Marginal Cost-effectiveness Ratio Research Articles

Can Technology Assistance be Cost Effective in TKA? A Simulation-Based Analysis of a Risk-prioritized, Practice-specific Framework.

Can Technology Assistance be Cost Effective in TKA? A Simulation-Based Analysis of a Risk-prioritized, Practice-specific Framework.

How Many Intensive Care Beds are Justifiable for Hospital Pandemic Preparedness? A Cost-effectiveness Analysis for COVID-19 in Germany.

IntroductionGermany is experiencing the second COVID-19 pandemic wave. The intensive care unit (ICU) bed capacity is an important consideration in the response to the pandemic. The purpose of this study was to determine the costs and benefits of maintaining or expanding a staffed ICU bed reserve capacity in Germany.MethodsThis study compared the provision of additional capacity to no intervention from a societal perspective. A decision model was developed using, e.g. information on age-specific fatality rates, ICU costs and outcomes, and the herd protection threshold. The net monetary benefit (NMB) was calculated based upon the willingness to pay for new medicines for the treatment of cancer, a condition with a similar disease burden in the near term.ResultsThe marginal cost-effectiveness ratio (MCER) of the last bed added to the existing ICU capacity is €21,958 per life-year gained assuming full bed utilization. The NMB decreases with an additional expansion but remains positive for utilization rates as low as 2%. In a sensitivity analysis, the variables with the highest impact on the MCER were the mortality rates in the ICU and after discharge.ConclusionsThis article demonstrates the applicability of cost-effectiveness analysis to policies of hospital pandemic preparedness and response capacity strengthening. In Germany, the provision of a staffed ICU bed reserve capacity appears to be cost-effective even for a low probability of bed utilization.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-020-00632-2.

The impact of increased post-progression survival on the cost-effectiveness of interventions in oncology.

Purpose: Cost-effectiveness analyses (CEA) of new technologies typically include “background” costs (eg, all “related” health care costs other than the specific technology under evaluation) as well as drug costs. In oncology, these are often expensive. The marginal cost-effectiveness ratio (ie, the extra costs and QALYs associated with each extra period of survival) calculates the ratio of background costs to QALYs during post-progression. With high background costs, the incremental cost-effectiveness ratio (ICER) can become less favorable as survival increases and the ICER moves closer to the marginal cost-effectiveness ratio, making cost-effectiveness prohibitive. This study assessed different methods to determine whether high ICERs are caused by high drug costs, high “background costs” or a combination of both and how different approaches can alter the impact of background costs on the ICER where the marginal cost-effectiveness ratio is close to, or above, the cost-effectiveness threshold.Methods: The National Institute for Health and Care Excellence oncology technology appraisals published or updated between October 2012 and October 2017 were reviewed. A case study was selected, and the CEA was replicated. Three modeling approaches were tested on the case study model.Results: Applying one-off “transition” costs during post-progression reduced the ongoing “incremental” costs of survival, which meant that the marginal cost-effectiveness ratio was substantially reduced and problems associated with additional survival were less likely to impact the ICER. Similarly, the use of two methods of additional utility weighting for end-of-life cases meant that the marginal cost-effectiveness ratio was reduced proportionally, again lessening the impact of increased survival.Conclusion: High ICERs can be caused by factors other than the cost of the drug being assessed. The economic models should be correct and valid, reflecting the true nature of marginal survival. Further research is needed to assess how alternative approaches to the measurement and application of background costs and benefits may provide an accurate assessment of the incremental benefits of life-extending oncology drugs. If marginal survival costs are incorrectly calculated (ie, by summing total post-progressed costs and dividing by the number of baseline months in that state), then the costs of marginal survival are likely to be overstated in economic models.

The health economics of cancer screening in Germany: Which population-based interventions are cost-effective?

