Potential Cost-effectiveness Research Articles

Abstract WP275: Potential Cost Effectiveness of the Melbourne Mobile Stroke Unit

Background: Mobile stroke units (MSUs) are ambulances with brain scanning capability and specialised staff. In Australia, the first MSU was launched in Melbourne, November 2017. The Melbourne MSU has two paramedics, a radiographer, a stroke neurologist and a stroke nurse specialist (5 days per week/ 8am-6pm). The MSU is co-dispatched with a standard ambulance to a patient with suspected stroke within metropolitan Melbourne (20km radius). In cases where the standard ambulance assessed the patient first and stroke is eliminated, the MSU is contacted to ‘stand-down’. The cost-effectiveness of this type of ‘pre-hospital’ service remains unclear. Methods: The potential cost-effectiveness of the Melbourne MSU was estimated for 2018 following the pilot period (Nov-Dec 2017). A simulation model was developed for 2018 with a) program costs: operational/finance reports, self-report program leads/senior operational staff; b) clinical processes: MSU medical records/historical data; and c) health effects of treatment taken from the literature for reperfusion therapies to patients with ischaemic stroke (i.e. benefits: additional patients treated/faster treatment). Primary outcome: incremental cost per disability adjusted life year (DALY) avoided. The comparison was to standard pre-hospital and emergency department historical ‘usual’ care. Probabilistic, multivariable uncertainty analyses with Monte Carlo (10,000) simulations and sensitivity analyses were conducted. Results: In 2018, the Melbourne MSU was dispatched for 1244 suspected strokes (200 operational days). Overall, 46.9 DALYs were potentially avoided (95% uncertainty interval 33.02, 82.15 DALYs). The net cost of operating the MSU was ~$US 980,000, and the incremental cost/DALY avoided was $US 20,681 compared to standard care (95% uncertainty interval $US 14,167, $US 32,214). Conclusion: The Melbourne MSU is a cost-effective model for stroke care based on a standard willingness-to-pay cost-effectiveness threshold (<$US 50,000 per DALY avoided). Future adaptations to the operational model may improve the cost-effectiveness of this service.

The cost-effectiveness of using pneumococcal conjugate vaccine (PCV13) versus pneumococcal polysaccharide vaccine (PPSV23), in South African adults

Streptococcus pneumoniae (pneumococcus) remains an important cause of morbidity and mortality. Pneumococcal vaccination is part of the South African pediatric public immunization program but the potential cost-effectiveness of such an intervention for adults is unknown. This study aimed to compare the cost-effectiveness of two widely used pneumococcal vaccines: pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) in South African adults, 18 years and older. Four analyses were carried out in a) both the private and public health care sectors; and b) for the HIV-infected population alone and for the total mixed population (all HIV-infected and -uninfected people). A previously published global pharmacoeconomic model was adapted and populated to represent the South African adult population. The model utilized a Markov-type process to depict the lifetime clinical and economic outcomes of patients who acquire pneumococcal disease in 2015, from a societal perspective. Costs were sourced in South African rand and converted to US dollar (USD). The incremental cost divided by the incremental effectiveness (expressed as quality-adjusted life years gained) represented the incremental cost-effectiveness ratio for PCV13 compared to PPSV23. Results indicated that the use of PCV13 compared to PPSV23 is highly cost-effective in the public sector cohorts with incremental cost-effectiveness ratios of $771 (R11,106)/quality-adjusted life year and $956 (R13,773)/quality-adjusted life year for the HIV-infected and mixed populations, respectively. The private sector cohort showed similar highly cost-effective results for the mixed population (incremental cost-effectiveness ratio $626 (R9,013)/quality-adjusted life year) and the HIV-infected cohort (dominant). In sensitivity analysis, the model was sensitive to vaccine price and effectiveness. Probabilistic sensitivity analyses found predominantly cost-effective ICERs. From a societal perspective, these findings provide some guidance to policy makers for consideration and implementation of an immunization strategy for both the public and private sector and amongst different adult patient pools in South Africa.

