Cost-effectiveness Analysis Of Methods Research Articles

Cost-effectiveness of England’s national ‘Safe At Home’ scheme for reducing hospital admissions for unintentional injury in children aged under 5

BackgroundInjuries in children aged under 5 years most commonly occur in the home and disproportionately affect those living in the most disadvantaged communities. The ‘Safe at Home’ (SAH) national home...

Contraceptive Counseling Strategies for Women Living With Human Immunodeficiency Virus: The Role of Integrating Reproductive Health and Human Immunodeficiency Virus Services to Prevent Perinatal Transmission in Colombia

ObjectivesThis study aimed to evaluate the cost-effectiveness of 2 contraceptive counseling strategies in Colombia for women living with human immunodeficiency virus (HIV). The first integrates (1) reproductive health and HIV services (integrated model [IM]), and the second (2) offers these services separately (non-IM). MethodsCost-effectiveness analysis from the third-party payer perspective (Colombian healthcare system). A decision analysis tree was used over a 24-month time horizon at a 3% discount rate, considering only direct costs. The outcome was the number of averted HIV perinatal transmission infections. We performed a discrete sensibility analysis and a probabilistic second-order sensitivity analysis with 10 000 iterations (Monte Carlo simulation). ResultsCompared with the non-IM, the IM prevented 3% additional HIV perinatal transmission infections, with an incremental cost-effectiveness of US dollar 525 and the highest net monetary benefit at the proposed willingness to pay. In the probabilistic sensitivity analysis, we found a substantial amount of parameter uncertainty that challenges the evidence in favor of the cost-effectiveness of the IM strategy. ConclusionsThis study opens the possibility of integrating reproductive health and HIV services for women living with HIV in Colombia. In addition, it raises the necessity to produce additional good quality local empirical evidence to inform better and support the estimation of the economic efficiency of such a model in the country.

Cost-effectiveness analysis for the parenteral anticoagulants in Jordan

Abstract Objectives Pharmacoeconomic dimensions linking clinical effectiveness of parenteral anticoagulants for management of acute venous thromboembolism (VTE) and cost of treatment are needed to support choices by healthcare providers. The objective of the study was to conduct a cost-effectiveness analysis for 5-day treatment with parenteral anticoagulants in Jordan. Methods Cost-effectiveness analysis was conducted based on decision analysis tree model. The perspective was the payer, considering direct medical costs. Probabilities of failure of treatment and major bleeding were derived from published clinical studies. Costs were estimated based on 2019 prices in Jordan. Key findings The average cost of VTE hospitalization and major bleeding management in Jordan were 2324.00 US$ and 3347.40 US$, respectively. Bemiparin was associated with the highest clinical efficacy and lowest probability of major bleeding. Nadroparin had the lowest clinical efficacy, while tinzaparin was found to have the highest risk of major bleeding. Bemiparin had the lowest average cost-effectiveness ratio (101.63 US$/success) and nadroparin had the highest cost-effectiveness ratio (295.56 US$/success). Throughout the sensitivity analysis calculations, bemiparin and nadroparin had the lowest and highest cost of treatment, respectively. Conclusions The cost of parenteral anticoagulant drugs, the same as many other drugs, does not always correlate with cost of VTE treatment. Other direct medical costs (e.g. treatment failure and management of bleeding) have a high contribution to the total cost calculation. Pharmacoeconomically, bemiparin is the dominant cost-effective parenteral anticoagulant in Jordan, while nadroparin is the dominated one.

A Cost-Effectiveness Analysis of Neuraminidase Inhibitors for Influenza Virus Infections in an Adult-Outpatient Setting in Japan

