Markov Model Of Cost-effectiveness Research Articles

Vaginal hysteropexy compared with vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year cost-effectiveness Markov model.

Our objective was to perform a 5-year cost-effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse. A decision analytic model assessed the cost-effectiveness of the surgical intervention over a 5-year horizon. This model was constructed using TreeAge® software. Healthy women undergoing surgery for uterine prolapse were modeled. A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed. The primary outcome was the incremental cost-effectiveness ratio (ICER) of <$100 000 per quality-adjusted life year (QALY). Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP-SS and HP-US are cost-effective at a willingness-to-pay (WTP) threshold of <$100 000 per QALY. The incremental cost-effectiveness ratio (ICER) for HP-US compared to HP-SS is $90 738.14, while VH-US and VH-SS are both dominated strategies. HP-US is the optimal cost-effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost-effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000. Hysteropexy surgical strategies are cost-effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost-effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost-effectiveness relationship between these different surgical approaches.

Cost-effectiveness analysis of palliative care of cancer patients in the end of life

Home palliative care services of terminal patients may associate home care preferences with desirable health outcomes. This study aimed to evaluate the cost-effectiveness of home palliative care of cancer patients in the last year of life in the public health subsector in a province of Argentina. A cost-effectiveness Markov model was developed from a social and the health funder's perspective in order to reflect the reality of home palliative care at the local level compared with usual care. Direct costs to the health system and indirect costs of unpaid informal care were estimated based on local information. Palliative care increased the likelihood of patients dying at home by 10.32% compared with usual care, with annual savings of USD 750 and USD 1,012 per patient, respectively, from both the social and the funder's perspective in the public health subsector in Río Negro. From both the social and financial perspective, the strategy to implement organized care services was more effective and lower-cost, measured by the percentage of patients who died at home. From a social perspective, the main cost inducer was the formal care provided by families, but from the funder's perspective, it refers to the salaries of the health team.

Cost-Effectiveness of PET Directed Versus Combined Modality Therapy for Early-Stage Favorable Hodgkin's Lymphoma.

The standard of care for early-stage Hodgkin Lymphoma (HL) is combined modality therapy (CMT) consisting of chemotherapy and involved site radiation therapy (ISRT). Recent treatment de-escalation trials have assessed the impact of omitting radiation with the use of positron emission tomography (PET) and have suggested a detriment in progression free survival (PFS) for patients who do not receive radiation therapy (RT) but similar overall survival. The purpose of this study was to compare the cost-effectiveness of PET-directed therapy versus standard of care CMT. This study used a cost-effectiveness Markov model simulating 5 year outcomes for 1 million patients with early-stage HL treated with either PET-directed therapy consisting of 2 cycles of ABVD chemotherapy ± ISRT or CMT consisting of 2 cycles of ABVD+ISRT. Patients progressed to no evidence of disease, progression of disease (PD), or death. Patients with PD underwent salvage therapy with high dose chemotherapy and stem cell transplant (HDC-SCT). The primary outcome measured was the incremental cost-effectiveness ratio. Deterministic sensitivity analyses were performed. We found that PET-directed therapy and CMT strategies were associated with costs of $47,362 and $41,167, respectively. The CMT strategy was equally as effective as the PET-directed therapy strategy with QALYs of 3.4. On 1-way sensitivity analyses, the model was most sensitive to CMT and HDC-SCT costs. Two-way sensitivity analyses showed the model was sensitive to the relative costs of these treatments. For patients with early-stage HL, CMT is the cost-effective strategy as compared with PET-directed therapy.

