Marginal Cost-effectiveness Research Articles

Cost-effectiveness analysis of tislelizumab plus chemotherapy versus placebo plus chemotherapy as first-line treatment for advanced gastric or gastroesophageal junction adenocarcinoma: perspectives from the United States and China.

The efficacy of tislelizumab plus chemotherapy in improving progression-free survival (PFS) and overall survival (OS) in unresectable gastric or gastroesophageal junction cancer (GC/GEJC) has recently been emphasized. This study compared the cost-effectiveness of tislelizumab plus chemotherapy versus placebo plus chemotherapy for the United States (US) and Chinese populations. Using data from the RATIONALE-305 phase 3 trial, a Markov model was developed to analyze quality-adjusted life years (QALYs), incremental cost-effectiveness ratios (ICERs), incremental net health benefits (INHBs), and incremental net monetary benefits (INMBs). The health state utilities and direct medical costs were obtained from the relevant literature and local cost databases. The model uncertainty was evaluated using sensitivity analyses. In the base-case analysis, the addition of tislelizumab to chemotherapy yielded an ICER of $37,768.48 per QALY in China, slightly below the willingness-to-pay (WTP) threshold of $38,042.49 per QALY, showing marginal cost-effectiveness with an INHB of 0.05 QALYs and an INMB of $1,852.49. Subgroup analyses revealed ICERs of $23,853.52 for patients with a PD-L1 TAP score ≥ 5% (TAP ≥ 5%). In the US, the ICER was $502,786.22 per QALY in the intent-to-treat (ITT) and $321,395.28 per QALY in the TAP ≥ 5% subgroup, exceeding the US WTP threshold of $150,000.00. In China, tislelizumab plus chemotherapy is a cost-effective first-line therapy for unresectable GC/GEJC in both ITT and TAP ≥ 5% subgroups. In the US, tislelizumab plus chemotherapy is not cost-effective.

Incorporating economic analysis in interventional cardiology research.

Evaluative research in interventional cardiology has focused on clinical and technical outcomes. Inclusion of economic data can enhance evaluative research by quantifying the relative economic burden incurred by different therapies. When combined with clinical outcomes, cost data can provide a measure of value (e.g., marginal cost-effectiveness). In some select situations, cost data can also be used as surrogates for complexity of care and morbidity. In this narrative review, we aim to provide a framework for the application of cost data in clinical trials and observational research, detailing how to incorporate this kind of data into interventional cardiology research.

Selective Fetoscopic Laser Photocoagulation or Expectant Management for Stage I Twin-Twin Transfusion: A Cost-Effectiveness Analysis

Background: Selective fetoscopic laser photocoagulation (SFLP) is the preferred intervention for stage II-IV twin-twin transfusion syndrome (TTTS); however, there is no consensus on whether SFLP or expectant management (EM) is the preferred strategy to manage Quintero stage I TTTS. Objective: The objective of this study is to estimate whether SFLP or EM is the cost-effective strategy for management of Quintero stage I TTTS. Study Design: A decision-analysis (DA) model compared SFLP to EM for 1,000 pregnant people with monochorionic-diamniotic twins affected by stage I TTTS. All subjects were assumed to be appropriate candidates for either SFLP or EM. Probabilities, costs, and utilities were derived from the literature. The DA was conducted from a healthcare payor perspective, and the analytic horizon was over the course of an offspring’s lifetime, with primary outcomes of survivorship (i.e., no intrauterine fetal demise or neonatal death) and long-term neurodevelopmental impairment. The model incorporated Markov processes with 4-week cycles throughout pregnancy. Incremental cost-effectiveness ratios (ICER) for each strategy were calculated and compared to estimate marginal cost effectiveness. An ICER of USD 100,000 per quality-adjusted life year was used to define the cost-effectiveness threshold. One-way sensitivity and Monte Carlo analyses (MCA), as well as microsimulations, were performed. Results: For base-case estimates, SFLP was found to be cost-effective compared to EM in the management of stage I TTTS. In one-way sensitivity analysis, varying each variable along pre-specified ranges did not result in changes in the conclusion. MCA projects SFLP as the cost-effective strategy in 100% of runs. Conclusions: With base-case estimates, SFLP is estimated to be the cost-effective strategy for the treatment of Quintero stage I TTTS when compared with EM. This remained true across a wide range of inputs.

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.