BackgroundPharmacoeconomic studies have been less performed in Japan. The objective of this study was to clarify which neuraminidase inhibitor (NI; oseltamivir, zanamivir, laninamivir, and peramivir) is most cost-effective in an adult outpatient setting in Japan. ObjectiveTo clarify which neuraminidase inhibitor (NI; oseltamivir, zanamivir, laninamivir, and peramivir) is most cost-effective in an adult outpatient setting in Japan. MethodsCost-effectiveness analysis was constructed from the healthcare payer’s perspective. A decision tree model was constructed with probabilities from relevant randomized controlled trials. Costs included medical costs and drug prices. Medical costs were obtained from the medical fee schedule table (2016 version). We also applied authorized medication costs. Outcomes of effectiveness were measured using EQ-5D-3L questionnaires for adult patients who had experienced influenza virus infections previously. Time horizon was 14 days in this study. ResultsCost-effectiveness ratios for oseltamivir, zanamivir, laninamivir, and peramivir were 393 674 Yen/quality-adjusted life year (QALY; US$3883.41/QALY), 408 241 (US$4027.10), 407 980 (US$4024.53), and 444 264 (US$4382.45), respectively. The cost-effectiveness analysis base-case analysis revealed oseltamivir as the most cost-effective NI. Zanamivir was dominated. Incremental cost effectiveness ratio (ICER) for laninamivir and peramivir were 1 129 459 Yen/QALY (US$11 141.58/QALY) and 1 287 118 (US$12 696.81), respectively. One-way sensitivity analyses revealed that minimum ICERs for laninamivir based on “quality of life (QOL) values (95% confidence interval)” was −596 850 Yen/QALY (US−$5887.64/QALY) owing to high cost and less effective. Also, maximum ICER for peramivir based on“QOL values” was 14 717 518 Yen/QALY (US$145 181.32/QALY); a value more than the 5 000 000 Yen/QALY threshold. ConclusionsThe study results reveal oseltamivir as the most cost-effective NI for the treatment of influenza virus infection in an adult outpatient setting. Our findings may provide decision makers with scientific evidence for clinical and economic evaluation to achieve optimal therapeutic outcomes.

Cost-effectiveness of a novel hybrid closed-loop system compared with continuous subcutaneous insulin infusion in people with type 1 diabetes in the UK

Aims The MiniMed 670 G insulin pump system is the first commercially available hybrid closed-loop (HCL) insulin delivery system and clinical studies have shown that this device is associated with incremental benefits in glycemic control relative to continuous subcutaneous insulin infusion (CSII) with or without continuous glucose monitoring (CGM). The aim was to evaluate the long-term cost-effectiveness of the MiniMed 670 G system versus CSII alone in people with type 1 diabetes (T1D) in the UK. Materials and methods Cost-effectiveness analysis was performed using the IQVIA CORE Diabetes Model. Clinical input data were sourced from a clinical trial of the MiniMed 670 G system in 124 adults and adolescents with T1D. The analysis was performed over a lifetime time horizon and both future costs and clinical outcomes were discounted at 3.5% per annum. The analysis was performed from a healthcare payer perspective. Results The use of the MiniMed 670 G system led to an improvement in quality-adjusted life expectancy of 1.73 quality-adjusted life years (QALYs), relative to CSII. Total lifetime direct costs were GBP 35,425 higher with the MiniMed 670 G system than with CSII resulting in an incremental cost-effectiveness ratio (ICER) of GBP 20,421 per QALY gained. Sensitivity analyses revealed that the ICER was sensitive to assumptions around glycemic control and assumptions relating to the quality-of-life benefit associated with a reduction in fear of hypoglycemia. Limitations Long-term projections from short-term data are inherently associated with uncertainty but represent arguably the best available evidence in lieu of long-term clinical trials. Conclusions In the UK, over patient lifetimes, the incremental clinical benefits associated with the use of MiniMed 670 G system means that it is likely to be cost-effective relative to the continued use of CSII in people with T1D, particularly for those with a fear of hypoglycemia or poor baseline glycemic control.

The cost-effectiveness of an HCV outreach intervention for at-risk populations in London, UK.