Early cost-utility analysis of tissue-engineered heart valves compared to bioprostheses in the aortic position in elderly patients

ObjectivesAortic valve disease is the most frequent indication for heart valve replacement with the highest prevalence in elderly. Tissue-engineered heart valves (TEHV) are foreseen to have important advantages over currently used bioprosthetic heart valve substitutes, most importantly reducing valve degeneration with subsequent reduction of re-intervention. We performed early Health Technology Assessment of hypothetical TEHV in elderly patients (≥ 70 years) requiring surgical (SAVR) or transcatheter aortic valve implantation (TAVI) to assess the potential of TEHV and to inform future development decisions.MethodsUsing a patient-level simulation model, the potential cost-effectiveness of TEHV compared with bioprostheses was predicted from a societal perspective. Anticipated, but currently hypothetical improvements in performance of TEHV, divided in durability, thrombogenicity, and infection resistance, were explored in scenario analyses to estimate quality-adjusted life-year (QALY) gain, cost reduction, headroom, and budget impact.ResultsDurability of TEHV had the highest impact on QALY gain and costs, followed by infection resistance. Improved TEHV performance (− 50% prosthetic valve-related events) resulted in lifetime QALY gains of 0.131 and 0.043, lifetime cost reductions of €639 and €368, translating to headrooms of €3255 and €2498 per hypothetical TEHV compared to SAVR and TAVI, respectively. National savings in the first decade after implementation varied between €2.8 and €11.2 million (SAVR) and €3.2–€12.8 million (TAVI) for TEHV substitution rates of 25–100%.ConclusionsDespite the relatively short life expectancy of elderly patients undergoing SAVR/TAVI, hypothetical TEHV are predicted to be cost-effective compared to bioprostheses, commercially viable and result in national cost savings when biomedical engineers succeed in realising improved durability and/or infection resistance of TEHV.

Field technical applicability and cost analysis for microwave based regenerating permeable reactive barriers (MW-PRBs) operating in Cs-contaminated groundwater treatment

The present study tests the potentiality of a novel microwave based regenerating permeable reactive barrier (MW-PRB) system as combined treatment for Cs-contaminated groundwater. Granular activated carbon (GAC) was selected as adsorptive materials in batch and column MW-regeneration experiments. Experimental and modeling data were elaborated for technical and economic considerations in order to assess the MW-PRB feasibility jointly with essential information regarding its real field applicability. Batch experiments investigated the effects of 10 adsorption-MW regeneration cycles under different MW irradiation conditions (applied electric field = 200–460 V m−1; irradiation times = 1–15 min) by assessing GAC variation properties in term of regeneration yield (δ), specific area and weight loss (WL) variation. Column tests were carried using a dedicated setup essentially including a column filled with GAC implanted in a MW oven cavity (MW electric field of 385 V m−1, irradiation times 5–15 min). Lab-scale results shown the ability of MW in Cs removal from GAC as demonstrated by regeneration yield (δ = 79–110%) and WL (6.78% for 10 cycles) values. This was confirmed in dynamic conditions by data from MW-column tests highlighting the highest Cs removal of ~80% when the maximum regeneration time was applied. Residual Cs concentration in breakthrough curves fitted well with the proposed Yoon and Nelson model (R2 = ~0.97). Results from techno-economic analysis revealed the MW-PRB viability and its advantages also in comparison with conventional PRB systems, demonstrating the concept of combined MW-PRB treatment. Saved cost obtained demonstrated in fact the potential cost effectiveness of MW-PRB system and, consequently, the implementation of novel approach is encouraged. Calculated PRB longevity vs groundwater velocity curves are useful in order to predict long-term PRB performance and the response of the remediation activities, as well as for guiding the design and the scaling-up of MW-PRB treatment.

Cost-effectiveness of a Pharmacogenomic Test for Stratified Isoniazid Dosing in Treatment of Active Tuberculosis.