PRO14 IMPROVED QUALITY OF LIFE AND LIFE-YEARS IN PATIENTS WITH INFANTILE-ONSET SMA FOLLOWING TREATMENT WITH NUSINERSEN

Spinal muscular atrophy (SMA) is a rare, hereditary neuromuscular disorder. Newborns with infantile-onset SMA have extremely limited motor abilities and a short life expectancy. Nusinersen is the only approved treatment for SMA. The objective of this study is to develop a cost-effectiveness (CE) model to report the clinical benefits and cost-offsets of nusinersen in infantile-onset SMA (most likely to develop SMA Type I or II) from a United States (US) third-party payer perspective. A deterministic cost-effectiveness Markov model was constructed based on the ENDEAR trial, natural history data, and clinical opinions. Health states were consistent with infantile-onset SMA and based on the Hammersmith Infant Neurological Examination motor abilities scale. Disease management costs and utility values specific to the US were obtained from the literature. Life years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of nusinersen compared with standard of care (SOC) were reported. Over a lifetime horizon of 60 years, patients treated with nusinersen had an estimated incremental 2.22 discounted LYs compared to SOC (4.37 and 2.15, respectively), and 1.64 discounted QALYs (2.05 and 0.41, respectively). While the ICER of nusinersen versus SOC exceeded $500,000/QALY threshold for orphan drugs, the estimated incremental cost offset of direct disease management was $175,772 for patients treated with nusinersen versus SOC who had not achieved any milestones. Additionally, nusinersen compared to SOC resulted in an estimated higher proportion of patients achieving motor milestones of sitting, standing or walking with assistance (42.8% versus 3.3%) and walking unaided (21.8% versus 0%). Compared with SOC, infantile-onset patients treated with nusinersen are estimated to live longer with less disease burden than patients who received SOC. It is important to consider the clinical benefits and overall survival when assessing the value of a rare-disease treatment in order to inform clinical practice.

Abstract 26: The Corrie Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) Study: 30-Day Readmission Rates and Cost-Effectiveness of a Novel Digital Health Intervention for Acute Myocardial Infarction Patients

Purpose: Determine if acute myocardial infarction (AMI) patients using a novel digital health intervention, the Corrie Health Digital Platform (Corrie), have reduced 30-day hospital readmissions and related healthcare costs compared to a historical comparison group. Methods: Corrie is deployed to patients admitted to Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Massachusetts General Hospital, and Reading Hospital for an AMI (STEMI or type 1 NSTEMI), as early as possible during their hospitalization in the inpatient cardiac units. AMI patients are enrolled if they are: over 18 years old; English-speaking; without auditory, visual, cognitive, or physical impairment; and own a smartphone. Corrie is deployed to patients using a standard operating procedure and consists of the following: (1) a smartphone medication, education, vitals, and follow-up appointments self-management app, (2) smartwatch for reminders and heart rate and physical activity tracking, and (3) a Bluetooth-enabled blood pressure cuff. Patients are either enrolled with their personal iPhone or a loaner iPhone, if they own any other type of smartphone, and a loaner smartwatch for usage during the 30 day study period. The historical comparison group consists of AMI patients, admitted at the same hospitals from October 1 st 2015-2016, who did not receive Corrie. All-cause readmission rates will be evaluated at 30 days after discharge in both groups and Cox proportional hazard models will be used to test differences in time to all-cause first readmission within 30 days between groups, controlling for covariates. To assess cost-effectiveness of Corrie, a Markov Model of cost-effectiveness will be built, based on 30-day readmission rates, to assess the Incremental Cost-Effectiveness Ratio of adopting Corrie. Results/Conclusions: The MiCORE study is being completed and results will be available for AHA QCOR by April 2019.

Comparing the Air Medical Prehospital Triage Score With Current Practice for Triage of Injured Patients to Helicopter Emergency Medical Services

Importance Little evidence exists to guide helicopter emergency medical services (HEMS) triage, and current practice is inefficient. The Air Medical Prehospital Triage (AMPT) score was developed to identify patients most likely to benefit from HEMS compared with ground EMS. To our knowledge, no studies have evaluated the potential effect on costs and outcomes of a more targeted HEMS triage strategy, such as the AMPT score. Objective To evaluate the cost-effectiveness of current practice compared with the AMPT score for HEMS scene triage of trauma patients. Design, Setting, and Participants A cost-effectiveness Markov model was developed for the US health care system to compare current practice with the AMPT score as HEMS scene triage strategies from the health care system perspective over a patient lifetime horizon. A base case was estimated using national data of patient characteristics from the National Trauma Databank from 2007 to 2012. Model inputs, including demographic information, health care costs, survival, and utility estimates, were derived from literature and national registries. Triage strategies were modeled as probability of HEMS transport. Multilevel logistic regression was used to evaluate survival probability between HEMS and ground EMS under the triage strategies. Costs considered included transport reimbursements, hospitalization, cost of health care in the first year postinjury, and annual cost of health care after the first year postinjury. Several sensitivity analyses were performed to evaluate robustness of model assumptions. Main Outcomes and Measures Incremental cost-effectiveness ratio, with a threshold of $100 000 or less per quality-adjusted life-year defining cost-effectiveness. Results The base case had an incremental cost-effectiveness ratio of $255 333 per quality-adjusted life-year for current practice compared with the AMPT score. Assuming 20% of patients have severe injuries and assuming HEMS only benefits these patients, current practice had an incremental cost-effectiveness ratio of $176 686 per quality-adjusted life-year. Probabilistic sensitivity analysis demonstrated that current practice is inferior in 85% of iterations, only becoming favored when the cost-effectiveness threshold is greater than $310 000 per quality-adjusted life-year. Conclusions and Relevance Current practice is not cost-effective compared with the AMPT score for HEMS scene triage. The AMPT score was the preferred strategy across a range of model input values in sensitivity analyses. The AMPT score identifies patients most likely to benefit from HEMS while potentially reducing costs to the health care system and should be considered in air medical transport protocols for trauma patients.