The cost-effectiveness of CO2 mitigation measures for the decarbonisation of shipping. The case study of a globally operating ship-management company

The International Maritime Organisation has set a goal to achieve a 50% reduction of the total annual greenhouse gas emissions related to the international shipping by 2050 compared to the 2008 baseline emissions. Thus, companies are looking for solutions and measures to align with the Organisation's goal. Marginal Abatement Cost Curves have been extensively used in the literature to rank several Greenhouse Gas mitigation measures based on their costs of reducing an additional unit of pollution. In this paper an expert-based, bottom-up approach was employed to construct Marginal Abatement Cost Curves for a globally operating ship-management company. Several mitigation measures were examined for the following vessel categories (a) Containerships 8000+ TEU, (b) Containerships 2000–2999 TEU, (c) Bulkers 35000–59999 DWT, and (d) Gas Tankers <49999 CBM. Furthermore, the fuel price fluctuation and carbon taxation were used to investigate the sensitivity of baseline Marginal Abatement Cost Curves. The measures, which remain cost-effective under all sensitivity analyses, undergo a Pareto Analysis and a Marginal Cost-Effectiveness Analysis. The results suggest that most of the recommended mitigation measures are of an operational and technical nature, with exception the burning of Liquified Natural Gas and the installation of Flettner Rotors for the Gas Tankers. The company could save up to 17% CO2 emissions and approximately 2 million dollars per year compared to the 2019 baseline by employing all recommended mitigation measures to all vessel categories. In addition, Carbon Storage and Capture could become a cost-effective solution with appropriate carbon taxation, but it is not the ultimate solution since it does not lead to independence from fossil fuels. The study also reveals that depending on the operating condition, even within the same vessel category, different mitigation measures should be employed.

A framework for allocating conservation resources among multiple threats and actions.

Land managers decide how to allocate resources among multiple threats that can be addressed through multiple possible actions. Additionally, these actions vary in feasibility, effectiveness, and cost. We sought to provide a way to optimize resource allocation to address multiple threats when multiple management options are available, including mutually exclusive options. Formulating the decision as a combinatorial optimization problem, our framework takes as inputs the expected impact and cost of each threat for each action (including do nothing) and for each overall budget identifies the optimal action to take for each threat. We compared the optimal solution to an easy to calculate greedy algorithm approximation and a variety of plausible ranking schemes. We applied the framework to management of multiple introduced plant species in Australian alpine areas. We developed a model of invasion to predict the expected impact in 50 years for each species-action combination that accounted for each species' current invasion state (absent, localized, widespread); arrival probability; spread rate; impact, if present, of each species; and management effectiveness of each species-action combination. We found that the recommended action for a threat changed with budget; there was no single optimal management action for each species; and considering more than one candidate action can substantially increase the management plan's overall efficiency. The approximate solution (solution ranked by marginal cost-effectiveness) performed well when the budget matched the cost of the prioritized actions, indicating that this approach would be effective if the budget was set as part of the prioritization process. The ranking schemes varied in performance, and achieving a close to optimal solution was not guaranteed. Global sensitivity analysis revealed a threat's expected impact and, to a lesser extent, management effectiveness were the most influential parameters, emphasizing the need to focus research and monitoring efforts on their quantification.

323 Selective fetoscopic laser or expectant management for quintero stage i twin-twin transfusion: a cost-effectiveness analysis

To determine whether selective fetoscopic laser photocoagulation (SFLP) or expectant management (EM) is a cost-effective strategy for management of Quintero stage I twin-twin transfusion syndrome (TTTS). A decision-analysis (DA) model compared SFLP to EM for 100000 pregnant people with monochorionic-diamniotic twins affected by stage I TTTS. All subjects were assumed to be appropriate candidates for either strategy. Probabilities, costs, and utilities were derived from the literature. The DA was conducted from a health care payor perspective and the analytic horizon was over the course of a child’s lifetime, with primary outcomes of survivorship (i.e., no intrauterine fetal demise or neonatal death) and long-term neurodevelopmental impairment (NDI). Markov processes were employed, cycling every 4 weeks throughout pregnancy. Incremental cost-effectiveness ratios (ICER) for each strategy were calculated and compared to determine marginal cost effectiveness. An ICER of $100,000 per quality-adjusted life year (QALY) was used to define the cost-effectiveness threshold. One-way sensitivity and Monte Carlo analyses (MCA) were performed. For base-case estimates, SFLP was found to be cost effective compared to EM in the management of stage I TTTS (Table). Compared to EM, SFLP resulted in 29184 fewer pregnancies affected with no survivors; 2346 more pregnancies with 1 survivor, and 26838 more pregnancies with 2 survivors. Furthermore, there were 4649 fewer cases of NDI. On one-way sensitivity analyses, if the probability of NDI after SFLP for pregnancies affected by stage I TTTS was above 0.078, then EM was the cost-effective strategy (Figure). MCA demonstrated that SFLP was cost-effective in 98.1% of runs. With base-case estimates, SFLP is a more cost-effective strategy than EM for the treatment of Stage I TTTS. However, given the limited data informing base-case estimates, further determination of outcome probabilities is needed to determine with high confidence which strategy is more cost-effective.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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.