BackgroundThere is marked interindividual variability in metabolism and resulting toxicity and effectiveness of drugs used for tuberculosis treatment. For isoniazid, mutations in the N-acetyltransferase 2 (NAT2) gene explain >88% of pharmacokinetic variability. However, weight-based dosing remains the norm globally. The potential clinical impact and cost-effectiveness of pharmacogenomic-guided therapy (PGT) are unknown.MethodsWe constructed a decision tree model to project lifetime costs and benefits of isoniazid PGT for drug-susceptible tuberculosis in Brazil, South Africa, and India. PGT was modeled to reduce isoniazid toxicity among slow NAT2 acetylators and reduce treatment failure among rapid acetylators. The genotyping test was assumed to cost the same as the GeneXpert test. The main outcomes were costs (2018 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.ResultsIn Brazil, PGT gained 19 discounted life-years (23 QALYs) and cost $11 064 per 1000 patients, a value of $476 per QALY gained. In South Africa, PGT gained 15 life-years (19 QALYs) and cost $33 182 per 1000 patients, a value of $1780 per QALY gained. In India, PGT gained 20 life-years (24 QALYs) and cost $13 195 per 1000 patients, a value of $546 per QALY gained. One-way sensitivity analyses showed the cost-effectiveness to be robust to all input parameters. Probabilistic sensitivity analyses were below per capita gross domestic product in all 3 countries in 99% of simulations.ConclusionsIsoniazid PGT improves health outcomes and would be cost-effective in the treatment of drug-susceptible tuberculosis in Brazil, South Africa, and India.

Surveillance of hepatocellular carcinoma in cirrhotic patients: Current knowledge and future directions.

Patients with cirrhosis are at the highest risk to develop hepatocellular carcinoma (HCC), with a variable annual risk of 1–8%. Currently, biannual abdominal ultrasound (USG) with or without alpha fetoprotein (AFP) is the recommended HCC surveillance strategy of major professional liver societies for all cirrhotic patients. However, the effectiveness of USG and AFP has been a sprawling subject of debate due to conflicting results and the low quality of the evidence. The role of cross-sectional imaging is controversial due to potential harm and cost-effectiveness concerns. Several novel serum biomarkers have been introduced for HCC screening, but have yet to be validated for various geographic regions. A risk-stratified algorithm is needed to increase the yield of HCC surveillance by distinguishing a high-risk group that requires more intense screening with cross-sectional imaging and serum biomarkers, and a low-risk group, where the standard surveillance strategy is continued. In this review, the strengths and concerns related to standard USG-based surveillance strategy are discussed, as well as efforts to increase the effectiveness of surveillance.

The clinical and cost-effectiveness of supplemental parenteral nutrition in oncology

BackgroundClinical guidelines recommend that parenteral nutrition (PN) is added to enteral nutrition (EN; supplemental parenteral nutrition (SPN)) in order to meet energy and protein needs in patients with cancer when EN alone is insufficient. However, although cancer-related malnutrition is common, there is poor awareness of the value of nutritional care, resulting in SPN being chronically underused.MethodsWe performed a targeted literature review and exploratory cost-utility analysis to gather evidence on the clinical effectiveness of SPN, and to estimate the potential cost-effectiveness of SPN versus EN alone in an example cancer setting.ResultsThe literature review identified studies linking SPN with malnutrition markers, and studies linking malnutrition markers with clinical outcomes. SPN was linked to improvements in body mass index (BMI), fat-free mass, phase angle (PhA) and prealbumin. Of these markers, BMI and PhA were strong predictors of survival. By combining published data, we generated indirect estimates of the overall survival HR associated with SPN; these ranged from 0.80 to 0.99 (mode 0.87). In patients with Stage IV inoperable pancreatic cancer, the incremental cost-effectiveness ratio versus EN alone was estimated to be £41 350 or £91 501 depending on whether nursing and home delivery costs for EN and SPN were combined or provided separately.ConclusionDespite a lack of direct evidence, the results of the literature review demonstrate that SPN may provide important clinical and quality of life benefits to patients with cancer. The potential for any improvement in outcomes in the modelled patient population is very limited, so cost-effectiveness may be greater in patients with less severe disease and other types of cancer.