BackgroundHCV disproportionately affects marginalized communities such as homeless populations and people who inject drugs (PWID), posing a challenge to traditional health services. The HepFriend initiative in London is a model of care utilizing HCV outreach screening and peer support to link vulnerable individuals to HCV treatment in secondary care.ObjectivesTo assess the cost-effectiveness of the HepFriend initiative from a healthcare provider perspective, compared with standard-of-care pathways (consisting of testing in primary care and other static locations, including drug treatment centres, and linkage to secondary care).MethodsCost-effectiveness analysis using a dynamic HCV transmission and disease progression model among PWID and those who have ceased injecting, including housing status and drug treatment service contact. The model was parameterized using London-specific surveillance and survey data, and primary intervention cost and effectiveness data (September 2015 to June 2018). Out of 461 individuals screened, 197 were identified as HCV RNA positive, 180 attended secondary care and 89 have commenced treatment to date. The incremental cost-effectiveness ratio (ICER) was determined using a 50 year time horizon.ResultsFor a willingness-to-pay threshold of £20000 per QALY gained, the HepFriend initiative is cost-effective, with a mean ICER of £9408/QALY, and would become cost saving at 27% (£10525 per treatment) of the current drug list price. Results are robust to variations in intervention costs and model assumptions, and if treatment rates are doubled the intervention becomes more cost-effective (£8853/QALY).ConclusionsNew models of care that undertake active case-finding with enhanced peer support to improve testing and treatment uptake amongst marginalized and vulnerable groups could be highly cost-effective and possibly cost saving.

Economic evaluation of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: The SHELf randomized controlled trial

ObjectivePricing strategies are a promising approach for promoting healthier dietary choices. However, robust evidence of the cost-effectiveness of pricing manipulations on dietary behaviour is limited. We aimed to assess the cost-effectiveness of a 20% price reduction on fruits and vegetables and a combined skills-based behaviour change and price reduction intervention. Design and methodsCost-effectiveness analysis from a societal perspective was undertaken for the randomized controlled trial Supermarket Healthy Eating for Life (SHELf). Female shoppers in Melbourne, Australia were randomized to: (1) skill-building (n = 160); (2) price reductions (n = 161); (3) combined skill-building and price reduction (n = 161); or (4) control group (n = 161). The intervention was implemented for three months followed by a six month follow-up. Costs were measured in 2012 Australian dollars. Fruit and vegetable purchasing and consumption were measured in grams/week. ResultsAt three months, compared to control participants, price reduction participants increased vegetable purchases by 233 g/week (95% CI 4 to 462, p = 0.046) and fruit purchases by 364 g/week (95% CI 95 to 633, p = 0.008). Participants in the combined group purchased 280 g/week more fruits (95% CI 27 to 533, p = 0.03) than participants in the control group. Increases were not maintained six-month post intervention. No effect was noticed in the skill-building group. Compared to the control group, the price reduction intervention cost an additional A$2.3 per increased serving of vegetables purchased per week or an additional A$3 per increased serving of fruit purchased per week. The combined intervention cost an additional A$12 per increased serving of fruit purchased per week compared to the control group. ConclusionsA 20% discount on fruits and vegetables was effective in promoting overall fruit and vegetable purchases during the period the discount was active and may be cost-effective. The price discount program gave better value for money than the combined price reduction and skill-building intervention.The SHELf trial is registered with Current Controlled Trials Registration ISRCTN39432901.

The Cost-Effectiveness of Bevacizumab in Advanced Ovarian Cancer Using Evidence from the ICON7 Trial

BackgroundBevacizumab is used extensively in the treatment of cancer, including advanced ovarian cancer, for which results of the International Collaborative Ovarian Neoplasm (ICON) 7 trial have been recently reported. The National Institute for Health and Care Excellence’s (NICE’s) recent decision not to recommend bevacizumab for advanced ovarian cancer was not based on evidence related to the unlicensed lower dosage (7.5 mg/kg) of the drug despite its use in the English National Health Service (NHS) and the ICON7 trial. ObjectiveTo report on the findings of an analysis that considered whether the lower dose is cost-effective. MethodsCost-effectiveness analysis is assessed from the perspective of the English NHS and health outcomes expressed in terms of quality-adjusted life-years (QALYs). The analysis focuses on a clinically predefined high-risk subgroup of the ICON7 trial. The price at which the lower dose of bevacizumab could be considered cost-effective for the English NHS is presented for a range of scenarios to inform decisions about price negotiations by international health systems. ResultsIn the base-case analysis, bevacizumab has an incremental cost-effectiveness ratio of £48,975 per additional QALY, which is above NICE’s standard cost-effectiveness threshold (£20,000–£30,000 per QALY). The official price of bevacizumab in 2013 was between £2.31 and £2.63 per milligram. A price reduction of between 46% and 67%, dependent on the NICE threshold, would be required for the product to be cost-effective in the high-risk subgroup. ConclusionsThe lower dose of bevacizumab for advanced ovarian cancer is not cost-effective based on the product’s list price and using NICE’s cost-effectiveness thresholds. Significant price discounts would be needed to make the drug affordable to the NHS.