Neural Network Modeling Based on the Bayesian Method for Evaluating Shipping Mitigation Measures

Climate change caused by greenhouse gas emissions is of critical concern to international shipping. A large portfolio of mitigation measures has been developed to mitigate ship gas emissions by reducing ship energy consumption but is constrained by practical considerations, especially cost. There are difficulties in ranking the priority of mitigation measures, due to the uncertainty of ship information and data gathered from onboard instruments and other sources. In response, a neural network model is proposed to evaluate the cost-effectiveness of mitigation measures based on decarbonization. The neural network is further enhanced with a Bayesian method to consider the uncertainties of model parameters. Three of the key advantages of the proposed approach are (i) its ability to simultaneously consider a wide range of sources of information and data that can help improve the robustness of the modeling results; (ii) the ability to take into account the input uncertainties in ranking and selection; (iii) the ability to include marginal costs in evaluating the cost-effectiveness of mitigation measures to facilitate decision making. In brief, a negative “marginal cost-effectiveness” would indicate a priority consideration for a given mitigation measure. In the case study, it was found that weather routing and draft optimization could have negative marginal cost-effectiveness, signaling the importance of prioritizing these measures.

Implementing Interventions with Varying Marginal Cost-Effectiveness: An Application in Precision Medicine.

Purpose. A range of barriers may constrain the effective implementation of strategies to deliver precision medicine. If the marginal costs and consequences of precision medicine vary at different levels of implementation, then such variation will have an impact on relative cost-effectiveness. This study aimed to illustrate the importance and quantify the impact of varying marginal costs and benefits on the value of implementation for a case study in precision medicine. Methods. An existing method to calculate the value of implementation was adapted to allow marginal costs and consequences of introducing precision medicine into practice to vary across differing levels of implementation. This illustrative analysis used a case study based on a published decision-analytic model-based cost-effectiveness analysis of a 70-gene recurrence score (MammaPrint) for breast cancer. The impact of allowing for varying costs and benefits for the value of the precision medicine and of implementation strategies was illustrated graphically and numerically in both static and dynamic forms. Results. The increasing returns to scale exhibited by introducing this specific example of precision medicine mean that a minimum level of implementation (51%) is required for using the 70-gene recurrence score to be cost-effective at a defined threshold of €20,000 per quality-adjusted life year. The observed variation in net monetary benefit implies that the value of implementation strategies was dependent on the initial and ending levels of implementation in addition to the magnitude of the increase in patients receiving the 70-gene recurrence score. In dynamic models, incremental losses caused by low implementation accrue over time unless implementation is improved. Conclusions. Poor implementation of approaches to deliver precision medicine, identified to be cost-effective using decision-analytic model-based cost-effectiveness analysis, can have a significant economic impact on health systems. Developing and evaluating the economic impact of strategies to improve the implementation of precision medicine will potentially realize the more cost-effective use of health care budgets.

Cost-effectiveness analysis of energy efficiency measures for maritime shipping using a metamodel based approach with different data sources

A large number of mitigation strategies including both technical and operational measures have been proposed to reduce ship energy consumption and hence carbon emissions. Under cost and other practical constraints, when prioritizing among mitigation measures, different data sources such as observed data from physical systems and simulated data from simulation models may be used. Data obtained from different sources have different characteristics in terms of accuracy and data volume. Therefore, it is important to integrate different data sources when evaluating alternative mitigation measures in a systematic and systemic manner. In response, a Gaussian process metamodel based method is proposed to evaluate energy saving measures when different data sources are combined synergistically. In addition, a cost-effectiveness analysis is used to prioritize the mitigation strategies based on cost considerations. A case study is developed to demonstrate the advantages of the proposed method in terms of accuracy and efficiency. All mitigation measures selected in the case study are found to have a negative cost which can translate to both energy and cost savings. Among the evaluated measures, speed reduction has shown to be the most plausible measure in terms of energy savings and marginal cost-effectiveness.