MRI Image Segmentation, Prediction and Diagnostic Accuracy: Deep Learning Framework and Machine Learning Techniques Analysis for Reducing The impact of Cardiac Diseases

Background: Usage of tele - monitoring system of electronic patient record (EHR) and magnetic reasoning is expected to increase rapidly in near future, yet numerous studies have examined cardiovascular risk prediction and statistic adoptive approach could improve clinical risk prediction. Objectives: To assess the performance outcomes of various techniques for predicting the risk of cardiovascular diseases and MRI image segmentation method on the basis of systematic review. Research Design: Retrospective Cardiovascular study. We associate UCI dataset, AHA dataset, real time patient datasets, hospital dataset and sunny broken dataset from 2017 to 2019, and predicted risk using the logistic regression, stochastic gradient boosted, random forest, SVM, ROC Curve, KNN algorithm, MXNET UNET. Measures: The proposed methods have been developed in four categories to accurately diagnose cardiovascular diseases. We assessed to analyze and compared the accuracy of four different machine learning algorithms with the ROC for assessing and diagnosing cardiovascular disease from UCI cardiac datasets. The research will then focus on to predict heart diseases automatically by segmenting and classifying the patients’ heart data in real- time with the help of machine learning algorithms, big data, wireless heart monitor and smart phones. We further improve the prediction accuracy by using logistic regression and ROC Curve to improve the prediction performance. Consequently, K- Nearest-Neighbor (KNN) method, R programming language and big data where applied to easily find the nearest hospitals, monitor and provide on-time visualization to the medical professionals. Finally, we propose automatic myocardial segmentation method for cardiac MRI on the basis of Deep Convolutional neural network. Results: Logistic Regression methods outperformed the standard accuracy rate even with application of ROC curve (AUC increased from 87% to 91%). Ever better performance was achieved in Models using additional Real time dataset attributes (AUC increased to 93% and KNN achieved approximately 83%). Proposed image segmentation method results tended using following techniques, Jaccard (0.6 ± 0.1 mean accuracy Dice’s value) outplays the dices co efficient (0.58 ± 0.1 mean accuracy Dice’s value) CCN reaches the value of the 0.9 (Table 7) and for the dice’s co-efficient respectively that can be compared to manual segmentation. The accuracy tended to decline while PM (Papillary muscles) we got 0.89 for the dice’s coefficient and mean squared error 0.01. Conclusions: The tele - monitoring system plays the important role for cardiovascular patients and the healthcare industry. Moreover, cardiac image classification demands a high level of expertise and significant time consumption on the part of the operator. Multicenter sufficiently powered and randomized controlled trials are needed to assess the potential benefits and cost-effectiveness of this intervention. Subsequently, our findings of image classification method will facilitate more advanced discovery.

Potential health impact and cost-effectiveness of bivalent human papillomavirus (HPV) vaccination in Afghanistan

IntroductionHuman papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making. MethodAn Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10–14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives. ResultsVaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country′s total immunization budget for 2018 or 0.13% of total health expenditures. ConclusionIn Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government′s willingness to pay for the projected health outcomes.

Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance.

IntroductionOral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation.MethodsWe calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15–24 years and female sex workers, and (2) availability for everyone aged 15–64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs.ResultsIn the context of PrEP use in adults aged 15–64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15–24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance.ConclusionsPrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.

The projected impact of geographic targeting of oral cholera vaccination in sub-Saharan Africa: A modeling study.

