Median Incremental Cost-effectiveness Ratio Research Articles

Cost-effectiveness analysis of community-led HIV self-testing among key populations in Côte d'Ivoire, Mali, and Senegal.

HIV self-testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community-led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost-effectiveness of community-led HIVST in Côte d'Ivoire, Mali and Senegal. An HIV transmission dynamics model was adapted and calibrated to country-specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP-female sex workers (FSW), and men who have sex with men (MSM)-and their sexual partners and clients. We compared the cost-effectiveness of two scenarios against a counterfactual without HIVST over a 20-year horizon (2019-2039). The ATLAS-only scenario mimicked the 2-year implemented ATLAS programme, whereas the ATLAS-scale-up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability-adjusted life-years (DALY) averted. Scenarios were compared using incremental cost-effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to $USD 2022 and estimated using a cost-function to accommodate economies of scale. The ATLAS-only scenario was highly cost-effective over 20 years, even at low willingness-to-pay thresholds. The median ICERs were $126 ($88-$210) per DALY averted in Côte d'Ivoire, $92 ($88-$210) in Mali and 27$ ($88-$210) in Senegal. Scaling-up the ATLAS programme would also be cost-effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale-up scenario were $199 ($122-$338) per DALY averted in Côte d'Ivoire, $224 ($118-$415) in Mali and $61 ($18-$128) in Senegal. Both the implemented and the potential scale-up of community-led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost-effective, as compared to a scenario without HIVST. These findings support the scale-up of community-led HIVST to reach populations that otherwise may not access conventional testing services.

Cost-effectiveness of interventions for HIV/AIDS, malaria, syphilis, and tuberculosis in 128 countries: a meta-regression analysis

Cost-effectiveness analyses have been conducted for many interventions for HIV/AIDS, malaria, syphilis, and tuberculosis, but they have not been conducted for all interventions that are currently recommended in all countries. To support national decision makers in the effective allocation of resources, we conducted a meta-regression analysis of published incremental cost-effectiveness ratios (ICERs) for interventions for these causes, and predicted ICERs for 14 recommended interventions for Global Fund-eligible countries. In the meta-regression analysis, we used data from the Tufts University Center for the Evaluation of Value and Risk in Health (Boston, MA, USA) Cost-Effectiveness Registries (the CEA Registry beginning in 1976 and the Global Health CEA registry beginning in 1995) up to Jan 1, 2018. To create analysis files, we standardised and mapped the data, extracted additional data from published articles, and added variables from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Then we selected ratios for interventions with a minimum of two published articles and three published ICERs that mapped to one of five GBD causes (HIV/AIDS, malaria, syphilis, drug-susceptible tuberculosis, or multi-drug resistant tuberculosis), and to a GBD country; reported a currency year during or after 1990; and for which the comparator intervention was defined as no intervention, standard of care, or placebo. Our meta-regression analysis used all available data on 25 eligible interventions, and quantified the association between ICERs and factors at country level and intervention level. We used a five-stage statistical model that was developed to synthesise evidence on cost-effectiveness analyses, and we adapted it for smaller sample sizes by grouping interventions by cause and type (ie, prevention, diagnostics, and treatment). Using the meta-regression parameters we predicted country-specific median ICERs, IQRs, and 95% uncertainty intervals in 2019 US$ per disability-adjusted life-year (DALY) for 14 currently recommended interventions. We report ICERs in league tables with gross domestic product (GDP) per capita and country-specific thresholds. The sample for the analysis was 1273 ratios from 144 articles, of which we included 612 ICERs from 106 articles in our meta-regression analysis. We predicted ICERs for antiretroviral therapy for prevention for two age groups and pregnant women, pre-exposure prophylaxis against HIV for two risk groups, four malaria prevention interventions, antenatal syphilis screening, two tuberculosis prevention interventions, the Xpert tuberculosis test, and chemotherapy for drug-sensitive tuberculosis. At the country level, ranking of interventions and number of interventions with a predicted median ICER below the country-specific threshold varied greatly. For instance, median ICERs for six of 14 interventions were below the country-specific threshold in Sudan, whereas 12 of 14 were below the country-specific threshold in Peru. Antenatal syphilis screening had the lowest median ICER among all 14 interventions in 81 (63%) of 128 countries, ranging from $3 (IQR 2-4) per DALY averted in Equatorial Guinea to $3473 (2244-5222) in Ukraine. Pre-exposure prophylaxis for HIV/AIDS for men who have sex with men had the highest median ICER among all interventions in 116 (91%) countries, ranging from $2326 (1077-4567) per DALY averted in Lesotho to $53 559 (23 841-108 534) in Maldives. Country-specific league tables highlight the interventions that offer better value per DALY averted, and can support decision making at a country level that is more tailored to available resources than GDP per capita and country-specific thresholds. Meta-regression is a promising method to synthesise cost-effectiveness analysis results and transfer them across settings. Bill & Melinda Gates Foundation.