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.

Long-Term Evaluation of Outcomes for Abdominal Ultrasound Screening for Hepatocellular Carcinoma

Background: Mass screening for hepatocellular carcinoma (HCC) with abdominal ultrasound (AUS) has been demonstrated in short-term follow-up in Taiwan, but long-term effectiveness and cost-effectiveness of AUS have not been well studied particularly when the recently emerging antiviral therapy has been introduced. The aim of this study is therefore to evaluate long-term outcomes of population-based organized service screening program without control group. Methods: AUS screening based on a risk score–guided invitation has been launched since October 2008 in Changhua. A total of 85,147 subjects aged 40-74 years attended the Changhua community-based integrated screening (CHCIS) program were targeted. Those with high score based on hepatitis virus infection, ALT, AST, type 2 diabetes, platelet count were invited to receive ultrasonography screening performed by board-certified gastroenterologists in town-based health center to identify liver cirrhosis, and suspected HCC cases. We developed a pseudo-control group by building up the disease natural history for HCC embedded with the risk prediction model and the survival by detection modes. The pseudo-control model was further used to the development of health economic decision model for cost-effectiveness of various preventive strategies. Results: We observed a 61% (RR = 0.39, 95% CI: 0.32-0.46) HCC mortality reduction with AUS by risk groups together with ∼30% coverage rate of antiviral therapy in an 8-year period. The simulated results indicates the additional contribution of 30% compliance rate of antiviral therapy (empirical estimate) to HCC mortality reduction was ∼22%. The corresponding figures were raised to 30% and 35% when the compliance rate of antiviral therapy was enhanced to 50% and 70%, respectively. The results of cost-effectiveness analysis shows the incremental cost-effectiveness ratio was $22,849 for the administration of AUS, and $101,849 for the administration of AUS plus 30% compliance to antiviral therapy. The corresponding figures for 50% and 70% compliance rate to antiviral therapy were $141,805 and $181,919, respectively. Conclusion: The population-based screening program for HCC together with antiviral therapy achieved HCC mortality reduction by 60%. The computer study design with a pseudo-control group on the basis of disease natural history of HCC embedded with the predictive model, and the survival part of HCC enables us to quantify the attributable proportion from different preventive regimes, and to estimate long-term effectiveness of the overall and marginal effectiveness and cost-effectiveness of AUS and antiviral therapy under different scenarios. Such approach provides the health policy-makers a reference for resource allocation.

Diminishing marginal cost-effectiveness in risk-targeted lung cancer screening

The article, entitled “Risk-Targeted Lung Cancer Screening: A Cost-Effectiveness Analysis,” published in the Annals of Internal Medicine (1), is the first to report that the marginal gain in cost-effectiveness would be modest using risk-targeted lung cancer screening.

Is it time for Universal Varicella Vaccination in Chile? A health economic analysis

Background: Although the Latin American Society of Pediatric Infectious Diseases (SLIPE) recommended adoption of Universal Varicella Vaccination (UVV) in 2016, UVV is not offered in Chile. In this study, we evaluate the health and economic impact of introducing UVV in Chile. Methods & Materials: A dynamic transmission model of varicella infection with proportionate mixing in a static population and force of infection varying over age, time, and vaccination status was adapted. Seroprevalence data from Argentina, indicating relatively low varicella virus transmission (with 15% of adults never been exposed to natural varicella), were used for calibration in the absence of available Chilean data. Healthcare resource utilization and costs were estimated from a recent study of the clinical characteristics and economic costs of hospitalized varicella patients in Chile. The Chilean immunization schedule currently has vaccination visits at 12 months, 18 months, and 6 years of age during which varicella vaccination could be offered; the following one- (1D) and two-dose (2D) vaccination strategies were considered (age at vaccination/vaccination coverage %): 1D-Early (12m/90%); 1D-Late (18m/85%); 2D-Early-Short (12m/90%, 18m/85%); 2D-Early-Long (12m/90%, 6y/85%); 2D-Late-Long (18m/85%, 6y/85%). Costs were evaluated in 2017 United States Dollars (USD) (1 USD = 633.527 Chilean Pesos). Costs and benefits were discounted at 3%; a 25-year time horizon was used. Results: The model estimates 185,419 varicella cases/year (incidence rate 1023/100,000) in Chile in the absence of UVV with 28 deaths per year. All vaccination strategies were cost saving. The most cost-saving strategy is 1D-Early. 1D-Early UVV will reduce the varicella case load by 87%/99.4%/99.5%/99.7% at 1/5/10/25 years after vaccination, and is estimated to save 3.6M/52M/109M/269M USD (discounted) respectively. Two-dose strategies are more effective, but more costly. Although two-dose strategies are cost effective compared to not vaccinating, the marginal incremental cost effectiveness compared to one-dose strategies is very high. 2D-short is the most effective and cost effective of the two-dose strategies, and can reduce breakthrough varicella by 65-75% compared to one-dose strategies. Conclusion: Both one- or two-dose UVV is estimated to be cost-saving in Chile. Because of historically low varicella transmission rates, UVV can rapidly and sustainably reduce the burden of varicella in Chile.