BackgroundCholera causes an estimated 100,000 deaths annually worldwide, with the majority of burden reported in sub-Saharan Africa. In May 2018, the World Health Assembly committed to reducing worldwide cholera deaths by 90% by 2030. Oral cholera vaccine (OCV) plays a key role in reducing the near-term risk of cholera, although global supplies are limited. Characterizing the potential impact and cost-effectiveness of mass OCV deployment strategies is critical for setting expectations and developing cholera control plans that maximize the chances of success.Methods and findingsWe compared the projected impacts of vaccination campaigns across sub-Saharan Africa from 2018 through 2030 when targeting geographically according to historical cholera burden and risk factors. We assessed the number of averted cases, deaths, and disability-adjusted life years and the cost-effectiveness of these campaigns with models that accounted for direct and indirect vaccine effects and population projections over time. Under current vaccine supply projections, an approach optimized to targeting by historical burden is projected to avert 828,971 (95% CI 803,370–859,980) cases (equivalent to 34.0% of projected cases; 95% CI 33.2%–34.8%). An approach that balances logistical feasibility with targeting historical burden is projected to avert 617,424 (95% CI 599,150–643,891) cases. In contrast, approaches optimized for targeting locations with limited access to water and sanitation are projected to avert 273,939 (95% CI 270,319–277,002) and 109,817 (95% CI 103,735–114,110) cases, respectively. We find that the most logistically feasible targeting strategy costs US$1,843 (95% CI 1,328–14,312) per DALY averted during this period and that effective geographic targeting of OCV campaigns can have a greater impact on cost-effectiveness than improvements to vaccine efficacy and moderate increases in coverage. Although our modeling approach does not project annual changes in baseline cholera risk or directly incorporate immunity from natural cholera infection, our estimates of the relative performance of different vaccination strategies should be robust to these factors.ConclusionsOur study suggests that geographic targeting substantially improves the cost-effectiveness and impact of oral cholera vaccination campaigns. Districts with the poorest access to improved water and sanitation are not the same as districts with the greatest historical cholera incidence. While OCV campaigns can improve cholera control in the near term, without rapid progress in developing water and sanitation services or dramatic increases in OCV supply, our results suggest that vaccine use alone is unlikely to allow us to achieve the 2030 goal.

The potential cost-effectiveness of mandatory restrictions on price promotions for sugar-sweetened beverages in Australia.

Restricting price promotions on unhealthy foods and beverages has been identified by governments as a promising approach for improving population diets. Using a limited societal perspective, this study assessed the potential cost-effectiveness of mandatory restrictions on price promotions for sugar-sweetened beverages (SSBs) in Australia. Australian dietary consumption data, together with UK data on the SSB sales uplift associated with price promotions, were used to estimate reductions in SSB purchases and consequent changes in body mass index following the intervention. A multi-state, multiple-cohort Markov model was used to estimate the obesity-related health and cost impacts over the lifetime of the 2010 Australian population. Costs included passing legislation, assisting retailer implementation, and compliance monitoring. The intervention was estimated to result in a mean change in daily energy intake of -12.52 kJ (95% Uncertainty Interval, UI: -15.91 to -9.58) per person, which translated to a mean body weight change of -0.11 kg (95%UI: -0.14 to -0.08) per person. Total Health Adjusted Life Years gained were estimated at 34,260 (95%UI: 24,922-45,504). Estimated costs were AUD17.0 million, with estimated healthcare cost savings of AUD376.0 million. The intervention was considered dominant (cost-saving and health promoting). The intervention remained cost-effective if retailers reduced average non-discounted SSB prices in response to the intervention by less than 5.36%. Restricting price promotions on SSBs is likely to be highly cost-effective, although its impact would depend on how industry and shoppers respond. Although Australian data are used, these results are likely to be transferable and highly relevant to the UK context. Policies for restricting price promotions should be considered as part of a comprehensive obesity prevention strategy.