Only asmall proportion of German health expenditure is spent on prevention and early detection (screening). The rationale for screening is to identify persons with disease precursors or at the early stage of diseases when they are still asymptomatic, in order to decrease disease-specific morbidity and mortality. In Germany, the economic evidence is one of the evaluation criteria for screening measures, which, among other things, takes into account the additional cost per additional case detected or per case-related event avoided, as well as acost-benefit balance.For this purpose, cost-effectiveness analyses, which report marginal or incremental cost effectiveness ratios, comparing ameasure with its appropriate alternatives, may be auseful tool. Their application requires adefensible benchmark (threshold) for cost effectiveness and asupplementary analysis of the necessary infrastructure and the budgetary impact associated with program implementation. Also (albeit not only) because of the usually long time required to observe the clinical outcomes of ascreening measure, the economic evaluation of such programs regularly involves the application of decision analytic simulation models. With regard to cancer screening programs, the available models indicate an excellent cost-benefit ratio for the fecal occult blood test and colonoscopy for colorectal cancer screening and, similarly, for the use of mammography for breast cancer screening. On the other hand, the economic evidence in favor of low-dose computed tomography for lung cancer screening does not yet appear sufficiently strong, and the currently available health economic evidence does not support the use of PSA testing for prostate screening.

Primary Spontaneous Pneumothorax: Looking Beyond the Usual

Primary Spontaneous Pneumothorax: Looking Beyond the Usual

Chest Computed Tomographic Image Screening for Cystic Lung Diseases in Patients with Spontaneous Pneumothorax Is Cost Effective.

Patients without a known history of lung disease presenting with a spontaneous pneumothorax are generally diagnosed as having primary spontaneous pneumothorax. However, occult diffuse cystic lung diseases such as Birt-Hogg-Dubé syndrome (BHD), lymphangioleiomyomatosis (LAM), and pulmonary Langerhans cell histiocytosis (PLCH) can also first present with a spontaneous pneumothorax, and their early identification by high-resolution computed tomographic (HRCT) chest imaging has implications for subsequent management. The objective of our study was to evaluate the cost-effectiveness of HRCT chest imaging to facilitate early diagnosis of LAM, BHD, and PLCH. We constructed a Markov state-transition model to assess the cost-effectiveness of screening HRCT to facilitate early diagnosis of diffuse cystic lung diseases in patients presenting with an apparent primary spontaneous pneumothorax. Baseline data for prevalence of BHD, LAM, and PLCH and rates of recurrent pneumothoraces in each of these diseases were derived from the literature. Costs were extracted from 2014 Medicare data. We compared a strategy of HRCT screening followed by pleurodesis in patients with LAM, BHD, or PLCH versus conventional management with no HRCT screening. In our base case analysis, screening for the presence of BHD, LAM, or PLCH in patients presenting with a spontaneous pneumothorax was cost effective, with a marginal cost-effectiveness ratio of $1,427 per quality-adjusted life-year gained. Sensitivity analysis showed that screening HRCT remained cost effective for diffuse cystic lung diseases prevalence as low as 0.01%. HRCT image screening for BHD, LAM, and PLCH in patients with apparent primary spontaneous pneumothorax is cost effective. Clinicians should consider performing a screening HRCT in patients presenting with apparent primary spontaneous pneumothorax.

The Cost of Increasing Physical Activity and Maintaining Weight for Midlife Sedentary African American Women

ObjectiveTo evaluate the marginal costs of increasing physical activity and maintaining weight for a lifestyle physical activity program targeting sedentary African American women. MethodsOutcomes included change in minutes of total moderate to vigorous physical activity, leisure-time moderate to vigorous physical activity and walking per week, and weight stability between baseline and maintenance at 48 weeks. Marginal cost-effectiveness ratios (MCERs) were calculated for each outcome, and 95% confidence intervals (CIs) were computed using a bootstrap method. The analysis was carried out from the societal perspective and calculated in 2013 US dollars. ResultsFor the 260 participants in the analysis, program costs were $165 ± $19, and participant costs were $164 ± $35, for a total cost of $329 ± $49. The MCER for change in walking was $1.50/min/wk (95% CI 1.28–1.87), for change in moderate to vigorous physical activity was $1.73/min/wk (95% CI 1.41–2.18), and for leisure-time moderate to vigorous physical activity was $1.94/min/wk (95% CI 1.58–2.40). The MCER for steps based on the accelerometer was $0.46 per step (95% CI 0.30-0.85) and weight stability was $412 (95% CI 399–456). ConclusionsThe Women’s Lifestyle Physical Activity Program is a relatively low-cost strategy for increasing physical activity. The marginal cost of increasing physical activity is lower than for weight stability. The participant costs related to time in the program were nearly half the total costs, suggesting that practitioners and policymakers should consider the participant cost when disseminating a lifestyle physical activity program into practice.