Clinical and economic implications of using daratumubab with lenalidomide in the 1st and 2nd lines of therapy for multiple myeloma patients

Objective: to assess clinical and economic implications of adding daratumumab (Dara) to the “lenalidomide + dexamethasone” (Rd) treatment program in early lines of therapy for patients with multiple myeloma (MM) ineligible for high-dose chemotherapy (HDCT) with subsequent autologous hematopoietic stem cell transplantation (autoHPSCT).Material and methods. Partitioned survival model was developed to compare overall survival in the treatment programs of MM patients in the 1st to 3rd lines of therapy. The following treatment options were included in the analysis: 1st line – Dara+Rd; 2nd line – “carfilzomib + lenalidomide” (K+Rd) or “ixazomib + lenalidomide” (Ixa+Rd) triplets; 3rd line – pomalidomide (Pom+dex) and Rd+(Dara+Rd)+(Pom+dex) versus Rd+(K/Ixa+Rd)+(Pom+dex/Dara). Probabilities of transition between health states (progression-free, progressed disease, and death) were based on published clinical data. Lifetime direct healthcare costs and incremental cost-effectiveness ratios (ICERs) per 1 life year gained were calculated from a Russian health care perspective. The indicator of the difference in costs between current and expected practice was used in budget impact analysis.Results. Dara+Rd combination increased life expectancy by 1.04 years (+16.05%) and 0.95 years (+14.57%) per patient, and in the target population (n=955) by 995.48 and 903.40 years for (Dara+Rd)+(K+Rd)+(Pom+dex) and (Dara+Rd)+(Ixa+Rd)+(Pom+dex) treatment programs, respectively, compared to Rd use in the 1st line. The ICER per 1 life year gained for Dara+Rd in 1st line therapy was 8.95 mln rubles for (Dara+Rd)+(K+Rd)+(Pom+dex) and 8.41 mln rubles for (Dara+Rd)+(Ixa+Rd)+(Pom+dex). It's lower than the median ICER of 13.64 million per 1 life year gained for antitumor drugs used to treat cancer of lymphatic and hematopoietic tissues (reference ICER). Dara+Rd triplet is used in 2nd line therapy after Rd, the number of life years gained in the target population due to greater efficacy is higher by 291.50 years compared with K+Rd and by 203.93 years compared with Ixa+Rd. The ICER per 1 life year gained for Dara+Rd is also lower than the ICER reference value: 9.25 mln rubles versus 13.64 mln rubles. The budget impact analysis showed that using Dara in early stages of MM therapy does not increase drug provision costs in the target population.Conclusion. The obtained results allowed to conclude that it is economically feasible to add Dara to the 1st and 2nd lines of therapy in lenalidomide treatment programs for MM patients who are not candidates for HDCT with autoHPSCT.

OP51 Use Of Real-World Data In Cost-effectiveness Analysis Of Sequential Biologic Treatment For Rheumatoid Arthritis

IntroductionIn health technology assessment (HTA), economic evaluations assessing biologic drugs for rheumatoid arthritis (RA) involve modeling patients’ responses to multiple treatments given sequentially over a lifetime horizon. When data from randomized controlled trials (RCTs) are scarce, data from non-randomized studies (e.g., single-arm trials [SATs] and disease registries) can be used to supplement the evidence base. This research aimed to demonstrate meta-analytic methods for combining effectiveness data from randomized and non-randomized studies and their corresponding impact on cost-effectiveness estimates.MethodsData comparing patients receiving second-line rituximab with continued background non-biologic treatment were extracted from one RCT and six SATs identified in an HTA assessing second-line rituximab for RA, and from the British Society for Rheumatology Biologics Register-Rheumatoid Arthritis, by applying a target trial emulation approach. A binomial meta-analysis model was used to estimate the probabilities of achieving the European League against Rheumatism (EULAR) response criteria by pooling data from the RCT, SATs, and the registry. The probabilities were entered into a decision model from a previous HTA to derive incremental cost-effectiveness ratio (ICER) estimates for treatment strategies with and without biologic drugs.ResultsCompared with the original analysis, the estimated probability of at least a moderate EULAR response on rituximab from combined sources was substantially lower. For example, the probability obtained from an RCT was 0.68 (95% credible interval [CrI]: 0.345, 0.907), but only 0.29 (95% [CrI]: 0.242, 0.333) when using RCT plus registry data and 0.29 (95% CrI: 0.244, 0.336) for combined RCT, registry, and SAT data. In the cost-effectiveness analysis, the median ICERs were higher when including real-world data.ConclusionsSynthesis of all relevant data, including RWD, provides additional information regarding the variability in cost-effectiveness estimates and can be considered in sensitivity analyses for HTA decision-making.