Economic evaluation among Chinese patients with nosocomial pneumonia caused by methicillin-resistant staphylococcus aureus and treated with linezolid or vancomycin: a secondary, post-hoc analysis based on a Phase 4 clinical trial study

Objective To assess cost-effectiveness of linezolid vs vancomycin in treating nosocomial pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA-NP) in China and the impact of renal failure on healthcare resource utilization (HCRU) and costs. Methods Cost-effectiveness analysis was conducted based on data from the ZEPHyR trial, with efficacy measured by treatment success and costs calculated from HCRU. Confidence intervals (CI) for cost, efficacy and incremental cost-effectiveness ratios (ICER) were calculated by non-parametric bootstrap. Chi-square test was used for renal failure rate and t-test for HCRU/cost comparisons. Impact of renal failure was assessed using regression model. Results Data from 448 patients (1:1 linezolid:vancomycin) were analyzed. More patients treated with linezolid achieved success (55% [95% CI = 48–62%]) than with vancomycin (45% [38–52%]). Treatment cost were ¥79,551 (95% CI = ¥72,421–¥86,680) for linezolid vs ¥77,587 (¥70,656–¥84,519) for vancomycin in Beijing, ¥90,995 (¥82,598–¥99,393) vs ¥89,448 (¥81,295–¥97,601) in Guangzhou, ¥82,383 (¥74,956–¥89,810) vs ¥80,799 (¥73,545–¥88,054) in Nanjing and ¥59,413 (¥54,366–¥64,460) vs ¥57,804 (¥52,613–¥62,996) in Xi’an. Per successful treatment, the ICER of linezolid over vancomycin were ¥19,719 (−¥143,553 to ¥320,980) (Beijing), ¥15,532 (−¥185,411 to ¥349,693) (Guangzhou), ¥15,904 (−¥161,935 to ¥314,987) (Nanjing) and ¥16,145 (−¥100,738 to ¥234,412) (Xi’an). From simulations, the majority of linezolid cases had greater efficacy and higher costs and more than one third had greater efficacy and lower costs. More vancomycin patients developed renal failure (15% vs 4%, p < 0.001). Patients with renal failure had higher cost (Nanjng: ¥100,449 (SD = ¥65,080) vs ¥74,944 (SD = ¥49,632), p = 0.002). Conclusion Linezolid was more cost-effective than vancomycin in treating MRSA-NP from a Chinese payer’s perspective, and associated with less renal failure, HCRU and cost.

Análisis de costo efectividad de ondansetrón para el tratamiento del vómito en niños menores de cinco años con gastroenteritis en Colombia

IntroductionOndansetron reduces hospitalization rates for diarrhea and vomiting in children, but is not yet routinely used. ObjectiveTo estimate from a social perspective the relative cost-effectiveness of ondansetron for the treatment of vomiting in children with gastroenteritis and at risk of dehydration in Colombia. MethodsCost-effectiveness analysis from a social perspective, including direct medical costs and costs for caregivers. With a decision tree we compared costs and health outcomes of usual treatment without antiemetic to usual treatment plus ondansetron in children under 5 years with gastroenteritis and vomiting. Effectiveness of intervention was measured as reduction in hospitalization rates, and the time horizon of the model was the episode. Probabilities were obtained from clinical trials and systematic reviews, measurement of resources use was based on protocols and expert opinions, while unit costs were obtained from Colombian tariff manuals. We performed a survey to estimate indirect costs for caregivers (n=81) that included questions about wage loss, transportation, meals expenditures and other out-of-pocket payments. Deterministic and probabilistic sensitivity analyses were performed. ResultsUsual treatment plus ondansetron is a dominant strategy compared to usual treatment without antiemetic yielding fewer hospitalizations and saving $44.562 Colombian pesos (23,98USD) per episode. Ondansetron was dominant in 98,91% of simulations of the probabilistic analysis. ConclusionsOndansetron is a dominant intervention that reduces hospitalization rates and costs for health system and caregivers. We recommend assessing the inclusion of this drug in the Colombian Health Benefit Plan for the treatment of gastroenteritis in children under 5 years.

