Potential Cost-effectiveness Research Articles

Clinical efficacy of convalescent plasma for treatment of COVID-19 infections: Results of a multicenter clinical study

Since Dec. 2019 the new coronavirus (SARS-CoV-2) has infected millions and claimed life of several hundred thousand worldwide. However, so far no approved vaccine or drug therapy is available for treatment of virus infection. Convalescent plasma has been considered a potential modality for COVID-19 infection. One hundred eighty-nine COVID-19 positive patients including 115 patients in plasma therapy group and 74 patients in control group, registered in the hospitals with confirmed COVID-19 infection, entered this multi-center clinical study. Comparison of outcomes including all-cause mortality, total hospitalization days and patients’ need for intubation between the two patient groups shows that total of 98 (98.2 %) of patients who received convalescent plasma were discharged from hospital which is substantially higher compared to 56 (78.7 %) patients in control group. Length of hospitalization days was significantly lower (9.54 days) in convalescent plasma group compared with that of control group (12.88 days). Only 8 patients (7%) in convalescent plasma group required intubation while that was 20 % in control group. This clinical study provides strong evidence to support the efficacy of convalescent plasma therapy in COVID-19 patients and recommends this treatment for management of these patients. Clinical efficacy, immediate availability and potential cost effectiveness could be considered as main advantages of convalescent plasma therapy.

Burden and Cost of Hospitalization for Respiratory Syncytial Virus in Young Children, Singapore.

Respiratory syncytial virus (RSV) is the most common cause of pediatric acute lower respiratory tract infection worldwide. Detailed data on the health and economic burden of RSV disease are lacking from tropical settings with year-round RSV transmission. We developed a statistical and economic model to estimate the annual incidence and healthcare cost of medically attended RSV disease among young children in Singapore, using Monte Carlo simulation to account for uncertainty in model parameters. RSV accounted for 708 hospitalizations in children <6 months of age (33.5/1,000 child-years) and 1,096 in children 6–29 months of age (13.2/1,000 child-years). The cost of hospitalization was SGD 5.7 million (US $4.3 million) at 2014 prices; patients bore 60% of the cost. RSV-associated disease burden in tropical settings in Asia is high and comparable to other settings. Further work incorporating efficacy data from ongoing vaccine trials will help to determine the potential cost-effectiveness of different vaccination strategies.

Quantifying and Describing the Natural History and Costs of Alzheimer's Disease and Effects of Hypothetical Interventions.

Background:A long-term horizon is necessary when the socioeconomic consequences and the potential effects of interventions in Alzheimer’s disease (AD) are estimated.Objectives:To illustrate the potential societal costs of AD across the disease continuum and to illustrate the potential cost-effectiveness of a hypothetical intervention with disease modifying treatment (DMT).Methods:Based on the Swedish dementia registry, a Markov model was used to simulate a virtual cohort of 100,000 people with mild cognitive impairment (MCI) due to AD (AD-MCI) in Sweden for 40 years starting at the age of 60. A simulated hypothetical intervention assumed a 25% reduction in progression rate during AD-MCI and mild AD-dementia. A comprehensive set of sensitivity analyses was included.Results:The cumulative risk to develop dementia was 96%. The mean simulated survival was 19.0 years. The net present value for a person year with dementia was 252,843 SEK (about 29,500 US$). The cost effectiveness model illustrated how the hypothetical scenario of a 25% reduction in progression to AD-dementia would require 41 AD-MCI patients to be treated to prevent one case of AD-dementia (2,447 avoided AD-dementia cases of 100,000 with AD-MCI). Most scenarios illustrated hypothetical cost effectiveness (based on a willingness to pay level of 600,000 SEK (70,000 US$) per gained QALY), but not cost savings.Discussion:Lifetime societal costs of AD are substantial. A future DMT may be potentially cost-effective given assumed treatment effects and costs, but cost savings are unlikely.

Attitude of infectious diseases physicians in Turkey about HIV pre-exposure prophylaxis: results of an online survey.

Pre-exposure prophylaxis (PrEP) is the provision of antiretroviral drugs before HIV exposure to prevent infection for those in whom it is indicated. We conducted an online survey about PrEP in a national sample of infectious diseases physicians in Turkey. They were surveyed from March to April 2019 and they were asked about their attitudes, knowledge and clinical practise about PrEP. Overall, 209 of 2100 (10%) completed the survey, of whom 66.3% were female, 69.5% were specialist and 41.1% were working at education and research hospitals. Most of the participants reported their PrEP knowledge as 'low'. Men who have sex with men was the most suitable group for PrEP according to participants. 27.9% of them were requested to prescribe PrEP which was to be paid by individuals themselves and 24.2% of the participants had recommended PrEP in their clinical practice. The primary concerns among those who would not recommend PrEP were the possible increase in sexually transmitted infections, the potential low cost-effectiveness of PrEP, the ineffectiveness of PrEP in HIV transmission and the time lost to following-up the individuals taking PrEP. Developing a national guideline would support clinicians in order to change their attitudes and to find answers to their concerns.

