isolated supplementation with omega-3 fatty acid (OMG3), an isolated multidomain intervention (IM) (nutritional counseling, physical exercise, cognitive stimulation) or both interventions together (OMG3+IM) on the change of cognitive functions in comparison with a placebo. We have used data from the Multidomain Alzheimer Preventive Trial (MAPT) study, which focus on change in memory function, through a composite score combining four cognitive tests, after 3 years of follow-up of frail subjects aged 70 years and older in France. Effectiveness used was the per-10 percent of no aggravation in memory function. Health insurance perspective was taken into account and direct costs were included in the analysis. Incremental Cost Effectiveness Ratio (ICER) and its 95% confident ellipse were implemented for each strategy in comparison with placebo. Analyses were carried out on 1525 patients. Per 10 percent of no aggravation at 3 years were respectively 2.92, 2.47, 3.18 and 2.99 for placebo, OMG3, IM and OMG3+IM strategy. Mean costs per patients at 3 years were respectively €5,508; €6,404; €6,164; €7,299 for placebo, OMG3, IM and OMG3 + IM strategies. The OMG3 strategy was dominated while ICER for IM and OMG3+IM were estimated to €2,538 and €24,341 per 10% of no aggravation respectively compared to the placebo. Conclusions do not change according to deterministic and probabilistic sensitive analyses. According to ICERs and confident ellipses the IM strategy were assessed as the most efficient intervention.

Budgetary impact from multiple perspectives of sustained antitobacco national media campaigns to reduce the harms of cigarette smoking

BackgroundHigh-intensity antitobacco media campaigns are a proven strategy to reduce the harms of cigarette smoking. While buy-in from multiple stakeholders is needed to launch meaningful health policy, the budgetary impact...

Costs of patients with chronic kidney disease in Germany.

BackgroundThis study aimed to determine the costs and distribution of healthcare spending of patients with chronic kidney disease (CKD) at stages 3 and 4 and on dialysis both at the individual and population level in Germany.MethodsThe study took the perspective of the German statutory health insurance (SHI) system and analyzed claims data on 3,687,015 insurees from the year 2014. To extrapolate costs to the whole SHI population, a literature search on the prevalence of CKD was conducted.ResultsAverage costs per person per year in an age- and gender-matched control group of the normal population were €2,876 (95% confidence interval [CI], €2,798 to €2,955) and ≥2.8-fold higher in CKD patients (€8,030 [95% CI, €7,848 to €8,212] at CKD stage 3, €9,760 [95% CI, €9,266 to €10,255] at CKD stage 4, and €44,374 [95% CI, €43,608 to €45,139] on dialysis). At CKD stages 3 and 4 the major cost driver was hospitalizations, contributing to more than 50% of total expenditures. Among dialysis patients, hospitalizations and dialysis-treatment costs contributed to 23% and 53% of total healthcare spending, respectively. At CKD stages 3 and 4, patients with the highest 20% of healthcare spending showed a considerable increase in per-patient costs over the reference population, while the bottom 80% of patients generated only moderately higher per-patient costs (p < 0.001). Comparing total CKD costs to total SHI expenditures yields that 10.2% of SHI expenditures was driven by patients at CKD stages 3 and 4 and 1.6% by dialysis patients.ConclusionsHealthcare spending of patients with CKD at stages 3 and 4 and on dialysis is concentrated among a small number of high-need patients. As hospitalizations and dialysis treatment are key drivers of total expenditures, strategies that lead to a reduction in hospitalizations, delay in dialysis onset, or increase in the availability of kidney donors should become important considerations by policymakers.

Lifetime cost of unilateral cochlear implants in adults: a Monte Carlo simulation.