Cost-effectiveness analysis of interventions to improve diagnosis and preventive therapy for paediatric tuberculosis in 9 sub-Saharan African countries: A modelling study.

Over 1 million children aged 0 to 14 years were estimated to develop tuberculosis in 2021, resulting in over 200,000 deaths. Practical interventions are urgently needed to improve diagnosis and antituberculosis treatment (ATT) initiation in children aged 0 to 14 years and to increase coverage of tuberculosis preventive therapy (TPT) in children at high risk of developing tuberculosis disease. The multicountry CaP-TB intervention scaled up facility-based intensified case finding and strengthened household contact management and TPT provision at HIV clinics. To add to the limited health-economic evidence on interventions to improve ATT and TPT in children, we evaluated the cost-effectiveness of the CaP-TB intervention. We analysed clinic-level pre/post data to quantify the impact of the CaP-TB intervention on ATT and TPT initiation across 9 sub-Saharan African countries. Data on tuberculosis diagnosis and ATT/TPT initiation counts with corresponding follow-up time were available for 146 sites across the 9 countries prior to and post project implementation, stratified by 0 to 4 and 5 to 14 year age-groups. Preintervention data were retrospectively collected from facility registers for a 12-month period, and intervention data were prospectively collected from December 2018 to June 2021 using project-specific forms. Bayesian generalised linear mixed-effects models were used to estimate country-level rate ratios for tuberculosis diagnosis and ATT/TPT initiation. We analysed project expenditure and cascade data to determine unit costs of intervention components and used mathematical modelling to project health impact, health system costs, and cost-effectiveness. Overall, ATT and TPT initiation increased, with country-level incidence rate ratios varying between 0.8 (95% uncertainty interval [UI], 0.7 to 1.0) and 2.9 (95% UI, 2.3 to 3.6) for ATT and between 1.6 (95% UI, 1.5 to 1.8) and 9.8 (95% UI, 8.1 to 11.8) for TPT. We projected that for every 100 children starting either ATT or TPT at baseline, the intervention package translated to between 1 (95% UI, -1 to 3) and 38 (95% UI, 24 to 58) deaths averted, with a median incremental cost-effectiveness ratio (ICER) of US$634 per disability-adjusted life year (DALY) averted. ICERs ranged between US$135/DALY averted in Democratic of the Congo and US$6,804/DALY averted in Cameroon. The main limitation of our study is that the impact is based on pre/post comparisons, which could be confounded. In most countries, the CaP-TB intervention package improved tuberculosis treatment and prevention services for children aged under 15 years, but large variation in estimated impact and ICERs highlights the importance of local context. This evaluation is part of the TIPPI study, registered with ClinicalTrials.gov (NCT03948698).

Cost-Effectiveness of Azacitidine and Ivosidenib in Newly Diagnosed Older, Intensive Chemotherapy-Ineligible Patients with IDH1-Mutant Acute Myeloid Leukemia