Shorter antibiotic regimens impact the control efforts in high tuberculosis burden regions of Taiwan

ObjectivesTo assess the potential epidemiological impact and cost-effectiveness of shorter antibiotic regimens in high tuberculosis (TB) burden regions of Taiwan. MethodsThis study combined the TB population dynamic model and cost-effectiveness analysis with local data to simulate the disease burdens, effectiveness and costs of hypothetical 4-month, 2-month and 7-day regimens compared with the standard regimen. ResultsThe main outcomes were the potential of shorter regimens for averted incidence, mortality and disability-adjusted life years, incremental cost-effectiveness ratio and net monetary benefit. Shorter regimens would lower incidence rates and mortality cases in a high TB burden region by an average of 19–33% and 27–41%, respectively, with the potential for cost-effectiveness or cost-saving. The 2-month and 7-day regimens would be more cost-effective than the 4-month regimen. The threshold daily drug prices for achieving cost-effectiveness and cost-saving for 4-month, 2-month and 7-day regimens were $US1, $US2 and $US70, respectively. Such cost-effectiveness would remain, even if the willingness-to-pay threshold was less than one gross domestic product per capita. ConclusionsThe findings support the inclusion of shorter regimens in global guidelines and regional-scale TB control strategies, which would improve disease control, particularly in settings with high rates of incidence and poor treatment outcomes.

Effects of geographic and economic heterogeneity on the burden of rotavirus diarrhea and the impact and cost-effectiveness of vaccination in Nigeria.

Child mortality from rotavirus gastroenteritis remains high in Nigeria, representing 14% of all rotavirus deaths worldwide. Here, we examine the potential impact and cost-effectiveness of national rotavirus vaccine introduction in geographic and economic subpopulations of Nigeria. We projected the health and economic outcomes of rotavirus vaccination in children over the first five years of life using a spreadsheet-based model. We modeled child populations using national survey data on rotavirus mortality risk factors and vaccination coverage to predict burden and impact across regional and wealth quintile subpopulations within Nigeria. Our base case considered introduction of a general rotavirus vaccine, modeled to encompass characteristics of existing vaccines, versus no vaccine. Base case costs were estimated from the government perspective, assuming Gavi subsidies, over the first five years. We also present estimates from the cost of vaccination from the perspective of Gavi. We explored uncertainty in model parameters through probabilistic uncertainty, one-way sensitivity, and scenario analyses. According to our estimates, rotavirus enteritis was responsible for 47,898 [95% Uncertainty Limits: 35,361; 63,703] child deaths per year, with approximately 80% of the national burden concentrated in the three northern regions of Nigeria. Rotavirus vaccination was estimated to prevent 6,454 [3,960; 9,721] deaths, 13% [9%; 18%] of the national annual RV burden. National ICERs for rotavirus vaccination from the Nigerian government and Gavi perspectives were US$47 [$18; $105] and $62 [$29; $130] per DALY averted, respectively. General rotavirus vaccination was projected to reduce rotavirus mortality by only 6% [4%; 9%] in the North West region compared to 35% [24%; 47%] in the South East region. Base case ICERs ranged from US$25 [10; 56] per DALY averted in North West to US$64 [18; 157] per DALY averted in South South. Gavi perspective ICERs ranged from US$33 [$15; $68] in North West to US$88 [35; 191] per DALY averted in South South. According to one-way sensitivity analyses, ICERs were most sensitive to vaccine efficacy, followed by estimated administrative costs and rotavirus mortality. Disparities in mortality reduction were largely driven by inequality in vaccination coverage across regions and between socioeconomic subpopulations. Due to high, persistent, and inequitable burden of rotavirus in Nigeria, routine vaccination with any of these rotavirus vaccines would be an high impact and cost-effective strategy in reducing child mortality.