Due to increasing prevalence of hearing loss and relaxation of candidacy criteria of cochlear implant (CI) supply, the number of implantations is likely to further increase. Statutory health insurances are facing ever more urgent financing challenges since CI treatment causes high life-long costs. Additionally, increasing life expectancy and earlier implantation may extend therapy time and cost. With every case being individual, this study aims to calculate the possible lifetime cost of unilateral CI treatment in adults including stochastic uncertainties. Taking a statutory health insurance perspective, relevant cost components of CI therapy and their values were identified. The Monte Carlo method was used to simulate lifetime cost considering age at first implantation and distributions of costrelevant variables. A sensitivity analysis was conducted to determine the most crucial variables impacting on lifetime cost. Lifetime cost of CI treatment varies according to age at first implantation, respectively remaining lifetime; the earlier the implantation, the higher the overall cost. According to our simulation, the average lifetime cost for an adult patient first implanted between the age of 20-80 is at 53,030 € (present value). Cost of implantation and periodic speech processor exchanges show the highest impact on the total cost. Health care systems could face rising expenses for CI supply by technical development. Innovative life-long CIs could achieve significant savings per case that could finance additional implant cost. Until then, further targeted research will be required. CI-related cost for statutory health insurance crucially depends on the patient-side demand for cochlear implants. Therefore, cost forecasts must also consider the development of demand.

Comparative cost-effectiveness of cabozantinib as second-line therapy for patients with advanced hepatocellular carcinoma in Germany and the United States

BackgroundCabozantinib was approved by the European Medicines Agency and the Federal Drug Administration as an option for sorafenib-resistant advanced hepatocellular carcinoma, increasing overall survival and progression-free survival compared with placebo. We evaluated the cost-effectiveness of cabozantinib in the second-line setting for patients with an advanced hepatocellular carcinoma from the German statutory health insurance perspective compared with an US scenario using US prices.MethodsA Markov model was developed to compare the costs and effectiveness of cabozantinib with best supportive care in the second-line treatment of advanced hepatocellular carcinoma over a lifetime horizon. Health outcomes were measured in discounted life years and discounted quality-adjusted life years. Survival probabilities were estimated using parametric survival distributions based on CELESTIAL trial data. Utilities were derived from the literature. Costs contained drugs, monitoring and adverse events measured in US Dollars. Model robustness was addressed in univariable, scenario and probabilistic sensitivity analyses.ResultsCabozantinib generated a gain of 0.18 life years (0.15 quality-adjusted life years) compared with best supportive care. The total mean cost per patient was $56,621 for cabozantinib and $2064 for best supportive care in the German model resulting in incremental cost-effectiveness ratios for cabozantinib of $306,778/life year and $375,470/quality-adjusted life year. Using US prices generated costs of $177,496 for cabozantinib and $4630 for best supportive care and incremental cost-effectiveness ratios of $972,049/life year and $1,189,706/quality-adjusted life year.ConclusionsOur analysis established that assuming a willingness-to-pay threshold of $163,371/life year (quality-adjusted life year) for the German model and $188,559/life year (quality-adjusted life year) for the US model, cabozantinib is not cost-effective compared with best supportive care. Sensitivity analyses showed that cabozantinib was not cost-effective in almost all our scenarios.

Identification of Patient Profiles with High Risk of Hospital Re-Admissions for Acute COPD Exacerbations (AECOPD) in France Using a Machine Learning Model.

PurposeTo characterise patients with chronic obstructive pulmonary disease (COPD) who are rehospitalised for an acute exacerbation, to estimate the cost of these hospitalisations, to characterise high risk patient sub groups and to identify factors potentially associated with the risk of rehospitalisation.Patients and MethodsThis was a retrospective study using the French National Hospital Discharge Database. All patients aged ≥40 years hospitalised for an acute exacerbation of COPD between 2015 and 2016 were identified and followed for six months. Patients with at least one rehospitalisation for acute exacerbation of COPD constituted the rehospitalisation analysis population. A machine learning model was built to study the factors associated with the risk of rehospitalisation using decision tree analysis. A direct cost analysis was performed from the perspective of national health insurance.ResultsA total of 143,006 eligible patients were hospitalised for an acute exacerbation of COPD (AECOPD) in 2015–2016 (mean age: 74 years; 62.1% men). 25,090 (18.8%) were rehospitalised for another exacerbation within six months. In this study, 8.5% of patients died during or immediately following the index hospitalisation and 10.5% died during or immediately after rehospitalisation (p <0.001). The specific cost of these rehospitalisations was € 5304. The overall total cost per patient of all AECOPD-related stays was € 9623, being significantly higher in patients who were rehospitalised (€ 16,275) compared to those who were not (€ 8208). In decision tree analysis, the most important driver of rehospitalisation was hospitalisation in the previous two years (contributing 85% of the information).ConclusionRehospitalisations for acute exacerbations of COPD carry a high epidemiological and economic burden. Since hospitalisation for an acute exacerbation is the most important determinant of future rehospitalisations, management of COPD needs to focus on interventions aimed at decreasing the rehospitalisation risk of in order to lower the burden of disease.