Maintenance Cognitive Stimulation Therapy: An Economic Evaluation Within a Randomized Controlled Trial

BackgroundCognitive Stimulation Therapy (CST) is effective and cost-effective for people with mild-to-moderate dementia when delivered biweekly over 7 weeks. AimsTo examine whether longer-term (maintenance) CST is cost-effective when added to usual care. MethodsCost-effectiveness analysis within multicenter, single-blind, pragmatic randomized controlled trial; subgroup analysis for people taking acetylcholinesterase inhibitors (ACHEIs). A total of 236 participants with mild-to-moderate dementia received CST for 7 weeks. They were randomized to either weekly maintenance CST added to usual care or usual care alone for 24 weeks. ResultsAlthough outcome gains were modest over 6 months, maintenance CST appeared cost-effective when looking at self-rated quality of life as primary outcome, and cognition (MMSE) and proxy-rated quality-adjusted life years as secondary outcomes. CST in combination with ACHEIs offered cost-effectiveness gains when outcome was measured as cognition. ConclusionsContinuation of CST is likely to be cost-effective for people with mild-to-moderate dementia.

Evaluación de costo/efectividad de tres combinaciones fijas de acetaminofén y opiáceos para el manejo del dolor agudo en Colombia

ObjectiveTo compare the cost–effectiveness of three different formulations indicated for moderate and severe acute pain, commercialized in Colombia [acetaminophen500 mg + codeine 30 mg (AC), acetaminophen 500 mg + hydrocodone 5 mg (AH) andacetaminophen 325 mg + tramadol 37.5 mg (AT)]. Materials and methodsCost–effectiveness analysis using the NNT as the health outcome indicator. The costs were evaluated in two specific settings: Institutional Channel (IC), rep-resenting the cost for the Colombian Ministry of Health (SISMED 2011); Retail Channel (RC), representing consumer prices, obtained from the IMS annual average for 2011, plus an adjustment to include the average profit margin for pharmacies (10%). The incremental cost effectiveness ratios (ICER) were calculated for the three formulations and the two settings(IC and RC). The intervention values are expressed in Colombian pesos (COP). ResultsThe prices/NNT for each formulation were $1816 COP/2.2 for AC, $4772 COP/2.3 for AH and $5342/2.6 for AT. Using these data and taking AC as the comparator, the ICER for the other formulations shows the following results: in the RC, $5065 COP for AT and $19,600COP for AH; in the IC setting, $8790 COP for AT and $29,460 COP for AH. The probabilistic sensitivity analysis demonstrated that the majority of simulation results fell between the1st and 4th quadrants of the cost–effectiveness matrix, using AC as a reference. ConclusionThe analysis, from the payer and patient perspectives, demonstrates that the AC formulation has a lower cost and is more effective in reducing pain within the first 4–6 h after administration, compared with the AH and AT formulations in their specific indications.

Cost/effectiveness evaluation of three fixed combinations of acetaminophen and opioids in the management of acute pain in Colombia

ObjectiveTo compare the cost–effectiveness of three different formulations indicated for moderate and severe acute pain, commercialized in Colombia [acetaminophen 500mg+codeine 30mg (AC), acetaminophen 500mg+hydrocodone 5mg (AH) and acetaminophen 325mg+tramadol 37.5mg (AT)]. Materials and methodsCost–effectiveness analysis using the NNT as the health outcome indicator. The costs were evaluated in two specific settings: Institutional Channel (IC), representing the cost for the Colombian Ministry of Health (SISMED 2011); Retail Channel (RC), representing consumer prices, obtained from the IMS annual average for 2011, plus an adjustment to include the average profit margin for pharmacies (10%). The incremental cost effectiveness ratios (ICER) were calculated for the three formulations and the two settings (IC and RC). The intervention values are expressed in Colombian pesos (COP). ResultsThe prices/NNT for each formulation were $1816 COP/2.2 for AC, $4772 COP/2.3 for AH and $5342/2.6 for AT. Using these data and taking AC as the comparator, the ICER for the other formulations shows the following results: in the RC, $5065 COP for AT and $19,600 COP for AH; in the IC setting, $8790 COP for AT and $29,460 COP for AH. The probabilistic sensitivity analysis demonstrated that the majority of simulation results fell between the 1st and 4th quadrants of the cost–effectiveness matrix, using AC as a reference. ConclusionThe analysis, from the payer and patient perspectives, demonstrates that the AC formulation has a lower cost and is more effective in reducing pain within the first 4–6h after administration, compared with the AH and AT formulations in their specific indications.