Primary Spontaneous Pneumothorax: Looking Beyond the Usual

Primary Spontaneous Pneumothorax: Looking Beyond the Usual

Cost-effectiveness of mammography from a publicly funded health care system perspective.

The implementation of population-wide breast cancer screening programs has important budget implications. We evaluated the cost-effectiveness of various breast cancer screening scenarios in Canada from a publicly funded health care system perspective using an established breast cancer simulation model. Breast cancer incidence, outcomes and total health care system costs (screening, investigation, diagnosis and treatment) for the Canadian health care environment were modelled. The model predicted costs (in 2012 dollars), life-years gained and quality-adjusted life-years (QALYs) gained for 11 active screening scenarios that varied by age range for starting and stopping screening (40-74 yr) and frequency of screening (annual, biennial or triennial) relative to no screening. All outcomes were discounted. Marginal and incremental cost-effectiveness analyses were conducted. One-way sensitivity analyses of key parameters assessed robustness. The lifetime overall costs (undiscounted) to the health care system for annual screening per 1000 women ranged from $7.4 million (for women aged 50-69 yr) to $10.7 million (40-74 yr). For biennial and triennial screening per 1000 women (aged 50-74 yr), costs were less, at about $6.1 million and $5.3 million, respectively. The incremental cost-utility ratio varied from $36 981/QALY for triennial screening in women aged 50-69 versus no screening to $38 142/QALY for biennial screening in those aged 50-69 and $83 845/QALY for annual screening in those aged 40-74. Our economic analysis showed that both benefits of mortality reduction and costs rose together linearly with the number of lifetime screens per women. The decision on how to screen is related mainly to willingness to pay and additional considerations such as the number of women recalled after a positive screening result.

Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative

Objectives To evaluate the impact of total knee replacement on quality of life in people with knee osteoarthritis and to estimate associated differences in lifetime costs and quality adjusted life...

Simplified Pneumococcal Vaccination Schedules for Adults Age 50 and Over Lead to Worse Health

Background: In 2014 the Advisory Committee on Immunization Practices (ACIP) approved a dose of 13-valent pneumococcal conjugate vaccine (PCV13) for all adults at age 65 years. This further complicated the pneumococcal vaccination schedule, which was already one of the most complicated schedules. Objective: This study documents simplified schedules that were considered and discarded by the pneumococcal working group before making the most recent recommendation. We examined the marginal cost-effectiveness of several simplified schedules for older adults (age 50+ years) when compared with current recommendations. Our primary outcome was the cost-effectiveness ratio of quality-adjusted life years to cost. Methods: We used a probabilistic model following a cohort of 50 year-olds with separate vaccination coverage and disease incidence data for healthy adults and adults at increased risk of pneumococcal disease. We compared incremental cost-effectiveness ratios from the schedule that was ultimately recommended with each potential simplified vaccination strategy. Results: Most schedules analyzed resulted in several hundred additional deaths. While several possible schedules resulted in cost savings, these cost savings were modest compared to the health costs associated with them. Conclusion: The schedule recommended by the ACIP in 2014, while complex, is the most health promoting compared to the modeled alternative schedules. The incremental cost-effectiveness ratio of the current schedule when compared to simplified alternatives is comparable to other vaccine-related interventions.