Development, present status and performance analysis of agriculture insurance schemes in India

PurposeAgriculture insurance is the panacea for the farming community. Many policy interventions were implemented for stimulating agriculture insurance access to farmers in India. However, access to agriculture insurance constantly remained one of the major challenges to Indian policy planners. The goal of the present paper is to explore current policy interventions in the area of agriculture insurance in India.Design/methodology/approachThe present paper reviews and analyzes the evidence literature through a content analysis method on development and performance analysis perspective of existing agriculture insurance schemes in India.FindingsAgriculture insurance is a significant risk management policy, but this is not easily reachable to the majority of farmers in India. The government of India introduces a novel agriculture scheme every decade, but every crop insurance scheme was inconsistent and ineffective owing to operational defects. Agriculture insurance in India is still developing in terms of coverage, scope, and exposure, but farmers' dissatisfaction about agriculture insurance turned out to be a negative word of mouth. Insurance illiteracy and farmers' preference for agriculture relief payments are the main reasons for limited access to agriculture insurance. The current crop insurance schemes are improperly operated because of implementation issues at the state level.Research limitations/implicationsThis paper will be useful for researchers and academicians to analyze the past and present status of crop insurance in India.Originality/valueThe paper is the unique work of the authors as it has attempted to present India's journey with agriculture insurance. An effort is made in the present study to provide a comprehensive and holistic developmental and performance analysis perspective of agriculture insurance in India.

Cost analysis of inpatient versus outpatient intravenous antibiotic treatment for periprosthetic joint infections : A simulation

HintergrundDie parenterale Antibiotikagabe im Rahmen der Therapie von periprothetischen Infektionen erfordert in der Regel eine stationäre Behandlung und geht mit hohen Kosten einher.FragestellungEs wurden tatsächliche stationäre Behandlungskosten („inpatient parenteral antibiotic therapy“ [IPAT]) mit simulierten Kosten einer ambulanten Behandlung („outpatient parenteral antibiotic therapy“ [OPAT]) von Patienten mit periprothetischen Gelenkinfektionen verglichen. Die Auswertung erfolgte aus Perspektive der Kostenträger (gesetzliche Krankenversicherung [GKV]) und Leistungserbringer (Krankenhäuser).Material und MethodenDie Analyse und Simulation erfolgten auf Grundlage einer ICD-10 (Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision) für das Behandlungsjahr 2015 mit der Diagnose T84.ErgebnisseDie simulierte Reduktion von 159 Bettentagen bei den in die Studie eingeschlossenen 12 Patienten erbrachte aus Sicht der Kostenträger eine Reduktion der Gesamtkosten um >18.000 €. Aus Perspektive der Leistungserbringer verbesserte sich der Reinerlös um >22.000 €. Die Gesamtkosten der OPAT für den Kostenträger beliefen sich auf >57.000 €. Für den Leistungserbringer zeigte sich in der Differenz von Poliklinikerlös und -kosten der OPAT ein Verlust von >1500 €.DiskussionDie OPAT ist für Leistungserbringer insgesamt finanziell vorteilhaft. Weitere Vorteile durch Opportunitätskosten erscheinen interessant. Für den Kostenträger ist die OPAT insbesondere durch die ambulanten Medikamentenkosten mit einem finanziellen Mehraufwand verbunden. Der niedergelassene Sektor sollte durch die anzunehmende Mehrbelastung ebenso wie der anzunehmende Patientenkomfort bedacht werden.

Abstract P2-14-10: Prosigna® test in clinical routine: Impact on adjuvant chemotherapy decision and medico-economic considerations in France