Introduction Ivosidenib (IVO) is an oral inhibitor of mIDH1 that is approved in the USA as monotherapy for pts with mIDH1AML, either relapsed/refractory or newly diagnosed, but older/unfit for intensive therapy. The recent AGILE trial (Montesinos et al. NEJM 2022) randomized newly diagnosed, older/intensive chemotherapy-ineligible mIDH1 AML pts to IVO + AZA vs placebo + AZA and showed improved event-free survival (EFS) and overall survival (OS) in the intervention arm. We sought to understand the health economic implications by conducting a cost-effectiveness analysis. Methods Pts with newly diagnosed mIDH1 AML entered our partitioned survival model at age 75 years and received either IVO/AZA or AZA monotherapy. We used recreated pt-level data derived from the Kaplan-Meier curves and at-risk tables for EFS and OS from the AGILE trial for the IVO/AZA arm to fit loglogistic parametric survival distributions. Hazard ratios (HRs) for EFS and OS were used to derive the EFS and OS curves for the AZA arm, respectively. Medication costs were derived from the average sales price (ASP) for AZA and cytarabine listed by the Centers for Medicare and Medicaid Services or the average wholesale price (AWP) for IVO and venetoclax (Ven), respectively. As ASP ranges between 26-30% below the AWP, we used a 28% discount off the AWP for the base-case scenario and varied this discount during sensitivity analyses between 18% and 38%. Costs and practice patterns of treatment discontinuation or treatment interruption due to adverse events, subsequent treatments, supportive and terminal care, and incidence of complications were derived from the original trial or published literature (Table 1). Costs were adjusted for inflation to 2021 US dollars using the personal consumption expenditure health index. Utilities were derived from the literature and were assumed to be equal between treatment arms for the base case scenario as the quality-of-life assessment were not statistically significantly different for IVO/AZA vs AZA in the AGILE trial at most timepoints. Costs and utilities were modeled over a 30-year time horizon and discounted by 3% annually. Model outputs were used to calculate the incremental cost-effectiveness ratio (ICER) for IVO/AZA, which represents the cost in 2021 US dollars (USD) of each additional quality adjusted life-year (QALY) gained compared to AZA. One-way sensitivity analyses were performed to evaluate the impact of individual parameters on the overall model. Utility values were varied with a 10% range and all other variables were varied across a 50% range. We also performed probabilistic sensitivity analyses, in which we described each parameter using a distribution and performed 10,000 Monte Carlo simulations, each time randomly sampling from the distributions of model inputs. Results In the base case scenario, IVO/AZA and AZA resulted in life-time costs of $652,088 and $242,828, respectively, for an incremental cost of $409,260 with IVO/AZA. With an incremental gain of 2.21 QALYs with IVO/AZA (IVO/AZA: 3.10 QALYs; AZA: 0.89 QALYs), the ICER of IVO/AZA compared to AZA was $185,024/QALY. In one-way sensitivity analyses, only a reduction in the AWP of IVO by 32.4% (from $33,693 to $22,788 per 28-day cycle) would yield a reduction in the ICER to below the conventional willingness-to-pay (WTP) threshold of $150,000/QALY. Figure 1 shows the ten variables with the greatest influence on the ICER demonstrating that variations in any of the variables would not achieve an ICER of less than $150,000/QALY. Probabilistic sensitivity analysis yielded a median ICER of $205,124/QALY (95% CI: $129,344 - $346,479) with AZA favored in 91.2% of 10,000 iterations at a WTP threshold of $150,000/QALY. Conclusion Even in the best-case scenario in favor of the IVO arm following AGILE trial assumptions, we calculated an ICER of $185,024/QALY, which makes IVO/AZA unlikely to be cost-effective compared to AZA alone when applying the traditional WTP threshold of $150,000/QALY in patients with newly diagnosed mIDH1 AML. Only a reduction in the price of IVO by 32.4% lowered the ICER to below $150,000/QALY. The influence of more frequent use of 2nd line IVO in the control arm, comparison against an AZA-Ven control arm, differences in utilities, and extended duration of follow up in the prematurely terminated trial on the ICER warrant additional analyses but are likely to further worsen the cost effectiveness of IVO. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: A modelling study

BackgroundExtracorporeal cardiopulmonary resuscitation (E-CPR) is a method of CPR that passes the patient’s blood through an extracorporeal membrane oxygenation (ECMO) device to provide mechanical haemodynamic and oxygenation support in cardiac arrest patients who are not responsive to conventional CPR (C-CPR). E-CPR is being adopted rapidly worldwide despite the absence of high quality trial data and its substantial cost. Published cost-effectiveness data for E-CPR are scarce. MethodsWe developed a mathematical model to estimate the cost-effectiveness of E-CPR relative to C-CPR in adult patients with refractory out-of-hospital cardiac arrest (OHCA). The model was a combination of a decision tree for the acute treatment phase and a Markov model for long-term periods. Cost-effectiveness was evaluated from the Australian health system perspective over lifetime. Cost-effectiveness was expressed as Australian dollars (AUD, 2021 value) per quality-adjusted life year (QALY) gained. Variables were parameterised using published data. Probabilistic and univariate sensitivity analyses were performed. ResultsThe incremental cost-effectiveness ratio (ICER) of E-CPR was estimated to be AUD 45,716 per QALY gained over lifetime (95% uncertainty range 22,102–292,904). The cost-effectiveness of E-CPR was most sensitive to the outcome of the therapy. ConclusionE-CPR has median ICER that is below common accepted willingness-to-pay thresholds. Local factors within the health care system need to be considered to determine the feasibility of implementing an effective E-CPR program.