Health economics of targeted intraoperative radiotherapy (TARGIT-IORT) for early breast cancer: a cost-effectiveness analysis in the United Kingdom

ObjectiveThe clinical effectiveness of targeted intraoperative radiotherapy (TARGIT-IORT) has been confirmed in the randomised TARGIT-A (targeted intraoperative radiotherapy-alone) trial to be similar to a several weeks’ course of whole-breast external-beam...

Abstract P1-10-18: The use of hypofractionated radiotherapy for the treatment of women with early breast cancer in the Brazilian public health system may increase access to treatment: Cost effectiveness and budget impact analyses

Abstract OBJECTIVES: To evaluate the cost effectiveness and economic impact of increasing the use of hypofractionated radiotherapy for the treatment of women older than 50 years, with early breast cancer(stages I and II) within the Brazilian National Health System(SUS).METHODS:Several studies show no difference concerning efficacy and safety between hypofractionated and conventional radiotherapy for the treatment of women older than 50 years with stages I and II disease.We built a cost-effectiveness Markov model in Excel which quantifies the cost and the amount of photon beams linear accelerator time used for the treatment of patients using hypofractionated(2.67Gy/fraction) or conventional(2Gy/fraction).The time horizon is 5 years.The perspective of the study is the SUS.The effectiveness was measured as amount of hours saved using hypofractionated in relation to conventional radiotherapy.Costs related to treatment are from DATASUS,and considered the cost of planning the radiotherapy, of the check-film and the use of photon beams linear accelerator.The discount we applied was 5% for costs and benefits.We performed univariate and probabilistic sensitivity analyses. The treatment fraction time was set as 15 minutes. We also built, in Excel, a budget impact model to simulate the increasing adoption of hypofractionated radiotherapy instead of conventional radiotherapyin the treatment of Brazilian women older than 50 years with early breast cancer.The model compares hypofractionated radiotherapy(2.67Gy/fraction) with conventional radiotherapy(2 Gy/fraction).We determined the number of women over 50 years with stages 1 and 2 breast malignant neoplasm that underwent adjuvant radiotherapy in 2013 and 2014, and then projected these populations for the years 2016 to 2020.We considered the costs of planning the radiotherapy, using the photon beams linear accelerator, and performing the check-film.We considered a yearly increase of 20% in the adoption of hypofractionated radiotherapy for the years 2016 to 2019(2016 20%;2017 40%;2018 60%;2019 80% and 2020 90%).The treatment fraction time was set as 15 minutes. RESULTS: The use of hypofractionated radiotherapy at 5 years was able to decrease the number of hours of treatment(-21,835hours) and the total cost of treatment (-$11,790,229.64).The technology is cost saving.Based on the budget impact analysis, the annual incremental impact would be of -$243,202.65, -$490,294.13, -$741,085.61, -$995,388.73 and -$1,127,712.81 providing 3,378, 6.810, 10,294, 13,826 and 15,664 free hours of the linear accelerator for the years 2016, 2017, 2018, 2019 and 2020, respectively.These photon beams linear accelerator free hours may allow 613, 1,380, 2,306, 3,392 and 4,010 additional patients to have access to breast cancer treatment during the years of 2016 to 2020 respectively. CONCLUSIONS:Considering the conditions proposed in these models increasing the use of hypofractionation as a radiotherapy technique to treat women older than 50 years, with early breast cancer within seems to increase the system efficiency saving money, optimizing the treatment schedule and providing access to treatment for more patients. Citation Format: Andrade TRdM, Nazário ACP, Fonseca MCM. The use of hypofractionated radiotherapy for the treatment of women with early breast cancer in the Brazilian public health system may increase access to treatment: Cost effectiveness and budget impact analyses [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-18.

