Microsimulation Modelling Study Research Articles

Supplementary data for a model-based health economic evaluation on lung cancer screening with low-dose computed tomography in a high-risk population.

This supplementary data is supportive to the research article entitled ‘Cost-effectiveness of lung cancer screening with low-dose computed tomography (LDCT) in heavy smokers: A micro-simulation modelling study’ (Yihui Du et al. 2020). This supplementary contains a description of the model input and the related model output data that were not included in the research article. The input data used for the tumour growth model and the self-detected tumour size model are provided. The output data of this article include the data used for cost-effectiveness analysis of lung cancer LDCT screening with the Dutch and international discount rates, the data of the sensitivity analysis, and the data of the model validation.

Cost-effectiveness of lung cancer screening with low-dose computed tomography in heavy smokers: a microsimulation modelling study

BackgroundLung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer mortality. The aim of this study was to evaluate the cost-effectiveness of lung cancer screening with LDCT in a high-risk population. MethodsThe study used an adapted microsimulation model in a cohort of Dutch heavy smokers for a lifetime horizon from a health insurance perspective. The main outcomes included average cost-effectiveness ratio (ACER), incremental cost-effectiveness ratio (ICER) and lung cancer mortality reduction. The comparator was no screening. Scenarios with different screening intervals and starting and stopping ages were evaluated for 100,000 male heavy smokers and 100,000 female heavy smokers. A cost-effectiveness threshold of 60 k€ per life year gained (LYG) was assumed acceptable. ResultsThe evaluated screening scenarios yielded ACERs ranging from 17.7 to 32.4 k€/LYG for men and from 17.8 to 32.1 k€/LYG for women. The lung cancer mortality reduction ranged from 9.3% to 16.8% for men and from 7.8% to 13.7% for women. The optimal screening scenario was annual screening from 55 to 80 years for men and biennial screening from 50 to 80 years for women, with an ICER of 51.6 and 45.8 k€ per LYG compared with its previous efficient alternative, respectively. Compared with no screening, the optimal screening scenario yielded an ICER of 27.6 k€/LYG for men and 21.1 k€/LYG for women. The mortality reduction of lung cancer was 15.9% for men and 10.6% for women. ConclusionsLung cancer LDCT screening is cost-effective in a high-risk population. The optimal screening scenario is dependent on sex.

Cerebral palsy in Canada, 2011-2031: results of a microsimulation modelling study of epidemiological and cost impacts

The objective of our study was to present model-based estimates and projections on current and future health and economic impacts of cerebral palsy in Canada over a 20-year time horizon (2011-2031). We used Statistics Canada's Population Health Model (POHEM)-Neurological to simulate individuals' disease states, risk factors and health determinants and to describe and project health outcomes, including disease incidence, prevalence, life expectancy, health-adjusted life expectancy, health-related quality of life and health care costs over the life cycle of Canadians. Cerebral palsy cases were identified from British Columbia's health administrative data sources. A population-based cohort was then used to generate the incidence and mortality rates, enabling the projection of future incidence and mortality rates. A utility-based measure (Health Utilities Index Mark 3) was also included in the model to reflect various states of functional health to allow projections of health-related quality of life. Finally, we estimated caregiving parameters and health care costs from Canadian national surveys and health administrative data and included them as model parameters to assess the health and economic impact of cerebral palsy. Although the overall crude incidence rate of cerebral palsy is projected to remain stable, newly diagnosed cases of cerebral palsy will rise from approximately 1800 in 2011 to nearly 2200 in 2031. In addition, the number of people with the condition is expected to increase from more than 75 000 in 2011 to more than 94 000 in 2031. Direct health care costs in constant 2010 Canadian dollars were about $11 700 for children with cerebral palsy aged 1-4 years versus about $600 for those without the condition. In addition, people with cerebral palsy tend to have longer periods in poorer health-related quality of life. Individuals with cerebral palsy will continue to face challenges related to an ongoing need for specialized medical care and a rising need for supportive services. Our study offers important insights into future costs and impacts associated with cerebral palsy and provides valuable information that could be used to develop targeted health programs and strategies for Canadians living with this condition.