A cost-benefit/cost-effectiveness analysis of an unsanctioned supervised smoking facility in the Downtown Eastside of Vancouver, Canada.

BackgroundSmoking crack involves the risk of transmitting diseases such as HIV and hepatitis C (HCV). The current study determines whether the formerly unsanctioned supervised smoking facility (SSF)—operated by the grassroot organization, Vancouver Area Network of Drug Users (VANDU) for the last few years—costs less than the costs incurred for health-care services as a direct consequence of not having such a program in Vancouver, Canada.MethodsThe data pertaining to the attendance at the SSF was gathered in 2012–2013 by VANDU. By relying on this data, a mathematical model was employed to estimate the number of HCV infections prevented by the former facility in Vancouver’s Downtown Eastside (DTES).ResultsThe DTES SSF’s benefit-cost ratio was conservatively estimated at 12.1:1 due to its low operating cost. The study used 70% and 90% initial pipe-sharing rates for sensitivity analysis. At 80% sharing rate, the marginal HCV cases prevented were determined to be 55 cases. Moreover, at 80% sharing rate, the marginal cost-effectiveness ratio ranges from $1,705 to $97,203. The results from both the baseline and sensitivity analysis demonstrated that the establishment of the SSF by VANDU on average had annually saved CAD$1.8 million dollars in taxpayer’s money.ConclusionsFunding SSFs in Vancouver is an efficient and effective use of financial resources in the public health domain; therefore, Vancouver Coastal Health should actively participate in their establishment in order to reduce HCV and other blood-borne infections such as HIV within the non-injecting drug users.

Custo-efetividade da escovação dental supervisionada convencional e modificada na prevenção da cárie em molares permanentes de crianças de 5 anos de idade

The cost-effectiveness of a modified supervised toothbrushing program was compared to a conventional program. A total of 284 five-year-old children presenting at least one permanent molar with emerged/sound occlusal surface participated. In the control group, oral health education and dental plaque dying followed by toothbrushing with fluoride dentifrice was carried outfour times per year. With the test group, children also underwent professional cross-brushing on surfaces of first permanent molar rendered by a dental assistant five times per year. Enamel/dentin caries were recorded on buccal, occlusal and lingual surfaces of permanent molars for a period of 18 months. The incidence density (ID) ratio was estimated using Poisson's regression model. The ID was 50% lower among boys in the test group (p = 0.016). The cost of the modified program was US$ 1.79 per capita. The marginal cost-effectiveness ratio among boys was US$ 6.30 per avoided carie. The modified supervised toothbrushing program was shown to be cost-effective in the case of boys.

Economic Analysis of Hepatitis B Screening and Treatment

Economic Analysis of Hepatitis B Screening and Treatment

Cost‐effectiveness of Telemetry for Hospitalized Patients With Low‐risk Chest Pain