Estimated Health Benefits, Costs, and Cost-Effectiveness of Eliminating Industrial Trans-Fatty acids in Australia

Abstract Objectives To assess the potential cost-effectiveness, health gains, and effects on health equality of eliminating industrial trans-fatty acids (TFAs) from the Australian food supply. Methods Markov cohort models were used to estimate the cost-effectiveness and policy impact on (ischemic heart disease) IHD burden and health equity of a national ban of industrial TFAs in Australia. Intake of TFA was assessed using the 2011–2012 Australian National Nutrition and Physical Activity Survey. The IHD burden attributable to TFA was calculated by comparing the current level of TFA intake to a counterfactual setting (0.5% energy per day from TFA; corresponding to TFA intake only from non-industrial sources, e.g., dairy foods). Policy costs, avoided IHD events and deaths, health-adjusted life years (HALYs) gained, and IHD-related healthcare costs saved were estimated over 10 years and lifetime of the adult Australian population. Cost-effectiveness was assessed by calculation of incremental cost-effectiveness ratios (ICER) using net policy cost and HALYs gained. Health benefits and health care cost changes were also assessed in subgroups based on socioeconomic status and remoteness. Results Elimination of industrial TFA was estimated to prevent 2,294 (95% uncertainty interval [UI]: 1,765; 2,851) IHD deaths and 9,931 (95% UI: 8,429; 11,532) IHD events over the first 10 years. The greatest health benefits were accrued to the most socioeconomically disadvantaged quintiles and among Australians living outside of major cities. The intervention was estimated to be cost-saving or cost-effective (i.e., ICER &amp;lt; 169,361 AUD/HALY) regardless of the time horizon, with ICERs of 1,073 (95% UI: dominant; 3,503) and 1,956 (95% UI: 1,010; 2,750) AUD/HALY over 10 years and life time, respectively. The TFA ban was estimated to be cost-saving or highly cost-effective in sensitivity analyses altering assumptions of post-intervention TFA intake, abundance of TFA-containing products, or discount rate. Conclusions A ban of industrial TFAs could avert substantial numbers of IHD events and deaths in Australia and will likely be a highly cost-effective strategy to reduce social-economic and urban-rural inequalities in health. Funding Sources National Health and Medical Research Council; and UNSW.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico

BackgroundIn rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018.MethodsFocusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent.ResultsThe programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4–15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262–588) at purchasing power parity.ConclusionsThese numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting.Trial registrationThis study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

Assessing the potential cost-effectiveness of the addition of atezolizumab to first-line platinum chemotherapy in advanced urothelial cancer: Implications for value-based pricing.

5031 Background: Data from interim analysis of IMvigor130 trial showed that 1st line treatment of advanced urothelial cancer (aUC) with atezolizumab (Atezo) + platinum-based chemotherapy (PBC) significantly improved progression-free survival (PFS), but not overall survival (OS), vs PBC. Switch maintenance anti-PD(L)1 after completion of PBC as 1st line therapy is an alternate strategy, recently reported to significantly prolong OS. We aimed to compare cost-effectiveness of combined treatment (Atezo+PBC) vs PBC based on IMvigor130. Methods: We used a partitioned-survival model to evaluate the potential cost-effectiveness of treatment with A) Atezo+PBC (gemcitabine with cisplatin or carboplatin) or B) PBC alone with checkpoint inhibitor pembrolizumab at progression (standard-of-care). PFS and OS curves were extracted from IMvigor 130 and parametric models were fit to approximate outcomes with Atezo+PBC with the hazard ratio (HR) from the trial used to project outcomes for PBC alone. We used a health-care payer perspective with a two-year time horizon. Model outputs — costs, life-years, quality-adjusted life years (QALYs) — were used to calculate an incremental cost-effectiveness ratio (ICER). A scenario analysis evaluated the “value-based price” needed for Atezo+PBC to be cost-effective; a one-way sensitivity analysis was also performed. Results: Results of the cost-effectiveness analysis are summarized in the table. The mean projected incremental cost of Atezo+PBC compared to PBC was $59,604 for a mean incremental gain of 0.09 life-years and 0.07 QALYs. This resulted in an ICER of $629,755/life-year and $895,800/QALY, respectively. A 33% reduction would be needed in the price of atezolizumab to make Atezo+PBC cost-effective at an ICER of $150,000/QALY. Results were sensitive to cost of pembrolizumab at progression, the cost of Atezo+PBC, and the OS HR between Atezo+PBC and PBC. Conclusions: Combined chemoimmunotherapy with atezolizumab and PBC would likely not be cost-effective for the first-line treatment of aUC. However, with a price rebate of 33%, it would approach being cost-effective at a widely used cost-effectiveness threshold. [Table: see text]

The potential cost-effectiveness of a risk-based pancreatic cancer screening strategy in new-onset diabetes.