Cost-effectiveness of rotavirus vaccination in children under five years of age in 195 countries: A meta-regression analysis

BackgroundRotavirus caused an estimated 151,714 deaths from diarrhea among children under 5 in 2019. To reduce mortality, countries are considering adding rotavirus vaccination to their routine immunization program. Cost-effectiveness analyses (CEAs) to inform these decisions are not available in every setting, and where they are, results are sensitive to modeling assumptions, especially about vaccine efficacy. We used advances in meta-regression methods and estimates of vaccine efficacy by location to estimate incremental cost-effectiveness ratios (ICERs) for rotavirus vaccination in 195 countries. MethodsBeginning with Tufts University CEA and Global Health CEA registries we used 515 ICERs from 68 articles published through 2017, extracted 938 additional one-way sensitivity analyses, and excluded 33 ICERs for a sample of 1,418. We used a five-stage, mixed-effects, Bayesian metaregression framework to predict ICERs, and logistic regression model to predict the probability that the vaccine was cost-saving. For both models, covariates were vaccine characteristics including efficacy, study methods, and country-specific rotavirus disability-adjusted life-years (DALYs) and gross domestic product (GDP) per capita. All results are reported in 2017 United States dollars. ResultsVaccine efficacy, vaccine cost, GDP per capita and rotavirus DALYs were important drivers of variability in ICERs. Globally, the median ICER was $2,289 (95% uncertainty interval (UI): $147–$38,993) and ranged from $85 per DALY averted (95% UI: $13–$302) in Central African Republic to $70,599 per DALY averted (95% UI: $11,030–$263,858) in the United States. Among countries eligible for support from Gavi, The Vaccine Alliance, the mean ICER was $255 per DALY averted (95% UI: $39–$918), and among countries eligible for the PAHO revolving fund, the mean ICER was $2,464 per DALY averted (95% UI: $382–$3,118). ConclusionOur findings incorporate recent evidence that vaccine efficacy differs across locations, and support expansion of rotavirus vaccination programs, particularly in countries eligible for support from Gavi, The Vaccine Alliance.

A Systematic Review of Economic Evaluations of COVID-19 Interventions: Considerations of Non-Health Impacts and Distributional Issues

ObjectivesThis study aims to conduct a systematic review of economic evaluations of COVID-19 interventions and to examine whether and how these studies incorporate non-health impacts and distributional concerns. MethodsWe searched the National Institutes of Health’s COVID-19 Portfolio as of May 20, 2021, and supplemented our search with additional sources. We included original articles, including preprints, evaluating both the health and economic effects of a COVID-19–related intervention. Using a pre-specified data collection form, 2 reviewers independently screened, reviewed, and extracted information about the study characteristics, intervention types, and incremental cost-effectiveness ratios (ICERs). We used an Impact Inventory to catalog the types of non-health impacts considered. ResultsWe included 70 articles, almost half of which were preprints. Most articles (56%) included at least one non-health impact, but fewer (21%) incorporated non-economic consequences. Few articles (17%) examined subgroups of interest. After excluding negative ICERs, the median ICER for the entire sample (n = 243 ratios) was $67,000/quality-adjusted life-year (QALY) (interquartile range [IQR] $9000-$893,000/QALY). Interventions including a pharmaceutical component yielded a median ICER of $93,000/QALY (IQR $4000-$7,809,000/QALY), whereas interventions including a non-pharmaceutical component were slightly more cost-effective overall with a median ICER of $81,000/QALY (IQR $12,000-$1,034,000/QALY). Interventions reported to be highly cost-effective were treatment, public information campaigns, quarantining identified contacts/cases, canceling public events, and social distancing. ConclusionsOur review highlights the lack of consideration of non-health and distributional impacts among COVID-19–related economic evaluations. Accounting for non-health impacts and distributional effects is essential for comprehensive assessment of interventions’ value and imperative for generating cost-effectiveness evidence for both current and future pandemics.