The majority of chest pain admissions originate in the emergency department (ED). Despite a low incidence of cardiac events, limited telemetry availability, and its questionable benefit, these patients are routinely admitted to a monitored setting. The objectives were to analyze the cost-effectiveness of admission to telemetry versus admission to an unmonitored hospital bed in low-risk chest pain patients and explore when the use of telemetry may be cost-effective. The authors constructed a decision analytic model to evaluate the scenario of an ED admission of an otherwise healthy 55-year-old patient with low-risk chest pain defined as an acute coronary syndrome (ACS) probability of 2%. Costs were estimated from 2009 Medicare data for hospital reimbursement and physician services, as well as published data on disability costs. Published studies were used to estimate the risk of ACS, cardiac arrest, time to defibrillation, survival, long-term disability, and quality of life. In the base case, telemetry was more effective (0.0044 quality-adjusted life-years [QALYs]) but more costly ($299.67) than a floor bed, resulting in a high marginal cost-effectiveness ratio (mCER) of $67,484.55 per QALY. In comprehensive sensitivity analyses, the mCER crossed below the willingness-to-pay (WTP) threshold of $50,000 per QALY when the following scenarios were met: the probability of ACS exceeds 3%, the probability of cardiac arrest is greater than 0.4%, the probability of shockable dysrhythmia is above 83%, the probability of delay in telemetry bed availability is below 52%, and the opportunity cost of delay to telemetry bed placement is below $119. Telemetry may be a "cost-effective" use of health care resources for chest pain patients when patients have a probability of ACS above 3% or for patients with a minimal delay and cost associated with obtaining a monitored bed. Further research is needed to better stratify low-risk chest pain patients to the appropriate inpatient setting and to understand the frequency and costs associated with delays in obtaining monitored beds.

Screening for Lymphangioleiomyomatosis by High-Resolution Computed Tomography in Young, Nonsmoking Women Presenting with Spontaneous Pneumothorax Is Cost-Effective

Women with pulmonary lymphangioleiomyomatosis (LAM) who present with a sentinel spontaneous pneumothorax (SPTX) will experience an average of 2.5 additional pneumothoraces. The diagnosis of LAM is typically delayed until after the second pneumothorax. We hypothesized that targeted screening of an LAM-enriched population of nonsmoking women between the ages of 25 and 54 years, who present with a sentinel pneumothorax indicated by high-resolution computed tomography (HRCT), will facilitate early identification, definitive therapy, and improved quality of life for patients with LAM. We constructed a Markov state-transition model to assess the cost-effectiveness of screening. Rates of SPTX and prevalence of LAM in populations stratified by age, sex, and smoking status were derived from the literature. Costs of testing and treatment were extracted from 2007 Medicare data. We compared a strategy based on HRCT screening followed by pleurodesis for patients with LAM, versus no HRCT screening. The prevalence of LAM in nonsmoking women, between the ages of 25 and 54 years, with SPTX is estimated at 5% on the basis of the available literature. In our base case analysis, screening for LAM by HRCT is the most cost-effective strategy, with a marginal cost-effectiveness ratio of $32,980 per quality-adjusted life-year gained. Sensitivity analysis showed that HRCT screening remains cost-effective for groups in which the prevalence of LAM in the population subset screened is greater than 2.5%. Screening for LAM by HRCT in nonsmoking women age 25-54 that present with SPTX is cost-effective. Physicians are advised to screen for LAM by HRCT in this population.

Additional Factors That Could Improve Cost-Effectiveness of Pharmacogenetic-Guided Dosing in Warfarin Therapy