VP131 Comparison Of Variation Methods For One-Way Sensitivity Analyses

INTRODUCTION:A common approach to one-way sensitivity analysis is to vary inputs by a constant percentage. An alternative is to derive ranges using evidence-based probability distributions from published sources. Our objective was to compare one-way sensitivity analysis results when using these two approaches for a reference case model, along with two additional case studies.METHODS:For the reference case, we replicated a published Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) cost-effectiveness Markov model (zidovudine versus zidovudine plus lamivudine in the UK) using TreeAge®. Health states included three HIV/AIDS states and death. We generated one-way sensitivity analyses by varying inputs in two ways: (i) using ±15 percent for all inputs, and (ii) using the 2.5 and 97.5 percentile values of the evidence-based probability distributions for all inputs. Our outcome was the mean difference between lower and upper incremental cost-effectiveness ratios (ICERs) for each variation method for the ten most influential inputs. We assessed the number of inputs with a mean difference between lower and upper ICERs of &gt;10 percent of the deterministic ICER.RESULTS:The deterministic ICER was GBP7,654/QALY (quality adjusted life year) for combination therapy versus monotherapy. The mean difference in ICER uncertainty for the evidence-based vs. ±15 percent variation method was GBP3,251/QALY (p = .0096). Six inputs had a mean difference in ICER uncertainty of &gt;10 percent of GBP7,654/QALY (that is, mean difference in ICER uncertainty &gt; GBP765) for the evidence-based variation method, compared to only two inputs for the constant percentage variation method.CONCLUSIONS:For the reference case, the magnitude of uncertainty in the outcome was larger for the evidence-based variation method compared to the constant percentage variation method. Evidence-based uncertainty in inputs should be used in all sensitivity analyses to reflect realistic uncertainty in an outcome and aid decision-making about future research strategies. Additional case studies will be presented using validated models in diabetes and asthma.

Cost-effectiveness of smoking cessation treatment initiated during psychiatric hospitalization: analysis from a randomized, controlled trial.

We examined the cost-effectiveness of smoking cessation treatment for psychiatric inpatients. Smokers, regardless of intention to quit, were recruited during psychiatric hospitalization and randomized to receive stage-based smoking cessation services or usual aftercare. Smoking cessation services, quality of life, and biochemically verified abstinence from cigarettes were assessed during 18 months of follow-up. A Markov model of cost-effectiveness over a lifetime horizon was constructed using trial findings and parameters obtained in a review of the literature on quit and relapse rates and the effect of smoking on health care cost, quality of life, and mortality. Among 223 smokers randomized between 2006 and 2008, the mean cost of smoking cessation services was $189 in the experimental treatment group and $37 in the usual care condition (P < .001). At the end of follow-up, 18.75% of the experimental group was abstinent from cigarettes, compared to 6.80% abstinence in the usual care group (P < .05). The model projected that the intervention added $43 in lifetime cost and generated 0.101 additional quality-adjusted life-years (QALYs), an incremental cost-effectiveness ratio of $428 per QALY. Probabilistic sensitivity analysis found the experimental intervention was cost-effective against the acceptance criteria of $50,000/QALY in 99.0% of the replicates. A cessation intervention for smokers identified in psychiatric hospitalization did not result in higher mental health care costs in the short-run and was highly cost-effective over the long-term. The stage-based intervention was a feasible and cost-effective way of addressing the high smoking prevalence in persons with serious mental illness. ClinicalTrials.gov identifier: NCT00136812.

Cost-Effectiveness of Integrating Tobacco Cessation Into Post-Traumatic Stress Disorder Treatment.