P63 REQUIREMENTS FOR A NEW DIAGNOSTIC TEST TO DETECT LYMPH NODE METASTASES IN ESOPHAGEAL CANCER: A HEALTH-ECONOMIC MODELLING STUDY

Abstract Background Curative treatment for esophageal cancer consists of neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy with lymph node dissection (LND). Despite only 31-38% of patients harbour positive lymph nodes, all patients undergo LND with associated morbidity. Ideally, a non-invasive diagnostic test would indicate if LND is needed, however it is unknown what requirements such a test should have to justify minimizing LND from a cost-effectiveness perspective. Objective To determine the potential cost-effectiveness, minimally required accuracy and maximum cost of a hypothetical new diagnostic test. Methods A decision tree with state-transition model was constructed for patients with resectable esophageal cancer who received nCRT and are scheduled for esophagectomy. The current strategy including LND was compared to omitting LND based on a hypothetical diagnostic test in terms of costs and QALYs. Input data for the LND strategy was derived from literature. Consequences of omitting LND on procedure time, complications and hospital stay were based on a worldwide case vignette study among esophageal surgeons (N=89). Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty. Results Assuming 100% sensitivity of LND and 100% accuracy of the hypothetical test at zero costs, the hypothetical test yielded 0.004 QALYs (95%CI -0.020 – 0.013), while saving €3,025 (95%CI -5652 – 3576) per patient compared to LND. Assuming 100% sensitivity of LND, the hypothetical test would require 98% sensitivity at zero costs to be cost-effective compared to LND. Sensitivity of LND might be lower, since not all LN stations are routinely dissected. Assuming 90% sensitivity of LND, it would require 88% sensitivity at zero costs or 89% at a maximum cost of €1,674 per patient to be cost effective. Conclusions The room for improvement for new diagnostic techniques is highly dependent on the sensitivity of LND. A new diagnostic test may have up to 2% lower sensitivity than LND to be cost-effective compared to LND.

Prevalence of undiagnosed atrial fibrillation in elderly individuals and potential cost-effectiveness of non-invasive ambulatory electrocardiographic screening: The ASSERT-III study

BackgroundIn approximately 10% of patients with implanted pacemakers or defibrillators, previously unrecognized atrial fibrillation (AF) is detected within 3 months. It is unknown whether elderly patients without implanted devices have a similar prevalence of undiagnosed AF using non-invasive ECG monitoring, and if this approach to screening in this population is cost-effective. MethodsIndividuals ≥80 years old attending outpatient clinics without a history of AF and with hypertension and one additional risk factor underwent 30 days of continuous ECG monitoring with an option for an additional 30 days of monitoring if no AF was detected. The primary outcome was AF ≥ 6 min. Cost-effectiveness to prevent stroke was estimated using a Markov model based on observed AF detection rates and data from the published literature. ResultsAmong 129 patients enrolled, 100 initiated monitoring for an average duration of 36 ± 21 days. The proportion of patients that completed at least 30 days of monitoring was 59%. Average age was 84 ± 3 years and mean CHA2DS2-VASc score was 4.5 ± 1.2. AF ≥ 6 min was documented in 14%, ≥6 h in 8%, and ≥24 h in 3%. One week of monitoring costed $50,000 per quality-adjusted life-year-gained, 30 days and 60 days of monitoring costed $70,000 and $84,000, respectively. ConclusionsContinuous non-invasive ECG monitoring is feasible in elderly patients. Undiagnosed AF is present in many elderly individuals, with 1 in 7 having episodes lasting ≥6 min. One week of monitoring may be cost-effective for stroke prevention in this population.

Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling study

SummaryBackgroundPrevious studies have found rotavirus vaccination to be highly cost-effective in low-income countries. However, updated evidence is now available for several inputs (ie, rotavirus disease mortality rates, rotavirus age distributions, vaccine timeliness, and vaccine efficacy by duration of follow-up), new rotavirus vaccines have entered the market, vaccine prices have decreased, and cost-effectiveness thresholds have been re-examined. We aimed to provide updated cost-effectiveness estimates to inform national decisions about the new introduction and current use of rotavirus vaccines in Gavi countries.MethodsWe calculated the potential costs and effects of rotavirus vaccination for ten successive birth cohorts in 73 countries previously and currently eligible for Gavi support, compared with no vaccination. We used a deterministic cohort model to calculate numbers of rotavirus gastroenteritis cases, outpatient visits, hospitalisations, and deaths between birth and 5 years, with and without rotavirus vaccination. We calculated treatment costs from the government and societal perspectives. The primary outcome measure was the incremental cost-effectiveness ratio (discounted US$ per disability-adjusted life-year averted). Country-specific model input parameters were based on the scientific literature, published meta-analyses, and international databases. We ran deterministic and probabilistic uncertainty analyses.FindingsOver the period 2018–27, rotavirus vaccination has the potential to prevent nearly 600 000 deaths in Gavi countries. Averted outpatient visits and hospitalisations could lead to treatment savings of approximately $484·1 million from the government perspective and $878·0 million from the societal perspective. The discounted dollars per disability-adjusted life-year averted has a very high probability (>90%) of being less than 0·5 times the gross domestic product per capita in 54 countries, and less than 1·0 times gross domestic product per capita in 63 countries.InterpretationRotavirus vaccination continues to represent good value for money across most Gavi countries despite lower rotavirus mortality estimates and more stringent willingness-to-pay thresholds.FundingBill & Melinda Gates Foundation.

PAM1 COST-CONSEQUENCES ANALYSIS OF PAEDIATRIC TRIPLE-CHAMBER-BAGS (3CBS) IMPACT ON HOSPITAL RESOURCES AND CLINICAL OUTCOMES IN PRETERM NEONATES ACROSS BELGIUM, PORTUGAL, SPAIN AND THE UK

Economic modelling to evaluate potential cost and clinical effects of including 3CBs in parenteral nutrition (PN) regimens for preterm neonates. A deterministic cost-consequence analysis was performed to estimate hospital costs and clinical impact of a 10% increased utilisation of 3CBs in preterm neonatal population in Belgium, Portugal, Spain and the UK. Included data variables were ingredients, consumables, staff-time and PN associated compounding errors, complications, and clinical events avoided or gained. Five PN preparation methods were considered: pharmacy (manual or automated), ward, outsourced third party and 3CBs with an estimated compounding error rate baseline of 37%, 22%, 37%, 1.7%, and 1%, respectively, derived from Flynn 1997 and Dickson 1993. Infection rate estimates of 0.66% per day of PN for manual pharmacy compounding, which was increased by 10% with ward compounding, and decreased by 10% and 19% with outsourced compounding and 3CBs, respectively which were calculated from Hoang 2008. Across four countries, in approximately 120,000 preterm neonatal births annually, 52% are estimated to receive PN regimens. The overall current estimated share of PN preparation methods is 64% in manual and 9% in automated pharmacy, 4% in ward, 13% outsourced and 10% pediatric 3CBs. Increasing 3CBs utilization by 10 % would lead to 57% manual, 8% automated, 3% ward and 13% outsourced distribution, and as a result, an estimated 91 blood stream infections, 47 severe compounding errors, and 406 significant compounding errors can be avoided annually. Additionally, up to 17 pharmacists, 17 pharmacy assistants and 8 neonatologists could optimise their time in provision of care. The overall potential incremental hospital cost-savings would be around € 2.6 million across four European countries. The use of pediatric 3CBs may provide substantial cost-savings to hospitals and clinical benefits to preterm neonates.

MRI-guided pulmonary vein isolation for atrial fibrillation: what is good enough? An early health technology assessment

Next to anticoagulation, pulmonary vein isolation (PVI) is the most important interventional procedure in the treatment of atrial fibrillation (AF). Despite widespread clinical application of this therapy, patients often require...

Hepatitis C virus elimination in Indonesia: Epidemiological, cost and cost-effectiveness modelling to advance advocacy and strategic planning.

In Indonesia 1.9 million people are chronically infected with hepatitis C virus (HCV), but a national strategic plan for elimination has not yet been developed, despite the availability of low-cost treatments which could save many lives. We used epidemiological and cost modelling to estimate targets and resource requirements of a national elimination program and explore the potential impact and cost-effectiveness. To model the HCV epidemic, we used a dynamic model, parameterised with Indonesia-specific data, accounting for disease progression, injecting drug use and demographics. Future scale-up scenarios were designed for 2018-2050 to capture possible policy choices. Costs of an initial 5-year national strategy and of long-term elimination were estimated for the most feasible scenario, as agreed with government and local partners. Cost savings from reduced drug and diagnostics prices were also estimated. The cost-effectiveness of baseline predictions and those with drug price reductions were compared to the no treatment scenario. Elimination by 2045, considered the most feasible path to scale-up, would prevent 739000 new infections and avert 158000 HCV-related deaths. The costs would be $5.6 billion (USD) using baseline prices but could fall to $2.7 billion if price reductions for HCV drugs and diagnostics are secured. With these price reductions, the incremental cost-effectiveness ratio for a 2045 elimination program would be cost-effective at $300 (USD) per year of life saved vs the no treatment scenario. This study has underpinned advocacy efforts to secure Indonesian government commitment to HCV elimination, and provides further inputs for HCV strategic planning efforts.

Cost-Effectiveness of More Intensive Blood Pressure Treatment in Patients with High Risk of Cardiovascular Disease in Saudi Arabia: A Modelling Study of Meta-Analysis.

Objective The current literature suggests that more intensive blood pressure (BP) treatment is clinically more effective than less intensive treatment in patients at high risk for cardiovascular disease (CVD). In this analysis, we evaluated the potential clinical benefit and cost-effectiveness of more intensive BP treatment in patients at high risk of developing CVD over their lifetimes. Methods A Markov state-transition model was developed for the BP strategies to estimate the lifetime incremental cost-effectiveness ratio (ICER) per quality-adjusted-life-year (QALY) using evidence published from a meta-analysis. The other model inputs were retrieved from previous studies. Estimated costs were collected from five hospitals in Riyadh. The model used a lifetime framework adopting Saudi payer perspective and applied a 3% annual discount rate. Sensitivity analysis was conducted using one-way and probabilistic sensitivity analysis (PSA) to evaluate the robustness and uncertainty of the estimates. Results Treating 10,000 patients with high CVD risk with more intensive BP therapy would avert a total of 873 CV events over their remaining lifetimes as compared with a less intensive strategy. The projections showed that more intensive BP therapy would be cost-effective compared to the less intensive strategy with incremental costs per QALY of $20,358. Probabilistic sensitivity analysis suggested more intensive control would be cost-effective compared with the less intensive control of BP 87.25 % of the time. Conclusion The result of this study showed that more intensive BP treatment appears to be a cost-effective choice for patients with a high risk of CVD in Saudi Arabia when compared with a less intensive BP strategy. Thus, this finding provides strong evidence for the adoption of this strategy within the Saudi healthcare system.

Health impact and cost-effectiveness of introducing the vaccine (Bexsero) against MenB disease into the Brazilian immunization programme

Invasive meningococcal disease (IMD) is associated with a high mortality and severe sequelae. The aim of the present study was to evaluate the potential cost-effectiveness of the Bexsero vaccine in Brazil. We used a cohort model to compare routine vaccination against MenB disease with no vaccination. Epidemiological and cost estimates were obtained from the Brazilian Health Information System. The cost per disability-adjusted life year (DALY) averted and incremental cost-effectiveness ratio (ICER) was estimated assuming a 3-dose vaccination schedule, at R$90 (£ 20.50) per vaccine dose, 82.0% vaccine efficacy against MenB disease and a vaccine uptake of 90.0%. We estimated that 1,527 MenB cases would be prevented and 78 deaths averted. This strategy would cost R$ 762,381, 000 (£ 174,059,503) with a R$ 4,364,280 (£ 996,410) reduction in disease treatment costs. However, at an ICER of 372,256 (£ 84,990) per DALY averted, a vaccination programme is unlikely to be cost-effective.