Optimizing the impact of medications for opioid use disorder at release from prison and jail settings: A microsimulation modeling study

Optimizing the impact of medications for opioid use disorder at release from prison and jail settings: A microsimulation modeling study

A Cost-effectiveness Analysis of Multigene Testing for All Patients With Breast Cancer

Moving to multigene testing for all women with breast cancer (BC) could identify many more mutation carriers who can benefit from precision prevention. However, the cost-effectiveness of this approach remains unaddressed. To estimate incremental lifetime effects, costs, and cost-effectiveness of multigene testing of all patients with BC compared with the current practice of genetic testing (BRCA) based on family history (FH) or clinical criteria. This cost-effectiveness microsimulation modeling study compared lifetime costs and effects of high-risk BRCA1/BRCA2/PALB2 (multigene) testing of all unselected patients with BC (strategy A) with BRCA1/BRCA2 testing based on FH or clinical criteria (strategy B) in United Kingdom (UK) and US populations. Data were obtained from 11 836 patients in population-based BC cohorts (regardless of FH) recruited to 4 large research studies. Data were collected and analyzed from January 1, 2018, through June 8, 2019. The time horizon is lifetime. Payer and societal perspectives are presented. Probabilistic and 1-way sensitivity analyses evaluate model uncertainty. In strategy A, all women with BC underwent BRCA1/BRCA2/PALB2 testing. In strategy B, only women with BC fulfilling FH or clinical criteria underwent BRCA testing. Affected BRCA/PALB2 carriers could undertake contralateral preventive mastectomy; BRCA carriers could choose risk-reducing salpingo-oophorectomy (RRSO). Relatives of mutation carriers underwent cascade testing. Unaffected relative carriers could undergo magnetic resonance imaging or mammography screening, chemoprevention, or risk-reducing mastectomy for BC risk and RRSO for ovarian cancer (OC) risk. Incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained and compared with standard £30 000/QALY and $100 000/QALY UK and US thresholds, respectively. Incidence of OC, BC, excess deaths due to heart disease, and the overall population effects were estimated. BRCA1/BRCA2/PALB2 multigene testing for all patients detected with BC annually would cost £10 464/QALY (payer perspective) or £7216/QALY (societal perspective) in the United Kingdom or $65 661/QALY (payer perspective) or $61 618/QALY (societal perspective) in the United States compared with current BRCA testing based on clinical criteria or FH. This is well below UK and US cost-effectiveness thresholds. In probabilistic sensitivity analysis, unselected multigene testing remained cost-effective for 98% to 99% of UK and 64% to 68% of US health system simulations. One year's unselected multigene testing could prevent 2101 cases of BC and OC and 633 deaths in the United Kingdom and 9733 cases of BC and OC and 2406 deaths in the United States. Correspondingly, 8 excess deaths due to heart disease occurred in the United Kingdom and 35 in the United States annually. This study found unselected, high-risk multigene testing for all patients with BC to be extremely cost-effective compared with testing based on FH or clinical criteria for UK and US health systems. These findings support changing current policy to expand genetic testing to all women with BC.

Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a microsimulation modelling study

ObjectiveTo estimate benefits and harms of different colorectal cancer screening strategies, stratified by (baseline) 15-year colorectal cancer risk.DesignMicrosimulation modelling study using MIcrosimulation SCreening ANalysis-Colon (MISCAN-Colon).SettingA parallel guideline committee (BMJ Rapid...

Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil

BackgroundBrazil’s Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)—a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs).MethodA synthetic cohort of 5507 Brazilian municipalities was created for the period 2017–2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects.ResultsUnder austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03–10.21%; 48,546 excess premature/under-70 deaths along 2017–2030) and 5.80% (95% CI 4.23–7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage.Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47–12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and nutritional deficiencies and would disproportionately impact poorer municipalities, with the concentration index for ACSC mortality 11.77% higher (95% CI 0.31–22.32%) and also ending historical declines in racial health inequalities between white and black/pardo Brazilians.ConclusionsReductions in primary healthcare coverage due to austerity measures are likely to be responsible for many avoidable deaths and may preclude achievement of SDGs for health and inequality in Brazil and in other low- and middle-income countries.

Cost-effectiveness of urine-based tuberculosis screening in hospitalised patients with HIV in Africa: a microsimulation modelling study.

Testing urine improves the number of tuberculosis diagnoses made among patients in hospital with HIV. In conjunction with the two-country randomised Rapid Urine-based Screening for Tuberculosis to Reduce AIDS-related Mortality in Hospitalised Patients in Africa (STAMP) trial, we used a microsimulation model to estimate the effects on clinical outcomes and the cost-effectiveness of adding urine-based tuberculosis screening to sputum screening for hospitalised patients with HIV. We compared two tuberculosis screening strategies used irrespective of symptoms among hospitalised patients with HIV in Malawi and South Africa: a GeneXpert assay (Cepheid, Sunnyvale, CA, USA) for Mycobacterium tuberculosis and rifampicin resistance (Xpert) in sputum samples (standard of care) versus sputum Xpert combined with a lateral flow assay for M tuberculosis lipoarabinomannan in urine (Determine TB-LAM Ag test, Abbott, Waltham, MA, USA [formerly Alere]; TB-LAM) and concentrated urine Xpert (intervention). A cohort of simulated patients was modelled using selected characteristics of participants, tuberculosis diagnostic yields, and use of hospital resources in the STAMP trial. We calibrated 2-month model outputs to the STAMP trial results and projected clinical and economic outcomes at 2 years, 5 years, and over a lifetime. We judged the intervention to be cost-effective if the incremental cost-effectiveness ratio (ICER) was less than US$750/year of life saved (YLS) in Malawi and $940/YLS in South Africa. A modified intervention of adding only TB-LAM to the standard of care was also evaluated. We did a budget impact analysis of countrywide implementation of the intervention. The intervention increased life expectancy by 0·5-1·2 years and was cost-effective, with an ICER of $450/YLS in Malawi and $840/YLS in South Africa. The ICERs decreased over time. At lifetime horizon, the intervention remained cost-effective under nearly all modelled assumptions. The modified intervention was at least as cost-effective as the intervention (ICERs $420/YLS in Malawi and $810/YLS in South Africa). Over 5 years, the intervention would save around 51 000 years of life in Malawi and around 171 000 years of life in South Africa. Health-care expenditure for screened individuals was estimated to increase by $37 million (10·8%) and $261 million (2·8%), respectively. Urine-based tuberculosis screening of all hospitalised patients with HIV could increase life expectancy and be cost-effective in resource-limited settings. Urine TB-LAM is especially attractive because of high incremental diagnostic yield and low additional cost compared with sputum Xpert, making a compelling case for expanding its use to all hospitalised patients with HIV in areas with high HIV burden and endemic tuberculosis. UK Medical Research Council, UK Department for International Development, Wellcome Trust, US National Institutes of Health, Royal College of Physicians, Massachusetts General Hospital.

Benefits and Harms of Gastric Cancer Screening and Prevention in Japan: A Microsimulation Modeling Analysis

Background: In 2016, gastric cancer is the second leading cause of cancer mortality worldwide. Globally, Japan and Korea are the only two countries implementing national screening program for gastric cancer. South Korea launched a biennial national -endoscopic screening program in 1999, which demonstrated a 47% reduction in gastric cancer mortality compared with no screening. In 2015, endoscopic screening was recommended by the Japanese Guideline for Gastric Cancer Screening. Currently, Japan's screening policy recommends endoscopic screening every 2 to 3 years for individuals aged 50 or above. Aim: This study aims to quantify the potential impacts of Japan's current national endoscopic screening policy and other alternative endoscopic screening options, and to identify a set of efficient endoscopic screening strategies for the current population of Japan. Methods: A microsimulation model of intestinal-type noncardia gastric adenocarcinoma was developed to simulate a virtual population with similar risk profile and life expectancy to the actual population of Japan. The model was calibrated and validated to the nationally-representative data from vital statistics and population-based cancer registries. The baseline scenario was modeled to project the current trend of gastric cancer. Variations among age of initiation (40, 45, 50, and 55), age of termination (75, 80, and 85), and screening interval (2, 5, 10, and 15 years) resulted in 39 unique endoscopic screening strategies for evaluation. In addition, the following three existing screening scenarios were included for analysis: the current screening program in Japan (screening every two or three years from age 50 years, with no termination) and Korea (biennial screening from age 40 years, with no termination). In total, 42 unique endoscopic screening strategies were simulated. Full adherence for all screening scenarios were assumed. Results: In comparison with baseline scenario, endoscopic screening strategies provided 43 to 203 life-years gained per 1000 individuals. The number of lifetime endoscopies per 1000 individuals ranged from 2281 to 28,635. The complications caused by screening were from 6 to 77 per 1000 individuals. The lifetime number of false-positive results ranged from 381 to 4941 per 1000 individuals. Scenarios simulating the current national endoscopic screening program in Japan and Korea fell below the efficient frontier. Under full adherence assumption, the most advantageous endoscopic screening strategy among evaluated scenarios is screening from age 40 to 80 years every 5 year. Conclusion: In this microsimulation modeling study with full adherence assumption, the findings suggest that the current national endoscopic screening program for gastric cancer in Japan might not be the most efficient screening option under benefit-to-harm consideration. The finding underpins the need for further investigation to bring up an efficient and cost-effective endoscopic screening program in Japan.

Multiple sclerosis in Canada 2011 to 2031: results of a microsimulation modelling study of epidemiological and economic impacts.

The objective of our study was to present model-based estimates and projections on current and future health and economic impacts of multiple sclerosis (MS) in Canada over a 20-year time horizon (2011-2031). Using Statistics Canada's Population Health Microsimulation Model (POHEM) framework, specifically the population-based longitudinal, microsimulation model named POHEM-Neurological, we identified people with MS from health administrative data sources and derived incidence and mortality rate parameters from a British Columbia population-based cohort for future MS incidence and mortality projections. We also included a utility-based measure (Health Utilities Index Mark 3) reflecting states of functional health to allow projections of health-related quality of life. Finally, we estimated caregiving parameters and health care costs from Canadian national surveys and health administrative data and included them as model parameters to assess the health and economic impact of the neurological conditions. The number of incident MS cases is expected to rise slightly from 4051 cases in 2011 to 4794 cases per 100 000 population in 2031, and the number of Canadians affected by MS will increase from 98 385 in 2011 to 133 635 in 2031. The total per capita health care cost (excluding out-of-pocket expenses) for adults aged 20 and older in 2011 was about $16 800 for individuals with MS, and approximately $2500 for individuals without a neurological condition. Thus, after accounting for additional expenditures due to MS (excluding out-of-pocket expenses), total annual health sector costs for MS are expected to reach $2.0 billion by 2031. As well, the average out-of-pocket expenditure for people with MS was around $1300 annually throughout the projection period. MS is associated with a significant economic burden on society, since it usually affects young adults during prime career- and family-building years. Canada has a particularly high prevalence of MS, so research such as the present study is essential to provide a better understanding of the current and future negative impacts of MS on the Canadian population, so that health care system policymakers can best plan how to meet the needs of patients who are affected by MS. These findings also suggest that identifying strategies to prevent MS and more effectively treat the disease are needed to mitigate these future impacts.

The appropriateness of more intensive colonoscopy screening than recommended in Medicare beneficiaries: a modeling study.

Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain. To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required). Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results. Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years. Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency). Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical. Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.

Endoscopic colorectal cancer screening provides long-lasting effect.

Endoscopic colorectal cancer screening provides long-lasting effect.

Productivity Savings from Colorectal Cancer Prevention and Control Strategies

Lost productivity represents a considerable portion of the total economic burden of colorectal cancer (CRC), but cost-effectiveness studies of CRC prevention and control have not included these costs and therefore underestimate potential savings from CRC prevention and control. To use microsimulation modeling study to estimate and project productivity costs of CRC and to model the savings from four approaches to reducing CRC incidence and mortality: risk factor reduction, improved screening, improved treatment, and a simultaneous approach where all three strategies are implemented. A model was developed to project productivity losses from CRC using the U.S. population with CRC incidence and mortality projected through the year 2020. Outcome measures were CRC mortality, morbidity, and productivity savings. With 2005 levels in risk factors, screening, and treatment, 48,748 CRC deaths occurred in 2010, amounting to $21 billion of lost productivity. Using prevention and treatment strategies simultaneously, 3586 deaths could have been avoided in 2010, leading to a savings of $1.4 billion. Cumulatively, by 2020, simultaneous strategies that reduce risk factors and increase screening and treatment could result in 101,353 deaths avoided and $33.9 billion in savings in reduced productivity loss. Improved screening rates alone led to nearly $14.7 billion in savings between 2005 and 2020, followed by risk factor reduction ($12.4 billion) and improved treatment ($8.4 billion). The savings in productivity loss from strategies to reduce CRC incidence and mortality are substantial, providing evidence that CRC prevention and control strategies are likely to be cost-saving.

Stool DNA Testing to Screen for Colorectal Cancer in the Medicare Population

The Centers for Medicare & Medicaid Services considered whether to reimburse stool DNA testing for colorectal cancer screening among Medicare enrollees. To evaluate the conditions under which stool DNA testing could be cost-effective compared with the colorectal cancer screening tests currently reimbursed by the Centers for Medicare & Medicaid Services. Comparative microsimulation modeling study using 2 independently developed models. Derived from literature. A cohort of persons aged 65 years. A sensitivity analysis was also conducted, in which a cohort of persons aged 50 years was studied. Lifetime. Third-party payer. Stool DNA test every 3 or 5 years in comparison with currently recommended colorectal cancer screening strategies. Life expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs. Assuming a cost of $350 per test, strategies of stool DNA testing every 3 or 5 years yielded fewer life-years and higher costs than the currently recommended colorectal cancer screening strategies. Screening with the stool DNA test would be cost-effective at a per-test cost of $40 to $60 for stool DNA testing every 3 years, depending on the simulation model used. There were no levels of sensitivity and specificity for which stool DNA testing would be cost-effective at its current cost of $350 per test. Stool DNA testing every 3 years would be cost-effective at a cost of $350 per test if the relative adherence to stool DNA testing were at least 50% better than that with other screening tests. None of the results changed substantially when a cohort of persons aged 50 years was considered. No pathways other than the traditional adenoma-carcinoma sequence were modeled. Stool DNA testing could be a cost-effective alternative for colorectal cancer screening if the cost of the test substantially decreased or if its availability would entice a large fraction of otherwise unscreened persons to receive screening.