Cost-Effectiveness of Liposomal Cytarabine-Daunorubicin (CPX-351) Compared to Conventional Cytarabine-Daunorubicin Chemotherapy in Acute Myeloid Leukemia

Cost-Effectiveness of Liposomal Cytarabine-Daunorubicin (CPX-351) Compared to Conventional Cytarabine-Daunorubicin Chemotherapy in Acute Myeloid Leukemia

Cost-effectiveness of pembrolizumab versus docetaxel as second-line treatment of non-small cell lung cancer in China.

BackgroundPharmacoeconomic information for pembrolizumab as a second-line lung cancer treatment is insufficient in China, so we aimed to assess its cost-effectiveness versus docetaxel as a second-line treatment for patients with non-small cell lung cancer (NSCLC) in China.MethodsA partitioned survival model was developed to assess the cost-effectiveness of pembrolizumab versus docetaxel in the treatment of NSCLC patients. A phase III clinical trial (KEYNOTE-010) was used as the clinical data. Long-term survival data were extrapolated based on the clinical study data. Lifetime cost and utility were calculated with a discount set at 3%. One-way deterministic sensitivity analyses and probabilistic sensitivity analysis were used to test the robustness of incremental cost-effectiveness ratios (ICER).ResultsIn the base-case scenario, the ICERs were $107,846/quality-adjusted life year (QALY) and $448,414/QALY for pembrolizumab (2 and 10 mg/kg) groups, respectively. Both ICER values were 3-fold higher than the threshold of China’s per-capita GDP in 2019 ($30,055.01). One-way deterministic sensitivity analyses showed that the price of pembrolizumab is the main factor affecting the result of ICER. Median ICERs were $108,658/QALY ($107,005/QALY–$110,089/QALY) for the pembrolizumab 2 mg/kg group and $451,590/QALY ($443,685/QALY–$457,496/QALY) for the pembrolizumab 10 mg/kg group using the current price in China. For patients receiving regimens with 2 mg/kg pembrolizumab, the probabilities will be exceeding 95% when the price of pembrolizumab decreases by 25% in a high-income region (willing to pay setting as $71,406/QALY).ConclusionsThe results suggest that for it to become a second-line treatment of NSCLC in China, a reduction in the cost of pembrolizumab is needed.

Do Centers for Medicare and Medicaid Services Quality Measures Reflect Cost-Effectiveness Evidence?

ObjectivesDespite its importance of quality measures used by the Centers for Medicare and Medicaid Services, the underlying cost-effectiveness evidence has not been examined. This study aimed to analyze cost-effectiveness evidence associated with the Centers for Medicare and Medicaid Services quality measures. MethodsAfter classifying 23 quality measures with the Donabedian’s structure-process-outcome quality of care model, we identified cost-effectiveness analyses (CEAs) relevant to these measures from the Tufts Medical Center CEA Registry based on the PICOTS (population, intervention, comparator, outcome, time horizon, and setting) framework. We then summarized available incremental cost-effectiveness ratios (ICERs) to determine the cost-effectiveness of the quality measures. ResultsThe 23 quality measures were categorized into 14 process, 7 outcome, and 2 structure measures. Cost-effectiveness evidence was only available for 8 of 14 process measures. Two measures (Tobacco Screening and Hemoglobin bA1c Control) were cost-saving and quality-adjusted life-years (QALYs) improving, and 5 (Depression Screening, Influenza Immunization, Colon Cancer Screening, Breast Cancer Screening, and Statin Therapy) were highly cost-effective (median ICER ≤ $50 000/QALY). The remaining measure (Fall Screening) had a median ICER of $120 000/QALY. No CEAs were available for 15 measures: 10 defined by subjective patient ratings and 5 employed outcome measures without specifying an intervention or process. ConclusionsWhen relevant CEAs were available, cost-effectiveness evidence was consistent with quality measures (measures were cost-effective). Nevertheless, most quality measures were based on subjective ratings or outcome measures, posing a challenge in identifying supporting economic evidence. Refining and aligning quality measures with cost-effectiveness evidence can help further improve healthcare efficiency by demonstrating that they are good indicators of both quality and cost-effectiveness of care.

Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial

SummaryBackgroundThe HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention.MethodsUsing an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014–30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014–17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030.FindingsDuring 2014–17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014–30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827–2462) per HIV infection averted in Zambia and $3248 (2472–3963) per HIV infection averted in South Africa; and $593 (95% CrI 526–674) per DALY averted in Zambia and $645 (538–757) per DALY averted in South Africa. In the PopART 2014–17 scenario, PopART averted one infection at a cost of $1318 (1098–1591) in Zambia and $2236 (1601–2916) in South Africa, and averted one DALY at $258 (225–298) in Zambia and $326 (266–391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014–30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa.InterpretationCombination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings.FundingUS National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.

Systematic review and meta-analysis of incremental cost-effectiveness ratio (ICER) for new cancer drugs.

66 Background: This systematic review and meta-analysis compared incremental cost-effectiveness ratios (ICERs) of cancer drugs and their relationship with society’s willingness to pay (WTP) across different countries, scenarios and indications. Methods: We sought for cost-effectiveness studies in PubMed, Embase, Cochrane and LILACS published from December 2012 to December 2017. CAR-T cell therapies were excluded given short follow-up. We converted ICERs value and respective annualized 1time the Gross Domestic Product per capita (GDP) - used as a proxy for WTP threshold - into purchase-parity-power dollars (PPP) for better economic reality comparisons. Economics data came from the International Monetary Fund website. Characteristics studied in the distribution of ICERs values were compared using the Mann-Whitney or Kruskal-Wallis U-test with multiple comparison correction and simple linear regression. The chance of ICER being below the 1x GDP threshold was expressed as odds ratio and 95% confidence interval, calculated by logistic regression. Results: We retrieved 354 drug-versus-drug different assessments. PPPconversion increased median ICER of middle-income countries ($32k to $68k;P < 0.001). Median ICER was highest in USA ($154k), followed by other high-income countries ($76k; P < 0.001). In multiple regression, anti-VEGF (P < 0.001) and US-led (P = 0.03) studies had highest ICERs, while curative therapies (p = 0.02) had the lowest ones. 22% of studies were below the WTP bar, none of anti-VEGF, sipuleucel, anti-CD-30, castration-resistant, hepatocarcinoma, and renal cell ones. Immune checkpoint inhibition (OR 8.70; P = 0.045) and middle-income (OR 7.40; P < 0.001) studies were more likely above WTP, whereas curative therapies were more likely below WTP. Conclusions: Cancer therapies’ cost exceeding the WTPs is a worldwide pattern, with some factors related to ICER variation. These findings may foster better understanding and aid stakeholders deal with the global issue of high oncology care costs.

Perspective and Costing in Cost-Effectiveness Analysis, 1974-2018.

ObjectiveOur objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs).MethodsWe analyzed the Tufts Medical Center’s CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives.ResultsStudy authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900–110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67–3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017–2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991–49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486–77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective.ConclusionResearchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.Electronic supplementary materialThe online version of this article (10.1007/s40273-020-00942-2) contains supplementary material, which is available to authorized users.

Screening for Nonalcoholic Fatty Liver Disease in Persons with Type 2 Diabetes in the United States Is Cost-effective: A Comprehensive Cost-Utility Analysis

Screening for Nonalcoholic Fatty Liver Disease in Persons with Type 2 Diabetes in the United States Is Cost-effective: A Comprehensive Cost-Utility Analysis

Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review.

We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations. Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars. Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions-including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment-showed inconsistent results. Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