Cost-effectiveness of enzyme replacement therapy for Fabry disease

BackgroundThe cost-effectiveness of enzyme replacement therapy (ERT) compared to standard medical care was evaluated in the Dutch cohort of patients with Fabry disease.MethodsCost-effectiveness analysis was performed using a life-time state-transition model. Transition probabilities, effectiveness data and costs were derived from retrospective data and prospective follow-up of the Dutch study cohort consisting of males and females aged 5–78 years. Intervention with ERT (either agalsidase alfa or agalsidase beta) was compared to the standard medical care. The main outcome measures were years without end organ damage (renal, cardiac en cerebrovascular complications), quality adjusted life years (QALYs), and costs.ResultsOver a 70 year lifetime, an untreated Fabry patient will generate 55.0 years free of end-organ damage (53.5 years in males, 56.9 years in females) and 48.6 QALYs (47.8 in males, 49.7 in females). Starting ERT in a symptomatic patient increases the number of years free of end-organ damage by 1.5 year (1.6 in males, 1.3 in females), while the number of QALYs gained increases by a similar amount (1.7 in males, 1.4 in females). The costs of ERT starting in the symptomatic stage are between €9 - €10 million (£ 7.9 - £ 8.8 million, $13.0- $14.5 million) during a patient’s lifetime. Consequently, the extra costs per additional year free of end-organ damage and the extra costs per additional QALY range from €5.5 - €7.5 million (£ 4.8 – £ 6.6 million, $ 8.0 – $ 10.8 million), undiscounted.ConclusionsIn symptomatic patients with Fabry disease, ERT has limited effect on quality of life and progression to end organ damage. The pharmaco-economic evaluation shows that this modest effectiveness drives the costs per QALY and the costs per year free of end-organ damage to millions of euros. Differentiation of patients who may benefit from ERT should be improved to enhance cost-effectiveness.

Cost-Effectiveness of Disease-Modifying Therapies in the Management of Multiple Sclerosis for the Medicare Population

Objective To evaluate the cost-effectiveness of disease-modifying therapies (DMTs) for the management of multiple sclerosis (MS) compared to best supportive care in the United States. Methods Cost-effectiveness analysis was undertaken using a state transition model of disease natural history and the impact of DMTs for the representative Medicare beneficiary with MS. Costs and outcomes were evaluated from the health-care payer perspective using a 50-year time horizon. Natural history data were drawn from a longitudinal cohort study. The effectiveness of the DMTs was evaluated through a systematic review. Utility data were taken from a study of patients with clinically definite MS in Nova Scotia. Resource use and cost data were derived from the Sonya Slifka database and associated literature. Results When based on placebo-controlled evidence, the marginal cost-effectiveness of interferon beta (IFNβ) and glatiramer acetate compared to best supportive care is expected to be in excess of $100,000 per quality-adjusted life-year gained. When evidence from head-to-head trials is incorporated into the model, the cost-effectiveness of 6 MIU IFNβ-1a is expected to be considerably less favorable. Treatment discontinuation upon progression to Expanded Disability Status Scale 7.0 is expected to improve the cost-effectiveness of all DMTs. Conclusions Further research is required to examine the long-term clinical effectiveness and cost-effectiveness of these therapies. There is no definitive guidance in the United States concerning discontinuation of DMTs; this study suggests that the prudent use of a treatment discontinuation rule may considerably improve the cost-effectiveness of DMTs.