We examined the cost-effectiveness of smoking cessation integrated with treatment for post-traumatic stress disorder (PTSD). Smoking veterans receiving care for PTSD (N = 943) were randomized to care integrated with smoking cessation versus referral to a smoking cessation clinic. Smoking cessation services, health care cost and utilization, quality of life, and biochemically-verified abstinence from cigarettes were assessed over 18-months of follow-up. Clinical outcomes were combined with literature on changes in smoking status and the effect of smoking on health care cost, mortality, and quality of life in a Markov model of cost-effectiveness over a lifetime horizon. We discounted cost and outcomes at 3% per year and report costs in 2010 US dollars. The mean of smoking cessation services cost was $1286 in those randomized to integrated care and $551 in those receiving standard care (P < .001). There were no significant differences in the cost of mental health services or other care. After 12 months, prolonged biochemically verified abstinence was observed in 8.9% of those randomized to integrated care and 4.5% of those randomized to standard care (P = .004). The model projected that Integrated Care added $836 in lifetime cost and generated 0.0259 quality adjusted life years (QALYs), an incremental cost-effectiveness ratio of $32 257 per QALY. It was 86.0% likely to be cost-effective compared to a threshold of $100 000/QALY. Smoking cessation integrated with treatment for PTSD was cost-effective, within a broad confidence region, but less cost-effective than most other smoking cessation programs reported in the literature.

Echo-based screening of rheumatic heart disease in children: a cost-effectiveness Markov model

Objectives:To project the cost-effectiveness of population-based echo screening to prevent rheumatic heart disease (RHD) consequences.Background:RHD is a leading cause of cardiovascular mortality and morbidity during adolescence and young adulthood in low- and middle-per capita income settings. Echocardiography-based screening approaches can dramatically expand the number of children identified at risk of progressive RHD. Cost-effectiveness analysis can inform public health agencies and payers about the net economic benefit of such large-scale population-based screening.Methods:A Markov model was constructed comparing a no-screen to echo screen approach. The echo screen program was modeled as a 2-staged screen of a cohort of 11-year-old children with initial short screening performed by dedicated technicians and follow-up complete echo by cardiologists. Penicillin RHD prophylaxis was modeled to only reduce rheumatic fever recurrence-related exacerbation. Quality-adjusted life years (QALYs) and societal costs (in 2010 Australian dollars) associated with each approach were estimated. One-way, two-way and probabilistic sensitivity analyses were performed on RHD prevalence and transition probabilities; echocardiography test characteristics; and societal level costs including supplies, transportation, and labor.Results:The incremental costs and QALYs of the screen compared to no screen strategy were −$432 (95% CI = −$1357 to $575) and 0.007 (95% CI = −0.0101 to 0.0237), respectively. The joint probability that the screen was both less costly and more effective exceeded 80%. Sensitivity analyses suggested screen strategy dominance depends mostly on the probability of transitioning out of sub-clinical RHD.Conclusion:Two-stage echo RHD screening and secondary prophylaxis may achieve modestly improved outcomes at lower cost compared to clinical detection and deserves closer attention from health policy stakeholders.

Cost Evaluation of Surgical and Pharmaceutical Options in Treatment for Vitreomacular Adhesions and Macular Holes

To evaluate cost-effectiveness and cost utilities for treatment options for vitreomacular adhesions (VMAs) and full-thickness macular holes (MHs). A Markov model of cost-effectiveness and utility. There were no participants. Outcomes of published clinical trials (index studies) of surgical treatment of VMAs and MHs and a prospective, multicenter clinical trial of pharmaceutical vitreolysis with intravitreal ocriplasmin with saline control were used to generate a model for costs of treatment and visual benefits. All techniques were assumed to result in a 2.5-line visual benefit if anatomy was resolved. Markov analysis, with cost data from the Centers for Medicare and Medicaid Services, was used to calculate imputed costs for each primary treatment modality in a facility setting, with surgery performed in a hospital serving as the highest end of the range and nonfacility setting with surgery performed in an ambulatory surgery center serving as the lowest end of the range. Imputed costs of therapy, cost per line saved, cost per line-year saved, cost per quality-adjusted life years (QALYs). When pars plana vitrectomy (PPV) was selected as the primary procedure, the overall imputed cost ranged from $5802 to $7931. The cost per line was $2368 to $3237, the cost per line-year saved was $163 to $233 and the cost per QALY was $5444 to $7442. If intravitreal injection of ocriplasmin was the primary procedure, the overall imputed cost was $8767 to $10 977. The cost per line ranged from $3549 to $4456, the cost per line-year saved was $245 to $307, and the cost per QALY was between $8159 and $10 244. If intravitreal saline injection was used as a primary procedure, the overall imputed cost was $5828 to $8098. The cost per line was $2374 to $3299, the cost per line-year saved was $164 to $227, and the cost per QALY was $5458 to $7583. As a primary procedure, PPV was the most cost-effective therapy in this model. The other treatments had similar costs per QALY saved and compare favorably with costs of therapy for other retinal diseases.