Letters7 July 2009Additional Factors That Could Improve Cost-Effectiveness of Pharmacogenetic-Guided Dosing in Warfarin TherapyMark H. Eckman, MD, MS, Jonathan Rosand, MD, MSc, Steven M. Greenberg, MD, PhD, and Brian F. Gage, MD, MScMark H. Eckman, MD, MSFrom University of Cincinnati, Cincinnati, OH 45267; Massachusetts General Hospital, Boston, MA 02114; and Washington University, St. Louis, MO 63110.Search for more papers by this author, Jonathan Rosand, MD, MScFrom University of Cincinnati, Cincinnati, OH 45267; Massachusetts General Hospital, Boston, MA 02114; and Washington University, St. Louis, MO 63110.Search for more papers by this author, Steven M. Greenberg, MD, PhDFrom University of Cincinnati, Cincinnati, OH 45267; Massachusetts General Hospital, Boston, MA 02114; and Washington University, St. Louis, MO 63110.Search for more papers by this author, and Brian F. Gage, MD, MScFrom University of Cincinnati, Cincinnati, OH 45267; Massachusetts General Hospital, Boston, MA 02114; and Washington University, St. Louis, MO 63110.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-151-1-200907070-00017 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We appreciate the comments of Drs. Geisler and Levin-Scherz and agree with many of their observations. The results of our analysis are more nuanced than a simple assertion that pharmacogenetic-guided dosing is not cost effective. Indeed, we used sensitivity analyses to explore how changes in either health care delivery systems or patient characteristics might affect the cost-effectiveness of pharmacogenetic-guided dosing. With regard to systems changes that might make this strategy cost-effective, we found that the marginal cost-effectiveness ratio drops below a societal willingness-to-pay threshold of $50 000 per quality-adjusted life-year when the cost of genotyping is less than $200 ...Reference1. Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151:713-9. [PMID: 16504638] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Mark H. Eckman, MD, MS; Jonathan Rosand, MD, MSc; Steven M. Greenberg, MD, PhD; Brian F. Gage, MD, MScAffiliations: From University of Cincinnati, Cincinnati, OH 45267; Massachusetts General Hospital, Boston, MA 02114; and Washington University, St. Louis, MO 63110.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCost-Effectiveness of Using Pharmacogenetic Information in Warfarin Dosing for Patients With Nonvalvular Atrial Fibrillation Mark H. Eckman , Jonathan Rosand , Steven M. Greenberg , and Brian F. Gage Additional Factors That Could Improve Cost-Effectiveness of Pharmacogenetic-Guided Dosing in Warfarin Therapy Benjamin P. Geisler and Jeffrey K. Levin-Scherz Metrics 7 July 2009Volume 151, Issue 1Page: 71KeywordsAdverse eventsConflicts of interestForecastingGenotypingHealth careHemorrhageMedical risk factorsQuality adjusted life yearsRandomized trialsRelative risk ePublished: 7 July 2009 Issue Published: 7 July 2009 Copyright & PermissionsCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Cost-effectiveness analysis of ED decision making in patients with non–high-risk heart failure

Background The ED disposition of patients with non–high-risk acute decompensated heart failure (ADHF) is challenging. To help address this problem, we investigated the cost-effectiveness of different ED disposition strategies. Methods We constructed a decision analytic model evaluating the cost-effectiveness of 3 possible ED ADHF disposition strategies in a 60-year-old man: (1) discharge home from the ED; (2) observation unit (OU) admission; (3) inpatient admission. Base case patients had no high-risk features. We used Medicare costs and the national physician fee schedule to capture ED, OU, and hospital costs, including costs of complications and death. All analyses were conducted using Decision Maker software (University of Medicine and Dentistry of New Jersey, Newark, NJ). Results Compared to ED discharge, OU admission had a reasonable marginal cost-effectiveness ratio ($44 249/quality adjusted life year), whereas hospital admission had an unacceptably high marginal cost-effectiveness ratio ($684 101/quality adjusted life year). Sensitivity analyses demonstrated that as the risk of early (within 5 days) and late (within 30 days) readmission exceeded 36% and 74%, respectively, in those discharged from the ED, OU admission became less costly and more effective than ED discharge. Similarly, an increase in relative risk of both early and late death in those discharged from the ED improves the marginal cost-effectiveness ratio of OU admission. Finally, as postdischarge event rates increase in those discharged from the OU, hospital admission became more cost-effective. Conclusion Observation unit admission for patients with non–high-risk ADHF has a societally acceptable marginal cost-effectiveness ratio compared to ED discharge. However, as ED and OU discharge event rates increase, hospital admission becomes the more cost-effective strategy.