PMU14 THE USE OF PERSPECTIVE AND COSTING APPROACHES IN COST-EFFECTIVENESS ANALYSIS

To analyze perspective and costing approaches used in published cost-effectiveness analyses (CEA) and their impact on reported incremental cost-effectiveness ratios (ICERs). We analyzed Tufts Medical Center’s CEA and Global Health CEA Registries, containing 6,907 cost-per-quality-adjusted-life-year (QALY) and 709 cost-per-disability-adjusted-life-year (DALY) studies, published from 1974 to 2018. Using collected information on analytic perspective, costing methodology, and reported ICERs, we examined how often published CEAs include cost components beyond those traditionally included and investigated how the inclusion of different cost components influences cost-effectiveness ratios. A healthcare sector perspective was most prevalent (75% of cost-per-QALY and 66% of cost-per-DALY literature). Some CEAs did not clearly state the perspective used (13% of cost-per-QALY and 20% of cost-per-DALY literature). Although most studies included intervention-related medical costs, CEAs seldom included unrelated medical costs. Cost-per-DALY studies were more likely to include at least one non-healthcare cost component than cost-per-QALY studies (34% vs. 21%). The most common non-healthcare cost component was productivity in the cost-per-QALY literature (11%) and patient transportation costs in the cost-per-DALY literature (21%). CEAs rarely assessed impacts on other non-healthcare sectors, such as education or criminal justice system. Of 18,206 cost-per-QALY ratios, the median ICER was $26,000/QALY (inter-quartile range, IQR:3,100-100,000), while 18% of ratios were cost-saving. Of 4,994 cost-per-DALY ratios, the median ICER was $440/DALY (IQR:75-3,400), while 7% of ratios were cost-saving. Among cost-per-QALY ratios calculated from a healthcare sector perspective, the median ICER ($25,000/QALY, IQR:3,100-100,000), was lower than the corresponding median from a societal perspective ($30,000/QALY, IQR:2,300-150,000). Non-industry sponsored studies reported higher ICERs than industry-sponsored studies from both perspectives. Key study attributes, including perspective and cost components, vary substantially in the CEA literature. Researchers and analysts should be transparent about their choices. Revised guidelines by the Second Panel, such as the inclusion of an Impact Inventory, help to reduce inconsistencies across studies and confusion.

Can cost-effectiveness results be combined into a coherent league table? Case study from one high-income country

BackgroundDoubts exist around the value of compiling league tables for cost-effectiveness results for health interventions, primarily due to methods differences. We aimed to determine if a reasonably coherent league table could be compiled using published studies for one high-income country: New Zealand (NZ).MethodsLiterature searches were conducted to identify NZ-relevant studies published in the peer-reviewed journal literature between 1 January 2010 and 8 October 2017. Only studies with the following metrics were included: cost per quality-adjusted life-year or disability-adjusted life-year or life-year (QALY/DALY/LY). Key study features were abstracted and a summary league table produced which classified the studies in terms of cost-effectiveness.ResultsA total of 21 cost-effectiveness studies which met the inclusion criteria were identified. There were some large methodological differences between the studies, particularly in the time horizon (1 year to lifetime) but also discount rates (range 0 to 10%). Nevertheless, we were able to group the incremental cost-effectiveness ratios (ICERs) into general categories of being reported as cost-saving (19%), cost-effective (71%), and not cost-effective (10%). The median ICER (adjusted to 2017 NZ$) was ~ $5000 per QALY/DALY/LY (~US$3500). However, for some interventions, there is high uncertainty around the intervention effectiveness and declining adherence over time.ConclusionsIt seemed possible to produce a reasonably coherent league table for the ICER values from different studies (within broad groupings) in this high-income country. Most interventions were cost-effective and a fifth were cost-saving. Nevertheless, study methodologies did vary widely and researchers need to pay more attention to using standardised methods that allow their results to be included in future league tables.

Cost-effectiveness of preventing hepatitis B virus reactivation in patients with lymphoma and resolved HBV infection

Hepatitis B virus (HBV) reactivation may occur in >10% of patients with lymphoma and resolved HBV infection who undergo rituximab-containing chemotherapy. Preventive strategies may have marked impact on resource allocation in HBV endemic areas. This study aims to compare the cost-effectiveness between prophylactic antiviral therapy and HBV DNA monitoring for the prevention of HBV-related complications. Data sources are studies of HBV-related events and survival for patients with lymphoma and resolved HBV infection published since 2006. Decision tree analysis was used to compare the incremental cost-effectiveness ratio (ICER) of preventing HBV-related death or liver decompensation for patients who undergo first-line rituximab-containing chemotherapy. Sensitivity analysis was performed to examine the impact of the preventive efficacy, the duration of prophylactic antiviral therapy, and the cost of different interventions. The direct medical cost was derived from the database of the NHI Administration, Taiwan. The time frame of our analysis was set to 3 years after the completion of chemotherapy. The median ICER of prophylactic antiviral therapy, according to current practice guidelines, ranged between USD 150,000 and 250,000 if we apply the guidelines generally. When a long-course (12 months after completion of chemotherapy according to clinical guidelines) prophylactic therapy was assumed, Option A was cheaper and more effective only in the anti-HBs-negative subgroup (median ICER US$149,932 vs. US$161,526, p=0.013). Identification of anti-HBs-negative subgroups is critical to improve the cost-effectiveness of prophylactic antiviral therapy in lymphoma patients with resolved HBV infection.