MP71-05 COST-EFFECTIVENESS MARKOV MODEL COMPARING HIGH- AND LOW-ENERGY TRANSURETHRAL MICROWAVE THERAPY FOR BENIGN PROSTATIC HYPERPLASIA

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II1 Apr 2014MP71-05 COST-EFFECTIVENESS MARKOV MODEL COMPARING HIGH- AND LOW-ENERGY TRANSURETHRAL MICROWAVE THERAPY FOR BENIGN PROSTATIC HYPERPLASIA James C. Ulchaker and MD FACS Melissa MartinsonMS PhD James C. UlchakerJames C. Ulchaker More articles by this author and Melissa MartinsonMelissa Martinson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2164AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transurethral microwave therapy (TUMT) can be grouped into low-energy (LE-TUMT) and high-energy (HE-TUMT) categories based on both microwave wattage and intraprostatic temperatures. Historical retreatment rates, meta-analyses and disease management guidelines point to greater durability and clinical effectiveness of HE-TUMT, but cost effectiveness has not previously been compared. We created an economic model comparing cost-effectiveness of LE-TUMT and HE-TUMT. METHODS We constructed a Markov model similar to published models on Benign Prostatic Hyperplasia (BPH) procedures using published outcomes and 2013 Medicare costs. American Urological Association Symptom scores (AUASS), adverse events (AEs), and retreatment rates at annual intervals were obtained from the literature. Costs to treat AEs and retreatment rates were included in calculating total costs. Quality Adjusted Life Years (QALYs) were calculated from preference weights from the literature for health states of BPH, successfully treated BPH, treated BPH with erectile dysfunction, and treated BPH with urinary incontinence, over the time spent in each. RESULTS The table below shows total costs, mean AUASS, and QALYs at 2 and 4 years. Using an incremental cost-effectiveness ratio (ICER) at 4 years, HE-TUMT dominated LE-TUMT where HE-TUMT was more effective and less expensive over time. HE-TUMT saved $3,026 at 4 years and achieved 3 points of greater symptom score improvement, saving $868 per incremental point reduction. CONCLUSIONS Due to higher retreatment rates, LE-TUMT is more expensive than HE-TUMT at 2 and 4 years and less effective. While HE-TUMT dominates LE-TUMT in cost effectiveness in this model, additional studies should compare these costs to BPH medication and surgical therapies. While Medicare costs are clearly lower for drugs on day 1 and higher for surgery on day 1, this type of model has the potential to help identify cost effective options across treatment modalities over the course of time. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e791 Advertisement Copyright & Permissions© 2014MetricsAuthor Information James C. Ulchaker More articles by this author Melissa Martinson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cost-Effectiveness of Retinal Detachment Repair

To evaluate costs and treatment benefits of rhegmatogenous retinal detachment (RD) repair. A Markov model of cost-effectiveness and utility. There were no participants. Published clinical trials (index studies) of pneumatic retinopexy (PR), scleral buckling (SB), pars plana vitrectomy (PPV), and laser prophylaxis were used to quantitate surgical management and visual benefits. Markov analysis, with data from the Center of Medicare and Medicaid Services, was used to calculate the adjusted costs of primary repair by each modality in a hospital-based and ambulatory surgery center (ASC) setting. Lines of visual acuity (VA) saved, cost of therapy, adjusted cost of therapy, cost per line saved, cost per line-year saved, and cost per quality-adjusted life years (QALY) saved. In the facility, hospital surgery setting, weighted cost for PR ranged from $3726 to $5901 depending on estimated success rate of primary repair. Weighted cost was $6770 for SB, $7940 for PPV, and $1955 for laser prophylaxis. The dollars per line saved ranged from $217 to $1346 depending on the procedure. Dollars per line-year saved ranged from $11 to $67. Dollars per QALY saved ranged from $362 to $2243. In the nonfacility, ASC surgery setting, weighted cost for PR ranged from $1961 to $3565 depending on the success rate of primary repair. The weighted costs for SB, PPV, and laser prophylaxis were $4873, $5793, and $1255, respectively. Dollars per line saved ranged from $139 to $982. The dollars per line-year saved ranged from $7 to $49, and the dollars per QALY saved ranged from $232 to $1637. Treatment and prevention of RD are extremely cost-effective when compared with other treatment of other retinal diseases regardless of treatment modality. Retinal detachment treatment costs did not vary widely, suggesting that providers can tailor patient treatments solely on the basis of optimizing anticipated results because there were no overriding differences in financial impact.