Cost, Effectiveness, and Cost-Effectiveness

Pluck the goose so as to obtain the most feathers with the least hissing . — —Jean-Baptiste Colbert, Minister of Finance to King Louis XIV of France Incremental or marginal cost-effectiveness ratios are founded on a number of assumptions that weaken their suitability as a way to balance competing economic and clinical priorities. We therefore propose a more relevant and responsible way to gauge the impact of clinical management strategies based on “consumer protection” principles—explicit disclosure of (1) the total magnitude of expected benefit in the target population (in life-years or quality-adjusted life-years), (2) the total monetary cost (in per capita inflation-adjusted dollars), and (3) a formal plan by which the added costs would be paid. Health policy decisions should therefore be based on the inherent trade-offs in the component measures of cost and effectiveness and not on a simple ratio of the two. Cost-effectiveness ratios are thereby rendered superfluous. Incremental or marginal cost-effectiveness ratios are widely viewed as rational ways to balance competing clinical and economic priorities that arise as a consequence of the inevitable disconnect between an individual’s wants and the society’s willingness to pay for those wants.1–5 The purpose of this essay is to question the practical relevance of these ratios with respect to strategic planning in health care, and offer a suitable alternative. In doing so, we will focus on the more pragmatic issues underlying cost-effectiveness analysis, and gloss over a variety of technical details such as the difference between a privately financed free market and the publicly financed healthcare market, between costs and charges, and between unadjusted and quality-adjusted outcomes. Our pragmatic perspective is not likely to be welcomed by orthodox experts in cost-effectiveness analysis. We believe, however, that any such criticisms can be blunted by recognizing the important distinctions between regulatory and clinical …

Clinical benefit and cost effectiveness of total knee arthroplasty in the older patient

PurposeTotal knee arthroplasty (TKA) is an effective, but also cost-intensive health care procedure for the elderly. Furthermore, bearing demographic changes in Western Europe in mind, TKA-associated financial investment for health care insurers will increase notably and thereby catalyze discussions on ressource allocation to Orthopedic surgery. To derive a quantitative rationale for such discussions within Western Europe's health care systems, a prospective assessment of both the benefit of TKA from a patient's perspective as well as its cost effectiveness from a health care insurer's perspective was implemented.MethodsA prospective cost effectiveness trial recruited a total of 65 patients (60% females), who underwent TKA in 2006; median age of patients was 66 years (interquartile range 61 - 74 years). Before and three months after surgery patients were interviewed by means of the EuroQol-5D and the WOMAC questionnaires to assess their individual benefit due to TKA and the subsequent inpatient rehabilitation. Both questionnaires' benefit estimates were transformed into the number of gained quality adjusted life years [QALYs]. Total direct cost estimates for the overall care were based on German DRG and rehabilitation cost rates [€]. The primary clinical endpoint of the investigation was the individual number of QALYs gained by TKA based on the WOMAC interview; the primary health economic endpoint was the marginal cost effectiveness ratio (MCER) relating the costs to the associated gain in quality of life [€/QALY].ResultsTotal direct costs for the overall procedure were estimed 9549 € in median. The WOMAC based interview revealed an overall gain of 4.59 QALYs (interquartile range 2.39 - 6.21 QALYs), resulting in marginal costs of 1795 €/QALY (1488 - 3288 €/QALY). The corresponding EuroQol based estimates were 2.93 QALYs (1.75 - 5.59 QALYs) and 3063 €/QALY (1613 - 5291 €/QALY). Logistic regression modelling identified the patients' age as the primary determinant of cost effectiveness (Likelihood Ratio p = 0.006): patients younger than 60 years showed a median gain of 6.45 QALYs and median marginal costs of 1463 €/QALY, patients between 60 - 70 years 5.47 QALYs and 1744 €/QALY, patients older than 70 years 2.76 QALYs and 3186 €/QALY.ConclusionTKA was proven to be cost effective from a health care insurer's perspective, although its marginal costs notably increased with increasing age. Note, however, that this age-related gradient in marginal cost effectiveness is of comparable order as the changes in cost effectiveness due to variation of the underlying assessment instrument.