Using Triple Antiplatelet Therapy in Patients with Non-ST Elevation Acute Coronary Syndrome Managed Invasively: A Cost-Effectiveness Analysis

Objectives To assess the incremental cost-effectiveness ratio (ICER) of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) pretreated with aspirin and clopidogrel undergoing an early invasive treatment strategy. Methods Cost-effectiveness analysis and cost-utility analysis were performed from a health-care system perspective, based on a Markov model with a time horizon of the patient life span. The risk of death and ischemic events was assessed using the Thrombolysis in Myocardial Infarction (TIMI) risk score. We compared three strategies: 1) routine upstream use of a GPIIb/IIIa inhibitor to all patients before angiography, 2) deferred selective use of abciximab in the catheterization laboratory just before angioplasty, and 3) double antiplatelet therapy without GPIIb/IIIa inhibitors. Both univariate sensitivity analysis and second-order probabilistic microsimulation were performed. Results In the base case (65 years old, TIMI score 3), strategy A was the most effective, with an ICER of €15,150 per quality-adjusted life-year gained. Strategy B was dominated by a combination of strategies A and C. The ICER was very sensitive to the age and baseline risk of the patient. According to the widely accepted cost-effectiveness thresholds, strategy A would be cost-effective only in patients with an intermediate to high TIMI score, especially within the younger age groups. The probability that strategy A was cost-effective under the base case was 91.2%. Conclusions The use of GPIIb/IIIa inhibitors upstream in high-risk NSTE-ACS patients (TIMI score ≥3) pretreated with aspirin and clopidogrel is cost-effective, particularly in the younger age groups.

Economic evaluation of MR cholangiopancreatography compared to diagnostic ERCP for the investigation of biliary tree obstruction

Background Use of magnetic resonance cholangiopancreatography (MRCP) for confirmation of presence of biliary obstruction is virtually risk-free. However, unlike diagnostic endoscopic retrograde cholangiopancreatography (ERCP), no therapeutic option can be offered simultaneously with MRCP. The aim of the study is to assess the cost-effectiveness of MRCP when compared with the conventional practice of diagnostic ERCP for the investigation of biliary obstruction in adults. Methods Cost-effectiveness analysis from the perspective of the health care provider. Sensitivity analysis includes presentation of a family of cost effectiveness acceptability curves and the impact of different risks of common bile duct stones associated with ultrasound and liver function test results. The main outcome measure is cost per quality adjusted life year (QALY). Results Baseline results, at 37% probability of common bile duct stones, show that MRCP is the dominant strategy, with expected savings of £149 (£325 to −£15) and expected QALY gain of 0.011 (0–0.030) per case. The probability of avoiding unnecessary therapeutic ERCP is 30%. For patients at high risk of common bile duct stones (probability >60%) ERCP is the preferable strategy. Conclusions The baseline estimate is that MRCP would be both cost saving and would result in improved quality of life outcomes compared to diagnostic ERCP, but its potential sources of economic benefit are highly dependent on access to, and waiting lists for adequate MRI technology at hospital level.

Weighing the economic evidence: guidelines for critical assessment of cost-effectiveness analyses.

Evidence-based medicine is concerned with the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. I Increasingly, health care providers are being asked to weigh economic evidence alongside clinical evidence when making decisions about the care of their patients. Although the idea that physicians should consider economics in their decision making is viewed as an anathema to many,2 this chapter takes the position that today's environment makes some consideration of economics inevitable. If one accepts the notion that economic considerations are unavoidable in clinical decision making, it seems reasonable then to take a position that only high-quality economic evidence should be used, in the spirit that evidence-based medicine is used to weigh clinical evidence. This article is devoted to giving clinicians the tools to evaluate economic evidence and determine whether that evidence is suitable for consideration in their clinical practice. This article is written for clinicians who are not well-versed in the purposes and methods cost-effectiveness analysis. It takes a position that costeffectiveness studies have much in common with the clinical literature that most physicians are comfortable reading and critically appraising. Thus, we will highlight important similarities and differences between sound economic and sound clinical evaluations. Some of the subtler aspects of cost-effectiveness analysis (eg, discounting of future costs and benefits, comparative measures of benefit) are not emphasized here. The interested reader can find greatly expanded discussions of these issues, along