Abstract The Prosigna® test has been performed in Institut Curie, France, since 2016 in clinical routine with a financial support of the health ministry dedicated to innovative procedures. The genomic platform at the Institut Curie performs the Prosigna® test for patients cared for at the Curie Hospital and in other institutions. Our main objective was to evaluate the impact of Prosigna® tests on adjuvant chemotherapy decisions. The second objective was to assess the costs associated with implementation of the test for patient management. Methods: Early breast cancer patients with estrogen receptor positive and human epidermal growth factor receptor 2-negative tumors, who had a Prosigna® test in clinical routine, were prospectively registered and observed. The Prosigna® test was indicated for a population candidate for a chemotherapy, with an intermediate risk of recurrence defined by our regional guidelines (1): grade 1 T1cN1, grade 1 T2N0-1, grade 2 T1cN0 with risk factors (Ki67&amp;gt;20% or lympho-vascular emboli), grade 2 T2N0, grade 3 T1cN0. The French Health Authority (FHA) has also recently defined the population who are candidates for genomic testing: T1c/T2 and N0/N1(mic) and grade 2 without risk factors (age&amp;lt;40, lympho-vascular emboli, T2; association of at least 2 criteria). To evaluate the decision impact of Prosigna® test, we compared the number patients recommended for chemotherapy before and after the test, in both the full real-life population and in the population defined by FHA. To evaluate costs, we compared the use of the test and the direct medical and non-medical costs of chemotherapy avoidance after tests results. All costs were considered at a National Health Insurance perspective. Genomic tests are reimbursed 1,849.50€. We previously evaluated the direct costs of the first year of management of early operable breast cancer including medical costs and non-medical costs (transportation, daily allowance), in a prospective study (2,3, ClinicalTrials.gov identifier: NCT02813317). The total added direct costs of chemotherapy were 9,737€/ patient. Results: Prosigna® test was performed for 831 patients in clinical practice from 2016 and 2019 at Institut Curie. Due to missing data, analyses have been performed on 735 patients. Median age was 57 years-old (28-80), and median size 18 mm (3-80). We observed a majority of grade 2 tumors (n=572, 78%), and 21% of lymph node involvement. Median Ki67 was 20 (0-100). Prosigna® tests classified respectively 234 (32%), 295 (40%) and 206 (28%) in high, intermediate and low risk categories. In the all real-life population (n=735), chemotherapy was avoided for 308 (42%) patients after Prosigna® test results, and in 192 (44%) cases in the population defined by the FHA (n=433). From a financial point of view, both the real-life data and the population defined by FHA demonstrated cost savings,1 739 614€ (n=735 patients). and 1 068 671€(n=433), respectively. Conclusion: This large real-life study showed a 40% decrease in adjuvant chemotherapy recommendations after introduction of the Prosigna® test in a population of chemotherapy candidates. Moreover, this therapeutic de-escalation demonstrated an overall cost savings for the health system despite the added cost of the test.

Real-world cost-effectiveness of rivaroxaban compared with vitamin K antagonists in the context of stroke prevention in atrial fibrillation in France.

ObjectiveThe objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective.MethodsA Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers.ResultsIn the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates.ConclusionsAlthough there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.

Hospital care pathway of women treated for Bartholin’s gland abscess and budget impact analysis of outpatient management: A national hospital database analysis

IntroductionBartholin's gland abscesses cause severe pain and are a source of frequent emergency room visits. The most widespread treatment in France is incision-drainage during hospitalisation. A Word catheter, whose efficiency and safety would be identical, could be used without the need for hospitalisation, thus reducing the costs of Bartholin's gland abscess management. DesignRetrospective cohort study. SettingFrench hospital (PMSI) database 2016-2017. Population3539 women with Bartholin's gland abscess. MethodFrom the PMSI database, we identified the population that was treated for incision-drainage of a Bartholin's gland abscess in 2016. We also looked for secondary hospitalisations occurring within 12 months of initial treatment of Bartholin's gland abscess using 2016 and 2017 PMSI database data. Main outcome(s)The identified population was described in terms of age, hospitalisation, length of stay and readmissions within 12 months and provided a 5-year budget impact analysis of the use of the Word catheter in France from a National Health Insurance perspective. ResultsIn 2016, 3539 women (36 +/- 11.8 years) were hospitalised for 3646 incisions of the major vestibular gland linked to a Bartholin's gland abscess. 11.38 % (403/3,539) underwent at least one new Bartholin's gland procedure during the following year. The use of the Word catheter would allow potential savings over 5 years of €7.4 million. ConclusionThe use of the Word catheter could be cost-saving. These results must be validated by a clinical research step evaluating efficiency in the French context, comparing the Word catheter and incision-drainage side-by-side.

Cost-effectiveness of FOLFIRI + cetuximab vs FOLFIRI + bevacizumab in the first-line treatment of RAS wild-type metastatic colorectal cancer in Germany: data from the FIRE-3 (AIO KRK-0306) study

Aims: This analysis evaluates the cost-effectiveness of first-line treatment with FOLFIRI + cetuximab vs FOLFIRI + bevacizumab for patients with RAS wild-type (wt) metastatic colorectal cancer (mCRC) in Germany based on the randomized phase 3 FIRE-3 trial. For patients with RAS wt mCRC, FOLFIRI + cetuximab yielded statistically significant median overall survival gains over FOLFIRI + bevacizumab.Materials and methods: A standard 3-state partitioned survival cost-utility model was developed to compare the health benefits and costs of treatment from a German social health insurance perspective using individual patient–level trial data. Health outcomes were reported in life-years (LYs) and quality-adjusted life-years (QALYs) gained. Survival was estimated based on Kaplan-Meier (KM) curves supplemented with best-fitting parametric survival model extrapolations. Subgroup analyses of patients with a left-sided primary tumor location or patients with metastases confined to the liver were performed.Results: In the modified intention-to-treat analysis, FOLFIRI + cetuximab, providing 0.68 additional LYs (0.53 QALYs), yielded incremental cost-effectiveness ratios (ICERs) of €36,360/LY and €47,250/QALY. In subgroup analyses, patients experienced improved survival gains without a corresponding increase in costs, resulting in lower ICERs. Our model was most sensitive to changes in treatment duration across all lines of therapy, utility of progressive disease, as well as patients’ weight and body surface area.Limitations: This cost-effectiveness analysis was based on patient-level data from the FIRE-3 trial. Trial outcomes may not adequately reflect those in the real-world setting. Additionally, resource use and costs were obtained from tariff lists, which do not account for differences in treatment practice. These considerations limit generalizability of outcomes to other countries, or within the German healthcare setting.Conclusions: Based on our analyses, FOLFIRI + cetuximab is cost-effective compared with FOLFIRI + bevacizumab in patients with RAS wt mCRC, with ICERs well below willingness-to-pay thresholds for diseases with a high burden.

Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus

BackgroundThe safe use of a prosthesis in activities of daily living is key for transfemoral amputees. However, the number of falls varies significantly between different prosthetic device types. This study aims to compare medical and economic consequences of falls in transfemoral amputees who use the microprocessor-controlled knee joint C-Leg with patients who use non-microprocessor-controlled (mechanical) knee joints (NMPK). The main objectives of the analysis are to investigate the cost-effectiveness and budget impact of C-Legs in transfemoral amputees with diabetes mellitus (DM) and without DM in Germany.MethodsA decision-analytic model was developed that took into account the effects of prosthesis type on the risk of falling and fall-related medical events. Cost-effectiveness and budget impact analyses were performed separately for transfemoral amputees with and without DM. The study took the perspective of the statutory health insurance (SHI). Input parameters were derived from the published literature. Univariate and probabilistic sensitivity analyses (PSA) were performed to investigate the impact of changes in individual input parameter values on model outcomes and to explore parameter uncertainty.ResultsC-Legs reduced the rate of fall-related hospitalizations from 134 to 20 per 1000 person years (PY) in amputees without DM and from 146 to 23 per 1000 PY in amputees with DM. In addition, the C-Leg prevented 15 or 14 fall-related death per 1000 PY. Over a time horizon of 25 years, the incremental cost-effectiveness ratio (ICER) was 16,123 Euro per quality-adjusted life years gained (QALY) for amputees without DM and 20,332 Euro per QALY gained for amputees with DM. For the period of 2020–2024, the model predicted an increase in SHI expenditures of 98 Mio Euro (53 Mio Euro in prosthesis users without DM and 45 Mio Euro in prosthesis users with DM) when all new prosthesis users received C-Legs instead of NMPKs and 50% of NMPK user whose prosthesis wore out switched to C-Legs. Results of the PSA showed moderate uncertainty and a probability of 97–99% that C-Legs are cost-effective at an ICER threshold of 40,000 Euro (≈ German GDP per capita in 2018) per QALY gained.ConclusionResults of the study suggest that the C-Leg provides substantial additional health benefits compared with NMPKs and is likely to be cost-effective in transfemoral amputees with DM as well as in amputees without DM at an ICER threshold of 40,000 Euro per QALY gained.