Cost effectiveness of recombinant factor VIIa for treatment of intracerebral hemorrhage

BackgroundPhase I/II placebo-controlled clinical trials of recombinant Factor VIIa (rFVIIa) suggested that administration of rFVIIa within 4 hours after onset of intracerebral hemorrhage (ICH) is safe, limits ICH growth, and improves outcomes. We sought to determine the cost-effectiveness of rFVIIa for acute ICH treatment, using published Phase II data. We hypothesized that rFVIIa would have a low marginal cost-effectiveness ratio (mCER) given the poor neurologic outcomes after ICH with conventional management.MethodsWe performed an incremental cost-effectiveness analysis from the societal perspective, considering conventional management vs. 80 ug/kg rFVIIa treatment for acute ICH cases meeting Phase II inclusion criteria. The time frame for the analysis was 1. 25 years: data from the Phase II trial was used for 90 day outcomes and rFVIIa complications – arterial thromboembolic events (ATE). We assumed no substantial cost differences in care between the two strategies except: 1) cost of rFVIIa (for an 80 mcg/kg dose in an 80 kg patient, assumed cost of $6,408); 2) cost of ATE side effects from rFVIIa (which also decrease quality of life and increase the chance of death); and 3) differential monetary costs of outcomes and their impact on quality of life, including disposition (home vs. nursing home), and outpatient vs. inpatient rehabilitation. Sensitivity analyses were performed to explore uncertainty in parameter estimates, impact of rFVIIa cost, direct cost of neurologic outcomes, probability of ATE, and outcomes after ATE.ResultsIn the "base case", treating ICH with rFVIIa dominates the usual care strategy by being more effective and less costly. rFVIIa maintained a mCER < $50,000/QALY over a wide range of sensitivity analyses. Sensitivity analyses showed that the cost of rFVIIa must exceed $14,500, or the frequency of ATE exceed 29%, for the mCER to exceed $50,000/QALY. Varying the cost and/or reducing the utility of health states following ATE did not impact results.ConclusionBased on data from preliminary trials, treating selected ICH patients with rFVIIa results in lower cost and improved clinical outcomes. This potential cost-effectiveness must be considered in light of the Phase III trial results.

Vaccinating adolescents against meningococcal disease in Canada: A cost-effectiveness analysis

One dose of serogroup C meningococcal conjugate vaccine (MCV-C) at 12 months of age is the most common immunization schedule in Canada, but immunity may wane over time. To assess the cost-effectiveness of a booster dose at 12 years of age with either MCV-C or a quadrivalent ACYW135 meningococcal conjugate vaccine (MCV-4). A simulation model for assessing both the direct and indirect effects of vaccination was developed. Age- and serogroup-specific incidence and fatality rates were derived from Canadian surveillance data. Vaccine efficacy was estimated from data from the U.K. and Spain, assuming an age-dependent decline of vaccine efficacy over time. Expected vaccine coverage rates were 90% at 12 months, and 70% at 12 years. Herd immunity was modeled using UK data. Vaccine purchase price per dose was $23 for MCV-C and $70 for MCV-4. Costs and health outcomes were discounted at 3% per year. Results, expressed in 2004 Canadian $ and from a societal perspective, were presented for a steady state situation and a population of 1 million. Under the "no vaccination" base scenario, 5.7 cases of vaccine-preventable meningococcal disease would occur each year. Vaccination at 12 months using MCV-C would reduce the burden of disease by 32%. Adding MCV-C at 12 years of age would reduce the number of cases by 55% at no marginal cost, while using MCV-4 would result in a disease reduction of 78% for a marginal cost of $31000 per QALY gained. Comparing MCV-4 with MCV-C as a booster dose, the incremental cost-effectiveness ratio would be $113000 per QALY. The efficacy of C-MCV vaccination at 12 months and the differential price between the two vaccines were the parameters having the strongest impact on the cost/QALY ratios. Any increase in the incidence of serogroup Y will improve the marginal cost-effectiveness ratio associated with MCV-4. Adolescent revaccination would be beneficial. Using C-MCV would be the most cost-effective option, while using MCV-4 would be more effective but would also require more investment.