Cost‐effectiveness of extended cessation treatment for older smokers

We examined the cost-effectiveness of extended smoking cessation treatment in older smokers. Participants who completed a 12-week smoking cessation program were factorial randomized to extended cognitive behavioral treatment and extended nicotine replacement therapy. A free-standing smoking cessation clinic. A total of 402 smokers aged 50 years and older were recruited from the community. The trial measured biochemically verified abstinence from cigarettes after 2 years and the quantity of smoking cessation services utilized. Trial findings were combined with literature on changes in smoking status and the age- and gender-adjusted effect of smoking on health-care cost, mortality and quality of life over the long term in a Markov model of cost-effectiveness over a lifetime horizon. The addition of extended cognitive behavioral therapy added $83 in smoking cessation services cost [P = 0.012, confidence interval (CI) = $22-212]. At the end of follow-up, cigarette abstinence rates were 50.0% with extended cognitive behavioral therapy and 37.2% without this therapy (P < 0.05, odds ratio 1.69, CI 1.18-2.54). The model-based incremental cost-effectiveness ratio was $6324 per quality-adjusted life year (QALY). Probabilistic sensitivity analysis found that the additional $947 in lifetime cost of the intervention had a 95% confidence interval of -$331 to 2081; the 0.15 additional QALYs had a confidence interval of 0.035-0.280, and that the intervention was cost-effective against a $50 000/QALY acceptance criterion in 99.6% of the replicates. Extended nicotine replacement therapy was not cost-effective. Adding extended cognitive behavior therapy to standard cessation treatment was cost-effective. Further intensification of treatment may be warranted.

A Choice That Matters?

Decision-analytic cost-effectiveness (CE) models combine many different parameters like transition probabilities, event probabilities, utilities and costs, which are often obtained after meta-analysis. The method of meta-analysis may affect the CE estimate. Our aim was to perform a simulation study that compares the performance of different methods of meta-analysis, especially with respect to model-based health economic (HE) outcomes. A reference patient population of 50,000 was simulated from which sets of samples were drawn. Each sample drawn represented a clinical trial comparing two fictitious interventions. In several scenarios, the heterogeneity between these trials was varied, by drawing one or more of the trials from predefined subpopulations. Parameter estimates from these trials were combined using frequentist fixed (FFE) and random effects (FRE), and Bayesian fixed (BFE) and random effects (BRE) meta-analysis. The pooled parameter estimates were entered into a probabilistic cost-effectiveness Markov model. The four methods of meta-analysis resulted in different parameter estimates and HE outcomes, which were compared with the true values in the reference population. Performance statistics were: (1) the percentage of repetitions that the confidence interval of the probabilistic sensitivity analysis covers the true value (coverage), (2) the difference between the estimated and true value (bias), (3) the mean absolute value of the bias (MAD) and (4) the percentage of repetitions that result in a statistically significant difference between the two interventions (statistical power). As the differences between methods could be due to chance, we repeated every step of the analysis 1,000 times to study whether differences were systematic. FFE, FRE and BFE lead to different parameter estimates, but, when entered into the model, they do not lead to large differences in the point estimates of the HE outcomes, even in scenarios where we built in heterogeneity. Random effects methods do not necessarily reduce bias when heterogeneity is added to the trials, and may even increase bias in certain situations. BRE tends to overestimate uncertainty reflected in the CE acceptability curve. FFE, FRE and BFE lead to comparable HE outcomes. BRE tends to overestimate uncertainty. Based on this study, we recommend FRE as the preferred method of meta-analysis.

Cost-Effectiveness of Lanthanum Carbonate in the Treatment of Hyperphosphatemia in Dialysis Patients: A Canadian Payer Perspective

BackgroundHyperphosphatemia is a common and potentially harmful condition in patients with end-stage kidney disease. In Canada, first-line treatment of hyperphosphatemia consists primarily of calcium carbonate (CC). Lanthanum carbonate (LC) and sevelamer hydrochloride (SH) are non–calcium phosphate binders that have been used as second-line therapy in patients intolerant of or not responsive to CC. ObjectivesThe primary objective of the present study was to assess the costs and clinical benefits of second-line use of LC after therapy failure with CC in patients receiving dialysis, from a Canadian payer perspective. The secondary objective was to perform an economic comparison between second-line LC therapy and second-line SH therapy, from a Canadian payer perspective. Short-term outcomes were treatment response and cost per additional responder, and long-term outcomes were survival, number of all-cause hospitalizations, and quality of life. MethodsA cost-effectiveness Markov model was populated with simulated cohorts of 1000 patients receiving incident dialysis, followed life-long. Patients not responsive to CC with a serum phosphate concentration >1.78 mmol/L (>5.5 mg/dL) received a trial regimen with LC. Patients not responsive to LC returned to CC therapy. Patient data from a randomized controlled trial of 800 patients receiving dialysis were used. Extensive (probabilistic) sensitivity analyses were performed. When available, model parameters were based on Canadian data or from a Canadian perspective. All costs are in 2010 Canadian dollars (C$). ResultsResults of the model estimated that in patients responsive to second-line LC therapy, survival increased, on average, 0.44 years (95% confidence interval [CI], 0.35–0.54) per patient when compared with continued CC therapy. The mean (range) costs per patient in the first year of treatment with LC was C$2600 (C$2400–C$2800). Over patients' lifetimes, the second-line LC strategy resulted in a gain of 48.8 (37.1–61.3) life-years and 29.3 (21.4–38.1) quality-adjusted life-years (QALYs). The cost-effectiveness of the second-line LC strategy was C$7900 (C$1800–C$14,600) per life-year and C$13,200 (C$3000–C$25,100) per QALY gained. Most sensitivity analyses did not change the cost-effectiveness outcomes; however, including unrelated future costs raised the incremental cost-effectiveness ratio to C$159,500 (95% confidence interval, C$133,300–C$191,600) per QALY gained. Compared with second-line SH therapy, second-line LC therapy had similar effectiveness and was 23% less expensive. ConclusionsSecond-line treatment with LC is cost-effective in the treatment of end-stage kidney disease in patients with hyperphosphatemia, from a Canadian payer perspective. Second-line treatment with LC is less expensive, with similar effectiveness as second-line treatment with SH. The primary limitation of health economic evaluations of phosphate binders is the relative scarcity of clinical data on the association between phosphate concentration and long-term outcome.

A cost-effectiveness analysis of using azacitidine vs. decitabine in treating patients with myelodysplastic syndromes

Objective:Azacitidine and decitabine are used to treat patients with myelodysplastic syndromes (MDS) in the United States (US). This study sought to assess their relative cost-effectiveness.Design and methods:The authors developed a cost-effectiveness Markov model (1-month cycles) tracking hypothetical cohorts of MDS patients treated with azacitidine or decitabine over 2 years. The model used a US payer perspective and 2009 costs. Health states modeled included MDS with Transfusion Dependence, MDS with Transfusion Independence, Progression to Acute Myelogenous Leukemia (AML), and Death. Incremental cost-effectiveness outcomes included cost per quality-adjusted life year (QALY), cost per life year (LY), cost per patient-month of transfusion independence, and cost per case of AML progression avoided. One-way sensitivity analyses were performed on key model parameters.Results:Compared to decitabine, azacitidine was associated with better survival (1.512 LYs vs 1.292), more QALYs gained (1.041 vs 0.870), more patient-months with transfusion independence (8.328 vs 6.224), and a greater proportion of patients avoiding progression to AML (50.9% vs 28.5%). Total per-patient costs over 2 years for azacitidine were lower than for decitabine ($150,322 vs $166, 212).Limitations:To inform and update the model over time, it will be important that randomized or observational clinical studies be conducted to directly compare azacitidine and decitabine, provide new information on how these medicines are used, and on their relative clinical effectiveness.Conclusion:Results demonstrate that azacitidine provides greater clinical benefit and costs less than decitabine across all key outcomes. These results accentuate the positive role of azacitidine in providing cost-effective care for MDS.