7017 Background: There are no established methods for pancreatic cancer (PC) screening, but the National Cancer Institute and the Pancreatic Cancer Action Network (PanCAN) are investigating risk-based screening strategies in new-onset diabetes (NOD)—a group with elevated PC risk. Preliminary estimates of the cost-effectiveness of these strategies can provide insights about potential value and inform supplemental data collection. Using data from the Enriching New-Onset Diabetes for Pancreatic Cancer (ENDPAC) risk model validation study, we assessed the potential value of CT screening for PC in those determined to be at elevated PC risk, as is being done in a planned PanCAN Early Detection Initiative (EDI) trial. Methods: We created an integrated decision tree and Markov state-transition model to assess the cost-effectiveness of screening those age ≥50 and with NOD for PC using CT imaging vs. no screening. PC prevalence, sensitivity, and specificity were derived from the ENDPAC validation study. PC stage distribution in the no screening strategy and PC survival were derived from SEER. Background mortality for diabetics, screening and cancer care expenditure, and health state utilities were derived from the literature. The base case assumed 40% of screen-detected PC cases were resectable, and a threshold analysis explored the fraction required for screening to be &lt;$100,000 per QALY gained. Life years (LYs), quality-adjusted life years (QALYs), and costs were tracked over a lifetime horizon and discounted at 3% per year. Results are presented in 2019 USD, and we took a U.S. payer perspective. Results: In the base case, screening resulted in 0.0055 more LYs, 0.0045 more QALYs, and $305 in additional expenditure for a cost per QALY gained of $68,059 (Table). Among PC cases, screening resulted in 0.67 more LYs, 0.55 more QALYs, and $22,691 in additional expenditure. In probabilistic analyses, screening resulted in a cost per QALY gained of &lt;$50,000 and &lt;$100,000 in 34% and 99% of simulations, respectively. In the threshold analysis, &gt;25% of screen-detected cases needed to be resectable for the cost per QALY gained with screening to be &lt;$100,000. Conclusions: We found that risk-based pancreatic cancer screening in NOD is likely to be cost-effective in the U.S. if even a modest fraction (&gt;25%) of screen-detected cases are resectable. Future studies should reassess the value of this intervention once PanCAN EDI data become available. [Table: see text]

Sit–stand desks to reduce sedentary behaviour in 9- to 10-year-olds: the Stand Out in Class pilot cluster RCT

BackgroundSedentary behaviour (sitting) is a highly prevalent negative health behaviour, with individuals of all ages exposed to environments that promote prolonged sitting. The school classroom represents an ideal setting for environmental change through the provision of sit–stand desks.ObjectivesThe aim of this study was to undertake a pilot cluster randomised controlled trial of the introduction of sit–stand desks in primary school classrooms, to inform a definitive trial. Objectives included providing information on school and participant recruitment and retention, acceptability of the intervention, and outcome measures. A preliminary estimate of the intervention’s effectiveness on the proposed primary outcome (change in weekday sitting time) for inclusion in a definitive trial was calculated, along with a preliminary assessment of potential cost-effectiveness. A full process evaluation was also undertaken.DesignA two-armed pilot cluster randomised controlled trial with economic and qualitative evaluations. Schools were randomised on a 1 : 1 basis to the intervention (n = 4) or control (n = 4) trial arms.SettingPrimary schools in Bradford, West Yorkshire, UK.ParticipantsChildren in Year 5 (i.e. aged 9–10 years).InterventionSix sit–stand desks replaced three standard desks (sitting six children) in the intervention classrooms for 4.5 months. Teachers were encouraged to ensure that all pupils were exposed to the sit–stand desks for at least 1 hour per day, on average, using a rotation system. Schools assigned to the control arm continued with their usual practice.Main outcome measuresTrial feasibility outcomes included school and participant recruitment and attrition, acceptability of the intervention, and acceptability of and compliance with the proposed outcome measures [including weekday sitting measured using activPAL™ (PAL Technologies Ltd, Glasgow, UK) accelerometers, physical activity, adiposity, blood pressure, cognitive function, musculoskeletal comfort, academic progress, engagement and behaviour].ResultsThirty-three per cent of schools approached and 75% (n = 176) of eligible children took part. At the 7-month follow-up, retention rates were 100% for schools and 97% for children. Outcome measure completion rates ranged from 63% to 97%. A preliminary estimate of intervention effectiveness, from a weighted linear regression model (adjusting for baseline sitting time and wear time) revealed a mean difference in change in sitting of –30.6 minutes per day (95% confidence interval –56.42 to –4.84 minutes per day) between the intervention and control trial arms. The process evaluation revealed that the intervention, recruitment and evaluation procedures were acceptable to teachers and children, with the exception of minor issues around activPAL attachment. A preliminary within-trial economic analysis revealed no difference between intervention and control trial arms in health and education resource use or outcomes. Long-term modelling estimated an unadjusted incremental cost-effectiveness ratio of Stand Out in Class of £78,986 per quality-adjusted life-year gained.ConclusionThis study has provided evidence of the acceptability and feasibility of the Stand Out in Class intervention and evaluation methods. Preliminary evidence suggests that the intervention may have a positive direction of effect on weekday sitting time, which warrants testing in a full cluster randomised controlled trial. Lessons learnt from this trial will inform the planning of a definitive trial.Trial registrationCurrent Controlled Trials ISRCTN12915848.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 8, No. 8. See the NIHR Journals Library website for further project information.

(Invited) Nasicon-Type NaV2(PO4)3 As a Cathode Material for Calcium-Ion Batteries

Li-ion batteries (LIBs) have been the most prevailing rechargeable batteries for the last three decades. However, the present LIBs have energy densities close to the theoretical limits, and the Li resources are scarce. Calcium-ion batteries (CIBs) are one of the promising candidates to overcome such limitations of LIBs. The divalency of calcium as the carrier ion can increase the capacity of a host material because two electrons are transferred per carrier ion. The earth-abundance of calcium resources provides potential cost-effectiveness to the products. Calcium has the redox potential (Ca/Ca2+ = −2.87 V vs. SHE) close to Li, potentially leading to a higher cell operating voltage. Calcium ion also has a relatively low effective intercalant-ion charge density (0.49 e/Å3), compared to other multivalent cations such as Mg2+ (1.28 e/Å3), Zn2+ (1.18 e/Å3), and Al3+ (4.55 e/Å3), enabling fast diffusion kinetics for Ca ions in solids as well as in electrolytes. Recent discoveries of reversible plating or alloying of calcium provoked considerable interest in calcium-based rechargeable batteries. Theoretical calculations also predict that the energy barriers for Ca diffusion are lower than other multivalent ions in some structures, and the development of positive materials are anticipated. However, only a few positive materials have been reported so far, only to exhibit low energy-storage capability and poor cyclability. In this work, we report NASICON-type NaV2(PO4)3 as a cathode material for nonaqueous CIBs, with high capacity and voltage with a good cyclability. This work demonstrates experimentally that an oxide material can be a good host structure for Ca diffusion at room temperature with high energy-storage capability.

Cost and Cost-effectiveness of Large-scale Screening for Type 1 Diabetes in Colorado.

OBJECTIVETo assess the costs and project the potential lifetime cost-effectiveness of the ongoing Autoimmunity Screening for Kids (ASK) program, a large-scale, presymptomatic type 1 diabetes screening program for children and adolescents in the metropolitan Denver region.RESEARCH DESIGN AND METHODSWe report the resource utilization, costs, and effectiveness measures from the ongoing ASK program compared with usual care (i.e., no screening). Additionally, we report a practical screening scenario by including utilization and costs relevant to routine screening in clinical practice. Finally, we project the potential cost-effectiveness of ASK and routine screening by identifying clinical benchmarks (i.e., diabetic ketoacidosis [DKA] events avoided, HbA1c improvements vs. no screening) needed to meet value thresholds of $50,000–$150,000 per quality-adjusted life-year (QALY) gained over a lifetime horizon.RESULTSCost per case detected was $4,700 for ASK screening and $14,000 for routine screening. To achieve value thresholds of $50,000–$150,000 per QALY gained, screening costs would need to be offset by cost savings through 20% reductions in DKA events at diagnosis in addition to 0.1% (1.1 mmol/mol) improvements in HbA1c over a lifetime compared with no screening for patients who develop type 1 diabetes. Value thresholds were not met from avoiding DKA events alone in either scenario.CONCLUSIONSPresymptomatic type 1 diabetes screening may be cost-effective in areas with a high prevalence of DKA and an infrastructure facilitating screening and monitoring if the benefits of avoiding DKA events and improved HbA1c persist over long-run time horizons. As more data are collected from ASK, the model will be updated with direct evidence on screening effects.

A trial-based economic evaluation of the Restore4Stroke self-management intervention compared to an education-based intervention for stroke patients and their partners

BackgroundSince stroke survivors are increasingly responsible for managing stroke-related changes in their own health and lifestyle, self-management skills are required. In a recent randomised controlled trial a self-management intervention based on proactive coping action planning (SMI) in comparison with an education-based intervention (EDU) in stroke patients was investigated. However, no relevant treatment effects on the Utrecht Proactive Coping Competence scale (UPCC) and the Utrecht Scale for Evaluation of Rehabilitation Participation (USER-Participation) were found. The current study is a trial-based economic evaluation from a societal perspective comparing the same interventions (SMI versus EDU).MethodsUPCC, USER-Participation and EuroQol (EQ-5D-3 L) and costs were measured at baseline, three, six and twelve months after treatment. For the cost-effectiveness analyses, incremental cost effectiveness ratios (ICERs) were calculated for UPCC and USER-Participation. For the cost-utility analyses the incremental cost utility ratio (ICUR) was expressed in cost per Quality Adjusted Life Years (QALYs). Outcomes were tested by means of AN(C)OVA analyses and costs differences by means of bootstrapping. Bootstrapping, sensitivity analyses and a subgroup analysis were performed to test the robustness of the findings.ResultsOne hundred thirteen stroke patients were included in this study. The mean differences in USER-Participation scores (95%CI:-13.08,-1.61, p-value = .013) were significant different between the two groups, this does not account for UPCC scores (95%CI:-.267, .113, p-value = not significant) and QALYs (p-value = not significant) at 12 months. The average total societal costs were not significantly different (95%CI:€-3380,€7099) for SMI (€17,333) in comparison with EDU (€15,520). Cost-effectiveness analyses showed a mean ICER of 26,514 for the UPCC and 346 for the USER-Participation. Cost-utility analysis resulted in an ICUR of €44,688 per QALY. Assuming a willingness to pay (WTP) threshold of €50,000 per QALY, the probability that SMI will be cost-effective is 52%. Sensitivity analyses and subgroup analysis showed the robustness of the results.ConclusionsSMI is probably not a cost-effective alternative in comparison with EDU. Based on the current results, the value of implementing SMI for a stroke population is debatable. We recommend further exploration of the potential cost-effectiveness of stroke-specific self-management interventions focusing on different underlying mechanisms and using different control treatments.

The effect of carrier addition on Anammox start-up and microbial community: a review

The Anaerobic Ammonia Oxidation (Anammox) wastewater treatment process has attracted significant attention ever since its discovery in the Netherlands in the 1990′s. This has mostly been due to the potential cost-effectiveness associated with the process in large scale application. However, the application of the Anammox process on an industrial-scale has been curtailed mainly due to the long start-up time of the Anammox bacteria. In order to ensure the feasibility of industrial-scale Anammox application, researchers have employed various means; experimenting with different reactor types, membrane types, as well as the usage of chemicals such as hydrazine, acyl-homoserinelactones (AHL), etc. Most recently however, more attention has been directed towards the addition of biomass carriers such as biochar, zeolites, sponges, non-woven membrane etc. for the optimization of the Anammox process. This article provides an up-to-date overview of the various carriers (Non-woven fabric, Biochar, Down-flow hanging sponge, Zeolite, Zero-violent iron, Polyethylene glycol gel, Activated-carbon, Polyethylene sponge, etc.) that have so far been used to better the performance of the Anammox process. It also focuses on the effect of these biomass carrier additions on the microbial growth and community structure. Understanding the metabolomics of microorganisms in carrier-amended media promises to enhance our knowledge of carriers’ influence on the microbial community structure. Generally, the metabolic effects of carrier-amendment on microbial growth and community are largely uninvestigated. Future researches focusing on this area could tremendously improve our comprehension of the inner-workings of the carrier amended Anammox set-up.

Cost-effectiveness of postpartum haemorrhage first response bundle and non-surgical interventions for refractory postpartum haemorrhage in India: an ex-ante modelling study

BackgroundPostpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide and India accounts for approximately 19% of global maternal deaths, with PPH as the leading cause. In recent years, care bundles have been shown to increase adherence to clinical guidelines and improve patient outcomes. The objective of this study was to develop a PPH cost-effectiveness model to estimate the potential health impact and cost-effectiveness of a quality improvement programme for PPH management featuring a first response bundle and a set of refractory PPH interventions in health facilities in Uttar Pradesh, India. MethodsWe used a decision tree model to compare the status quo delivery of PPH care in Uttar Pradesh with two scenarios in which recommended bundles for PPH management were optimally applied. Status quo PPH care includes intravenous fluids, uterotonics, and uterine massage delivered with a setting-specific probability that increases with the level of health facility. In the strengthened PPH care scenario, status quo interventions are combined with tranexamic acid in a first response bundle which is used in all PPH cases, plus manual placenta removal and suturing when indicated. In the enhanced PPH care scenario, PPH care is further enhanced through implementation of non-surgical interventions for managing refractory PPH (including uterine balloon tamponade, aortic compression, and non-pneumatic anti-shock garment). For each scenario, we conducted a Monte Carlo simulation of cohorts of 1 million women delivering at home, subcentres, primary-health clinics, community-health centres, and district hospitals. The results were scaled to represent the annual number of deliveries in Uttar Pradesh and their distribution across health facilities. The main outcomes were PPH cases, PPH deaths, and PPH surgical procedures. FindingsCompared with status quo, perfect implementation of enhanced PPH care was predicted to reduce PPH-related maternal mortality in intervention facilities by 98%, from 10·7 to 0·3 per 100 000 deliveries, averting 450 deaths per year in Uttar Pradesh. Although enhanced PPH care would increase annual costs associated with the active management of the third stage of labour and non-surgical PPH management by US$190 000 and $300 000, respectively, service delivery costs were reduced by $1·42 million per year. Strengthened PPH care was predicted to prevent PPH deaths and reduce service delivery costs compared with status quo, but to have only 66% of the health impact and 63% of the cost-savings compared with enhanced PPH care. The upfront programme implementation costs and persistence of change in PPH management after implementation are uncertain. If enhanced PPH care were implemented with up to $2300 per facility, and the change in PPH management persisted for at least 2 years, the programme is estimated to be cost-effective (<0·5 GDP per capita per life year gained). InterpretationImplementation of an enhanced PPH care programme, including the first response bundle and non-surgical refractory PPH interventions, is likely to be cost-effective and life-saving in Uttar Pradesh, India. Moreover, enhanced PPH care is likely to generate more health impact and cost-savings compared with strengthened PPH care because of the greater reduction in number of surgeries needed. FundingBill & Melinda Gates Foundation

Protocol for a multi-centre randomised controlled stand-alone feasibility trial to assess potential effectiveness and cost-effectiveness of digital hearing aids in patients with tinnitus and hearing loss (the HUSH trial)

BackgroundThe most common management strategy for tinnitus provided in the UK audiology clinics is education and advice. This may also be combined with some form of sound therapy (e.g. digital hearing aids). While education and advice is generally provided by all clinics, there is a marked variability in provision of hearing aids that depends very much on clinical decisions. A recent Cochrane review concluded a lack of evidence to support or refute hearing aid use as a routine intervention for people with tinnitus and hearing loss. This lack of evidence is reflected in the inconsistency of tinnitus management in the UK. The aim of the HUSH trial is to determine the feasibility of conducting a definitive randomised controlled trial (RCT) of the effectiveness and cost-effectiveness of hearing aids for adults with tinnitus and hearing loss.MethodsThis is a multicentre randomised controlled feasibility trial. Up to 100 adults, aged 18 and over, presenting to 5 UK audiology clinics with a complaint of tinnitus and measurable hearing loss are being randomised to receive either (i) education and advice (treatment as usual) or (ii) education and advice with digital hearing aids. Feasibility outcomes are being collected around recruitment, retention, patient and healthcare professional acceptability and clinical outcome assessment. Outcomes are being collected via postal questionnaire at 12 weeks post baseline. A nested interview study will supplement clinical and other outcome data, providing a detailed understanding of participants’ and audiologists’ experience of both tinnitus management and the research processes.DiscussionThis feasibility trial will help us to (i) determine if it is feasible to conduct a multicentre RCT comparing treatment as usual and treatment as usual plus digital hearing aids; (ii) optimise the design of a future definitive, multicentre RCT; and (iii) inform which outcome(s) is/are relevant for patients. This work presents an important first step in determining the effectiveness of hearing aids as a tinnitus management strategy.Trial registrationISRCTN, ISRCTN14218416. Registered on 30 July 2018.

Evaluation of the acceptability and usability of the MAGIC-GLASS virtual reality solution as part of the care pathway in people with acute, sub-acute and chronic stroke: a study protocol

Background: Intensive rehabilitation is one of the most important aspects of care for people with stroke, and there is evidence that it leads to better recovery and higher levels of independence. However, pressure on resources in government funded secondary and primary healthcare settings means that for many people with stroke, intense rehabilitation is not available. Effective and efficient ways of increasing rehabilitation intensity, engagement, and motivation for rehabilitation are needed; as well as innovative treatment approaches that enable people with stroke to self-manage this rehabilitation. Technology offers a solution; virtual reality (VR) computer games have the potential to enhance engagement, improve adherence, and outcomes in stroke rehabilitation therapy. However, their integration into current health care pathways needs to be tested.Aims: The aim of the trial is to test the feasibility of incorporating VR computer games into a stroke rehabilitation system called ‘MAGIC-GLASS’, and its integration into the current care pathway for people with stroke.Design: Multicenter, prospective uncontrolled, pre-post intervention study.Setting: Participants will be recruited from Stroke Services, GP Practices or via Stroke Support Groups, and the intervention will be carried out in the hospital setting, or at home after discharge.Population: Adults (≥18 years) who have had a stroke.Interventions: Magic Glass is a clinician facilitated VR-based stroke rehabilitation system. Clinical facilitation includes a minimum of one initial face-to-face contact followed by up to 13 weekly/fortnightly remote contacts (to month six) with a clinician.Outcomes: The usability and acceptability of the intervention; process and resource requirements for the new care pathway; changes in clinical outcomes and potential cost-effectiveness of the solution will be measured to assess change from baseline to six months post intervention.Sample size: In order to have 50 patients in the subgroups identified (time since stroke; severity of stroke; age) we plan to recruit 300 participants, 150 in Northern Ireland and 150 in Italy. Fifty is considered the optimal sample size for this feasibility analysis.Duration: 18 months. Follow up will be post intervention (up to six months post entry into the study). The nested qualitative study will start once the first cohort of participants has completed and will continue throughout the intervention period.

Potential cost-effectiveness of a maternal Group B streptococcal vaccine in The Gambia

ObjectiveTo estimate neonatal health benefits and healthcare provider costs of a theoretical Group B streptococcal (GBS) hexavalent maternal vaccination programme in The Gambia, a low-income setting in West Africa. MethodsA static decision analytic cost-effectiveness model was developed from the healthcare provider perspective. Demographic data and acute care costs were available from studies in The Gambia undertaken in 2012–2015. Further model parameters were taken from United Nations and World Health Organisation sources, supplemented by data from a global systematic review of GBS and literature searches. As vaccine efficacy is not known, we simulated vaccine efficacy estimates of 50–90%. Costs are reported in US dollars. Cost-effectiveness thresholds of one (US$473, very cost effective) and three (US$1420, cost effective) times Gambian GDP were used. ResultsVaccination with a hexavalent vaccine would avert 24 GBS disease cases (55%) and 768 disability adjusted life years compared to current standard of care (no interventions to prevent GBS disease). At vaccine efficacy of 70%, the programme is cost-effective at a maximum vaccine price per dose of 12 US$ (2016 US$), and very cost-effective at a maximum of $3/dose. The total costs of vaccination at $12 is $1,056,962 for one annual cohort of Gambian pregnant women. One-way sensitivity analysis showed that GBS incidence was the most influential parameter on the cost effectiveness ratio. ConclusionThe introduction of a hexavalent vaccine would considerably reduce the current burden of GBS disease in The Gambia but to be cost-effective, the vaccine price per dose would need to be $12/dose or less.

Increasing the Price of Alcohol as an Obesity Prevention Measure: The Potential Cost-Effectiveness of Introducing a Uniform Volumetric Tax and a Minimum Floor Price on Alcohol in Australia.

The objective of this study was to estimate, from an obesity prevention perspective, the cost-effectiveness of two potential policies that increase the price of alcohol in Australia: a volumetric tax applied to all alcohol (Intervention 1) and a minimum unit floor price (Intervention 2). Estimated changes in alcoholic drink consumption and corresponding changes in energy intake were calculated using the 2011–12 Australian Health Survey data, published price elasticities, and nutrition information. The incremental changes in body mass index (BMI), BMI-related disease outcomes, healthcare costs, and Health Adjusted Life Years (HALYs) were estimated using a validated model. Costs associated with each intervention were estimated for government and industry. Both interventions were estimated to lead to reductions in mean alcohol consumption (Intervention 1: 20.7% (95% Uncertainty Interval (UI): 20.2% to 21.1%); Intervention 2: 9.2% (95% UI: 8.9% to 9.6%)); reductions in mean population body weight (Intervention 1: 0.9 kg (95% UI: 0.84 to 0.96); Intervention 2: 0.45 kg (95% UI: 0.42 to 0.48)); HALYs gained (Intervention 1: 566,648 (95% UI: 497,431 to 647,262); Intervention 2: 317,653 (95% UI: 276,334 to 361,573)); and healthcare cost savings (Intervention 1: $5.8 billion (B) (95% UI: $5.1B to $6.6B); Intervention 2: $3.3B (95% UI: $2.9B to $3.7B)). Intervention costs were estimated as $24M for Intervention 1 and $30M for Intervention 2. Both interventions were dominant, resulting in health gains and cost savings. Increasing the price of alcohol is likely to be cost-effective from an obesity prevention perspective in the Australian context, provided consumers substitute alcoholic beverages with low or no kilojoule alternatives.