Inkrementelle Kosteneffektivität der multifokalen Kataraktchirurgie

Supplementation of cataract patients with multifocal intraocular lenses involves an additional financial investment when compared to the corresponding monofocal supplementation, which usually is not funded by German health care insurers. In the context of recent resource allocation discussions, however, the cost effectiveness of multifocal cataract surgery could become an important rationale. Therefore an evidence-based estimation of its cost effectiveness was carried out. Three independent meta-analyses were implemented to estimate the gain in uncorrected near visual acuity and best corrected visual acuity (vision lines) as well as the predictability (fraction of patients without need for reading aids) of multifocal supplementation. Study reports published between 1995 and 2004 (English or German language) were screened for appropriate key words. Meta effects in visual gain and predictability were estimated by means and standard deviations of the reported effect measures. Cost data were estimated by German DRG rates and individual lens costs; the cost effectiveness of multifocal cataract surgery was then computed in terms of its marginal cost effectiveness ratio (MCER) for each clinical benefit endpoint; the incremental costs of multifocal versus monofocal cataract surgery were further estimated by means of their respective incremental cost effectiveness ratio (ICER). An independent meta-analysis estimated the complication profiles to be expected after monofocal and multifocal cataract surgery in order to evaluate expectable complication-associated additional costs of both procedures; the marginal and incremental cost effectiveness estimates were adjusted accordingly. A sensitivity analysis comprised cost variations of +/- 10 % and utility variations alongside the meta effect estimate's 95 % confidence intervals. Total direct costs from the health care insurer's perspective were estimated 3363 euro, associated with a visual meta benefit in best corrected visual acuity and near visual acuity of 5.1 lines (95 % confidence interval 3.8 - 6.4 lines) and 6.1 lines (4.7 - 7.5 lines), respectively, and a meta predictability estimate of 81 % (72 - 89 %). The mean MCER for best corrected visual acuity results became 659 euro per gained visual acuity line (sensitivity range 473 - 973 euro). For near visual acuity, a mean MCER of 555 euro (sensitivity range 404 - 787 euro) per gained visual line was found. In terms of incremental costs, multifocal cataract surgery implied an additional mean investment of 63 euro (sensitivity range 0 - 234 euro) per additionally gained near visual acuity line, and 5 euro (0 - 18 euro) per additionally gained percentage point in predictability, when compared to monofocal cataract surgery as the standard treatment. The meta-analysis on complication profiles revealed posterior capsule opacification (meta incidence 20 %) and vitreous loss (meta incidence 2 %) as the complications to be expected most frequently. The cost adjustment for expectable complication patterns after multifocal cataract surgery implied total direct costs of 3491 euro, resulting in marginal costs of 576 euro per line (sensitivity range 419 - 817 euro per line) gained in near visual acuity and 684 euro per line (491 - 1011 euro per line) gained in best corrected visual acuity. Bearing incremental costs of 63 euro per additionally gained vision line (near visual acuity) in mind, multifocal cataract surgery comprises a cost effective alternative to the monofocal standard treatment.

Cost-Effectiveness of Intravenous Thrombolysis With Alteplase Within a 3-Hour Window After Acute Ischemic Stroke

The aim of this study was to assess the costs and cost-effectiveness of intravenous thrombolysis treatment with alteplase (Actilyse) of acute ischemic stroke with 24-hour in-house neurology coverage and use of magnetic resonance imaging. A health economic model was designed to calculate the marginal cost-effectiveness ratios for time spans of 1, 2, 3 and 30 years. Effect data were extracted from a meta-analysis of six large-scale randomized and placebo-controlled studies of thrombolytic therapy with alteplase. Cost data were extracted from thrombolysis treatment at Aarhus Hospital, Denmark, and from previously published literature. The calculated cost-effectiveness ratio after the first year was $55,591 US per quality-adjusted life-year (base case). After the second year, computation of the cost-effectiveness ratio showed that thrombolysis was cost-effective. The long-term computations (30 years) showed that thrombolysis was a dominant strategy compared with conservative treatment given the model premises. A high-quality thrombolysis treatment with 24-hour in-house neurology coverage and magnetic resonance imaging might not be cost-effective in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings.