Quality-adjusted Life-year Analysis Research Articles

218 Cost-Effectiveness and Quality-Adjusted Life Years Analysis for Endovascular Management of Acute Stroke With a Large Ischemic Region

INTRODUCTION: Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the infarction is large (defined as ASPECT score of < 5). However, a recent trial (RESCUE-Japan) published in NEJM, showed that patients with large cerebral infarctions had better functional outcomes, measured as mRS of 0-3 at 90 days, with MT compared to best medical management (BMM) alone. METHODS: Treeage, a decision-analytic software, was used to construct a cost effectiveness analysis model that compares the cost-effectiveness of MT vs. BMM alone based on the RESCUE-Japan study. The model includes a short-term decision model that examines costs and clinical outcomes of patients with acute ischemic stroke during the initial three months of treatment. Additionally, a long-term Markov state transition model is created to estimate expected outcomes and costs annually over a 20-year timeframe, with patients potentially experiencing recurrent strokes, transitioning to lower health states, and death from stroke. The success of each treatment was evaluated using QALYs. Then, to assess the robustness of this model, a sensitivity analysis was performed. RESULTS: In the base–case analysis of the total study population using a time horizon of 20 years, MT and BMM alone were found to have a 2.86 QALY and 1.44 QALY, respectively. This increase in the number of QALY by MT came at a lower cost of $275,805 compared to BMM alone, which had a cost $282,476. The incremental cost-effectiveness ratio (ICER) was determined at $-4697/QALY. The results were further supported by the 1-way deterministic and probabilistic sensitivity analyses. CONCLUSIONS: This study shows that, besides having a better clinical outcome, MT was more cost effective and associated with higher QALYs compared to BMM alone, when accounting for health care cost associated with treatment outcome.

Risk and Benefit of mRNA COVID-19 Vaccines for the Omicron Variant by Age, Sex, and Presence of Comorbidity: A Quality-Adjusted Life Years Analysis.

The development of the mutant omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the coronavirus disease 2019 (COVID-19) pandemic raised the importance of reevaluating the risk and benefit of COVID-19 vaccines. With a decision tree model, we calculated the benefit-risk ratio and the benefit-risk difference of receiving monovalent messenger RNA (mRNA) COVID-19 vaccine (primary 2 doses, a third dose, and a fourth dose) in the 4-5 months after vaccination using quality-adjusted life years. The analysis was stratified by age, sex, and the presence of comorbidity. Evidence from peer-reviewed publications and gray literature was reviewed on September 16, 2022, to inform the study. Benefit-risk ratios for receipt ofthe BNT162b2 vaccine (Pfizer-BioNTech) ranged from 6.8 for males aged 12-17 years without comorbidity for the primary doses to 221.3 for females aged ≥65 years with comorbidity for the third dose. The benefit-risk ratios for receipt of the mRNA-1273 vaccine (Moderna) ranged from 7.2 for males aged 18-29 years without comorbidity for the primary doses to 101.4 for females aged ≥65 years with comorbidity for the third dose. In all scenarios of the one-way sensitivity analysis, the benefit-risk ratios were more than 1, irrespective of age, sex, comorbidity status, and type of vaccine, for both primary and booster doses. The benefits of mRNA COVID-19 vaccines in protecting against the omicron variant outweigh the risks, irrespective of age, sex, and comorbidity.

Human health benefit and burden of the schizophrenia health care pathway in Belgium: paliperidone palmitate long-acting injections

BackgroundEnvironmental impact assessments of pharmaceuticals typically consider only a part of the pharmaceutical supply chain, e.g. tablet formulation. While the environmental impact can be expressed in environmental Human Health burden due to resource use and emissions, the Human Health benefit of the pharmaceutical treatment of patients is currently not simultaneously taken into account. The study aims include a cradle-to-grave assessment of all Human Health impacts of the production, administration and disposal of two antipsychotics for the treatment of schizophrenia. This is complemented with the environmental impact of health care providers such as hospitals. The aim is to holistically quantify to what extent the environmental Human Health burden compares to the Human Health benefit associated with the treatment.MethodsWe applied an overall framework which included Life Cycle Assessment to model the environmental Human Health impacts of the pharmaceutical supply chain, administration and disposal of the drug and health care providers. To model the patient benefit, this was complemented with a Markov model with a 1-year time horizon. Three patient groups were modeled: medicine coverage of paliperidone palmitate for either one month (PP1M) or three months (PP3M) at a time, and compared to Treatment Interruption (TI) as a control group. Outcomes were quantified using Years of Life Lost (YLL), Years Lived with Disability (YLD) and Disability-Adjusted Life Years (DALY).ResultsThe main environmental impacts were visits to the psychiatrist and psychiatric hospitals. The pharmaceutical supply chain had a limited impact. For 1000 patients for 1 year, PP1M and PP3M respectively avoided 0.38 and 0.49 environmental DALYs compared to TI. PP1M and PP3M further avoided 45.60 and 57.87 YLL and 23.31 and 29.91 YLD compared to TI. The main outcome was the sum of environmental DALYs, YLL and YLD, in which PP1M and PP3M respectively avoided 69.29 and 88.26 DALYs. Alternative analysis of Quality-Adjusted Life Years confirmed the results.ConclusionsThe overall environmental burden was lower for PP1M and PP3M treatment than Treatment Interruption because patients are kept more stable, which reduces the environmental burden due to hospitals. Moreover, the Human Health burden was outweighed by the Human Health benefit.

PSY217 - INCREMENTAL QUALITY-ADJUSTED SURVIVAL ANALYSIS WHEN NO HEAD TO HEAD DATA ARE AVAILABLE: A CASE STUDY OF MIDOSTAURIN (MIDO) VERSUS STANDARD OF CARE (SOC) IN PATIENTS WITH ADVANCED SYSTEMIC MASTOCYTOSIS (ASM)

Decision-making can be difficult when head-to-head trial data are absent. We present a case study to assess overall and quality-adjusted survival in such cases. Here, MIDO was compared to SOC in ASM. A partitioned survival model with a lifetime horizon was used and included four health states: treatment initiation, responder on treatment, treatment failure/discontinuation, and death. Since the CPKC412D2201 trial for MIDO trial was single-arm, the SOC comparator was modeled via hazard mapping for overall survival based on a propensity-score matching study comparing compassionate use MIDO with a historical control group. Response for SOC was based on weighted averages from relevant clinical trials. Piecewise extrapolations with log normal functional forms for OS and for treatment duration were used, as they had the most reasonable fit. The economic endpoints in the model were quality-adjusted life years (QALYs) and life years saved (LYs). Health-related-quality-of-life data were obtained in the trial using the SF-12 questionnaire and were mapped to the EQ-5D scale using an established algorithm. Utility varied between on treatment with response, on treatment with no response, and post-progression. MIDO-treated patients gained 2.48 LYs when compared to SOC, and had more time in the response state (0.74 LYs versus 0.47 LYs in the SOC arm). MIDO-treated patients also showed quality survival gains, with an incremental gain of 1.90 QALYs versus SOC. Deterministic and probabilistic sensitivity analyses generally showed consistency with base case findings. When additional scenarios were explored, QALYs were most sensitive to variations in discount rate and the OS functional form. This analysis demonstrated that in absence of head-to-head trials and usable quality-of-life trial data, hazard and utility mapping may be valuable in aiding with QALY analysis, particularly in orphan diseases with limited data. In this analysis, MIDO showed gains in LYs and QALYs compared with SOC.

DP3 - Analysis of quality-adjusted life years (QALYs) in HIV-positive and HIV-negative subjects enrolled to the UPBEAT (Understanding the Pathology of Bone Disease in HIV Infected Subjects) cohort

DP3 - Analysis of quality-adjusted life years (QALYs) in HIV-positive and HIV-negative subjects enrolled to the UPBEAT (Understanding the Pathology of Bone Disease in HIV Infected Subjects) cohort

A cost-effectiveness analysis of school-based suicide prevention programmes

Suicide is one of the leading causes of death among young people globally. In light of emerging evidence supporting the effectiveness of school-based suicide prevention programmes, an analysis of cost-effectiveness is required. We aimed to conduct a full cost-effectiveness analysis (CEA) of the large pan-European school-based RCT, Saving and Empowering Young Lives in Europe (SEYLE). The health outcomes of interest were suicide attempt and severe suicidal ideation with suicide plans. Adopting a payer's perspective, three suicide prevention interventions were modelled with a Control over a 12-month time period. Incremental cost-effectiveness ratios (ICERs) indicate that the Youth Aware of Mental Health (YAM) programme has the lowest incremental cost per 1% point reduction in incident for both outcomes and per quality adjusted life year (QALY) gained versus the Control. The ICERs reported for YAM were €34.83 and €45.42 per 1% point reduction in incident suicide attempt and incident severe suicidal ideation, respectively, and a cost per QALY gained of €47,017 for suicide attempt and €48,216 for severe suicidal ideation. Cost-effectiveness acceptability curves were used to examine uncertainty in the QALY analysis, where cost-effectiveness probabilities were calculated using net monetary benefit analysis incorporating a two-stage bootstrapping technique. For suicide attempt, the probability that YAM was cost-effective at a willingness to pay of €47,000 was 39%. For severe suicidal ideation, the probability that YAM was cost-effective at a willingness to pay of €48,000 was 43%. This CEA supports YAM as the most cost-effective of the SEYLE interventions in preventing both a suicide attempt and severe suicidal ideation.Trial registration number DRKS00000214.

Toward Explicit Prioritization for the Caribbean: An EQ-5D Value Set for Trinidad and Tobago

BackgroundResource allocation decision making in the Caribbean can be greatly enhanced by the introduction of cost per quality-adjusted life-year (QALY) analysis on the basis of local preferences. In the valuation literature there have been recommendations for the elicitation methods of the EuroQol five-dimensional questionnaire (EQ-5D) that combine discrete-choice experiment (DCE) for bulk valuation with a time trade-off component for rescaling. ObjectivesTo create a three-level EQ-5D value set for Trinidad and Tobago using an elicitation method that takes into account the local constraints, and that can be easily deployed in other Caribbean islands. MethodsA D-efficient DCE was completed by a representative sample of 307 adults. A time trade-off procedure was used to obtain values for rescaling the DCE model on a scale anchored at 0 (dead) and 1 (full health). ResultsA mixed logit analysis of the DCE data produced an internally valid model that is similar to the results obtained in earlier pilot studies. ConclusionsThis EQ-5D value set allows cost per QALY analyses to be carried out on the basis of preferences from Trinidad and Tobago, and the approach to the DCE design can be taken for similar value sets to be created in the small, resource-constrained health systems of the Caribbean. Some guidelines for the initial application and introduction of cost per QALY analysis into the Trinidad and Tobago health system are also presented.

BJOG Editor's Choice

Women choose to have an elective caesarean section for the delivery of their second child for a variety of reasons. Most cases relate to previous caesarean section, some because of psychological reasons, such as unresolved delivery-related post-traumatic stress disorder, and others because of previous physical maternal birth trauma. The last includes previous serious perineal tears, the rate of which appears to be increasing across Europe. In the UK the rate of third- and fourth-degree perineal tears in primiparous women tripled from 1.8% to 5.9% during the period 2000–12 (Gurol-Urganci et al. BJOG 2013;120:1516–25) and in Finland it rose from 0.5% in 1997–99 to 1.8% in 2006/07 (Räisänen et al. Prev Med 2009;49:535–40). In Norway, in primiparous women, the rate rose from 0.6% in 1967 to 7% in 2004 and did so in parallel for both instrumental and noninstrumental deliveries. The rise persisted after adjusting for demographic and other risk factors and confounders (Baghestan et al. Obstet Gynecol 2010;116:25–34). Whether this rise is as a result of more accurate reporting or a change in practice is unclear. It has been suggested that the ‘hands off’ practice for normal delivery, promoted from the 1960s and 1970s (McCandlish, J Midwifery Womens Health 2001;46:396–401), may have contributed to the increased occurrence of obstetric anal sphincter injuries in noninstrumental deliveries. In the 1980s, when I was a very junior obstetrician and my wife was a very junior midwife, I am sure I was part of a culture where mild (e.g. 3a) tears as a result of an instrumental delivery were under-reported. At the same time my wife was part of a culture where midwives were expected to be very ‘hands on’ with their deliveries and even a second-degree tear was considered a heinous crime and would have the midwife brought before a formidable and unsympathetic midwifery sister. Regardless of the reasons for the increase in rate, a previous anal sphincter injury has important implications for a future delivery. On page 1695 Edozien et al. report findings from a UK-wide study of 639 402 primiparous women who had a singleton, vaginal, live birth between 2004 and 2011, and who also had a second birth by March 2012. They measured the mode of delivery and recurrence of tears at the second birth. For women who had a vaginal delivery at second birth, the rate of third/fourth-degree tear was 7.2% in women with a previous third/fourth-degree tear compared with 1.3% in women without. The latter finding is similar to most previous reports from smaller studies and will assist in counselling women who have had a previous anal sphincter injury. The rate of elective caesarean for the second birth in women who have had previous sphincter injury was 24%, a figure that is much higher than the range of 6–18% reported previously in other countries, but remarkably similar to the figure of 22% of UK obstetricians who, according to a recent survey, would recommend an elective caesarean section to prevent anal incontinence following previous anal sphincter injury (Fernando et al. BMC Health Serv Res 2002;2:9). Whether this advice is sound is unclear. The rate of faecal incontinence 12 years after delivery does not differ between women who have only elective caesarean sections and women who have only vaginal deliveries (MacArthur et al. BJOG 2011;118:1001–7). If we are to practice evidence-based obstetrics then a return to the ‘hands on’ approach to delivery may be a better solution, for which there is increasing evidence of benefit (Hals et al. Obstet Gynecol 2010;116:901–8; Stedenfeldt et al. BJOG 2014;121:83–91). Around 15% of cases of cerebral palsy are clearly attributable to adverse events during labour, of which nearly one-half are probably avoidable. On page 1720, using published data regarding the incidence and aetiology of cerebral palsy, Leigh et al. simulated the outcomes of a hypothetical cohort of UK live births using survival and quality-adjusted life-years analysis. They calculated that 207 (95% confidence interval 169–245) cases of asphyxia-related cerebral palsy were projected among UK children born during 2014, causing a loss valued by the NHS at £62.9 million. One proposed strategy to reduce error in the management of labouring women is the introduction of Practical Obstetric Multi-Professional Training (PROMPT), which involves hospital-based training comprising short lectures and scenario-based simulation training in obstetric emergencies delivered by trainers drawn from the hospital staff. On page 1710 we present a study from Australia on the effects of the introduction of PROMPT in eight maternity units, which includes an analysis of the effects on neonatal outcome in a total of 43 408 babies born before and after the time of its introduction. About 50% of all possible staff were trained in the first year of the programme. Statistically significant positive effects of training on neonatal outcomes are shown in Figures 1 and 2.

Vagus nerve stimulation therapy in a developing country: A long term follow up study and cost utility analysis

PurposeTo evaluate clinical outcomes, quality-adjusted life years (QALY), cost effectiveness and cost utility associated with VNS therapy in children with refractory epilepsy in a developing country. MethodsRetrospective review of all children who underwent VNS implantation at King Abdullah University Hospital and Jordan University Hospital in Jordan. ResultsTwenty eight patients (16 males) had implantation of the VNS therapy system between the years 2007 and 2011. Mean age at implantation was 9.4 years. Mean duration of epilepsy prior to implantation was 6.5 years. The most common seizure type was generalized tonic clonic seizures. Fifteen patients showed a 50% or more reduction in seizure frequency. There was a significant reduction in total number of seizures (p=0.002) and emergency room (ER) visits (p=0.042) after VNS therapy. Atonic seizures were more likely to respond than generalized tonic clonic seizures, p=0.034. Direct hospital costs prior to VNS implantation were analyzed in relation to ER visits and intensive care unit (ICU) admissions. Cost savings per patient did reduce the financial burden of the device by about 30%. There was a QALY gain per lifetime of 3.78 years for children and 1 year for adolescents. ConclusionResponse to VNS implantation in Jordan was favorable and similar to what has been previously reported. QALY gain and cost per QALY analysis were encouraging. Cost savings were related to reduction in seizure severity. In circumstances of limited resources as in developing countries, targeting patients with frequent utilization of health services would improve cost effectiveness.

Economic evaluation of initial antiretroviral therapy for HIV-infected patients: an update of Italian guidelines

IntroductionHighly active antiretroviral therapy (HAART) has allowed many HIV-infected patients to enjoy longer survival and a better quality of life. We performed an economic analysis to estimate the cost-effectiveness of HAART regimens in Italy for managing HIV-naïve infected patients with a viral load below 100,000 copies/mL.Patients and methodsThe population considered in the model consisted of adult subjects with an HIV viral load below 100,000 copies/mL who received antiretroviral HAART treatment for the first time, according to the Italian National Guidelines with recommendation grade A1. The incremental cost-effectiveness analysis of quality-adjusted life years (QALYs) was carried out by means of a Markov model. Both the outcomes (QALYs) and the costs were discounted by 3.5%. The time horizon adopted in the model was 10 years. The point of view of the analysis was that of the Italian national health service.ResultsThe tenofovir (TDF)/emtricitabine (FTC)/rilpivirine (RPV) single-tablet regimen (STR) (€7,417.00) revealed the lowest mean treatment cost. TDF/FTC + raltegravir (RAL) showed a better quality of life (0.906 QALY/year), followed by TDF/FTC/RPV (STR; 0.900 QALY/year), TDF/FTC + RPV (multipill regimen) (0.889 QALY/year), and TDF/FTC + atazanavir (ATV/r) (0.886 QALY/year). TDF/FTC/RPV (STR) appeared to be the most cost-effective therapeutic choice (€13,655.00), followed by TDF/FTC + RPV (multipill regimen) (€15,803.00), and TDF/FTC + efavirenz (EFV) (€16,181.00). The sensitivity analysis on the main variables confirmed the validity of the base case scenario.ConclusionSTR (TDF/FTC/RPV) is the most cost-effective treatment strategy compared with the other therapeutic regimens recommended by the Italian guidelines for the treatment of naïve patients with a viral load <100,000 copies/mL. The inclusion of adverse-event management of HIV-infected patients affects the cost-effectiveness ratio of all HAART regimens.

Do modern total knee replacements offer better value for money? A health economic analysis

Cost effectiveness is an increasingly important factor in today's healthcare environment, and selection of arthroplasty implant is not exempt from such concerns. Quality adjusted life years (QALYs) are the typical tool for this type of evaluation. Using this methodology, joint arthroplasty has been shown to be cost effective; however, studies directly comparing differing prostheses are lacking. Data was gathered in a single-centre prospective double-blind randomised controlled trial comparing the outcome of modern and traditional knee implants, using the Short Form 6 dimensional (SF-6D) score and quality adjusted life year (QALY) methodology. There was significant improvement in the SF-6D score for both groups at one year (p < 0.0001). The calculated overall life expectancy for the study cohort was 15.1 years, resulting in an overall QALY gain of 2.144 (95% CI 1.752-2.507). The modern implant group demonstrated a small improvement in SF-6D score compared to the traditional design at one year (0.141 versus 0.143, p = 0.94). This difference resulted in the modern implant costing £298 less per QALY at one year. This study demonstrates that modern implant technology does not influence the cost-effectiveness of TKA using the SF-6D and QALY methodology. This type of analysis however assesses health status, and is not sensitive to joint specific function. Evolutionary design changes in implant technology are thus unlikely to influence QALY analysis following joint replacement, which has important implications for implant procurement.

Cost-efficacy of acceleration partial-breast irradiation compared with whole-breast irradiation

The purpose of this study was to analyze the cost-efficacy of multiple accelerated partial-breast irradiation (APBI) techniques compared with whole breast irradiation (WBI) delivered utilizing 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT). A previously reported matched-pair analysis consisting of 199 patients receiving WBI and 199 patients receiving interstitial APBI formed the basis of this analysis. Cost analyses included a cost minimization analysis, incremental cost- effectiveness ratio (ICER) analysis, and cost per quality adjusted life year (QALY) analysis. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI IMRT is $14.9 million, $10.9 million, $8.8 million, $5.0 million, and $9.7 million for APBI 3D-CRT, APBI IMRT, APBI single-lumen (SL), APBI multi-lumen (ML), and APBI interstitial, respectively. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI 3D-CRT is $6.0 million, $2.0 million, and $0.7 million for APBI 3D-CRT, APBI IMRT, and APBI interstitial, respectively. The cost per QALY for APBI SL, APBI ML, and APBI interstitial compared with APBI 3D-CRT are $12,273, $66,032, and $546, respectively. When incorporating non-medical costs and cost of recurrences the cost per QALY was $54,698 and $49,009 for APBI ML compared with APBI 3D-CRT. When compared to WBI IMRT, all APBI techniques are cost-effective based on cost minimization, ICER, and QALY analyses. When compared to WBI 3D-CRT, external beam APBI techniques represent a more cost-effective approach based on cost minimization with brachytherapy representing a cost-effective approach based on cost per QALY.

Quality of life (QOL) evaluation within a randomized phase III study of gemcitabine plus S-1 (GS) versus S-1 versus gemcitabine (GEM) in unresectable, advanced pancreatic cancer (PC) in Japan and Taiwan: GEST study.

9070 Background: The GEST study, a randomized 3-arm phase III study, was designed to assess the non-inferiority of S-1 alone and the superiority of GS to GEM. Primary endpoint was overall survival (OS). The non-inferiority of S-1 was confirmed, GS was superior to GEM but the difference was not statistically significant. QOL was a secondary endpoint. Here we report QOL results from this study. Methods: Chemotherapy-naïve patients with unresectable advanced PC, ECOG PS of 0-1, with adequate organ functions were enrolled. Patients were equally randomized to one of three arms: GEM (1000 mg/m2, iv, d1, 8 and 15, q4w) , S-1 (80/100/120 mg/day based on BSA, po, d1-28, q6w) , or GS (GEM 1000 mg/m2, iv, d1 and 8 plus S-1 60/80/100 mg/day based on BSA po, d1-14, q3w). The patients were assessed with EQ-5D questionnaire at baseline, and at 6,12,24,48 and 72 weeks from first administration. Changes over time of EQ-5D utility score and Quality-adjusted life years (QALY) were calculated. In addition, we explored the relationship between QOL and clinical characteristics. Results: Among 832 patients, full analysis set of this study, 736(88%) had completed both baseline questionnaire and at least one questionnaire after randomization. In the EQ-5D utility score analysis by including deaths as score 0, there was a statistically significant difference in score over time between GS and GEM (p=0.0031, repeated measures ANOVA), and no statistically significant difference between S-1 and GEM. In the analysis of QALY, there was a statistically significant difference between GS and GEM (p=0.0008, generalized Wilcoxon test), but no statistically significant difference between S-1 and GEM. In the population of PS 1, GS is remarkably better than GEM in favor of EQ-5D utility score and QALY. Conclusions: Patients treated with S-1 resulted in clinically equivalent efficacy outcomes without any impact on patient QOL compared with GEM. Patients treated with GS had a statistically significant difference in QOL compared with GEM, in both overall and PS1 populations. Further research is needed to confirm the efficacy of GS in unresectable advanced PC.

A review of studies mapping (or cross walking) non-preference based measures of health to generic preference-based measures

Clinical studies use a wide variety of health status measures to measure health related quality of life, many of which cannot be used in cost-effectiveness analysis using cost per quality adjusted life year (QALY). Mapping is one solution that is gaining popularity as it enables health state utility values to be predicted for use in cost per QALY analysis when no preference-based measure has been included in the study. This paper presents a systematic review of current practice in mapping between non-preference based measures and generic preference-based measures, addressing feasibility and validity, circumstances under which it should be considered and lessons for future mapping studies. This review found 30 studies reporting 119 different models. Performance of the mappings functions in terms of goodness-of-fit and prediction was variable and unable to be generalised across instruments. Where generic measures are not regarded as appropriate for a condition, mapping does not solve this problem. Most testing in the literature occurs at the individual level yet the main purpose of these functions is to predict mean values for subgroups of patients, hence more testing is required.

Modelling the cost‐effectiveness and capacity impact of changes to colposcopy referral guidelines for women with mild dyskaryosis in the UK Cervical Screening Programme

To evaluate the capacity implications and health economic impact of new guidelines recommending referral to colposcopy after one mild result during cervical screening rather than after two consecutive mild results. A mathematical model of the country's colposcopy services and the clinical pathways from smear result through to treatment is constructed. The model incorporates national questionnaire data on referral numbers and management practices, routine data and published research results. All English NHS colposcopy services. Women aged 25 to 64 years. The national average workload impact of the change in referral guidelines is predicted, and the impact in differing local circumstances is evaluated within the model. A long-term health economic model examines the resulting costs and predicted change in quality-adjusted life years (QALYs). Colposcopy workload implications for single mild dyskaryosis referral and cost per QALY analysis. We found that single mild dyskaryosis referral implies, on average, a 21% increase in colposcopy workload for services not currently operating this policy. The health economic model predicted a cost per QALY gained as a result of the implementation of the new referral guidelines of around pound7,500. Referral after one mild result will increase workload at colposcopy; however, it may be possible to counterbalance the additional workload by altering other clinical practice. The change to referral guidelines would be considered cost-effective in comparison with many interventions routinely available on the NHS.

Cost-effectiveness of cemented versus cementless total hip arthroplasty. A Markov decision analysis based on implant cost

BackgroundProbabilistic decision analysis is a means of reflecting the uncertainty parameter in models and of presenting it in a comprehensible manner to decision-makers.Materials and methodsA cost-effectiveness model was constructed to compare the cementless and cemented total hip prostheses implanted at our department in terms of lifetime costs and quality-adjusted life-years (QALY). Revision rates were obtained from the Orthopaedic Prosthesis Register of the Laboratory of Medical Technology, Istituti Ortopedici Rizzoli, Bologna, Italy.ResultsThe risk of early revision (at 5 years of follow-up) for cementless and cemented prostheses was 1.6% and 1.4%, respectively, resulting in equal QALY for the two implant types. Analysis of mean cost and QALY indicated that use of either implant is not associated with cost savings.DiscussionManagement with cementless or cemented total hip prostheses in a theoretical cohort of 70-year-old patients with fracture of the femoral neck or arthritis involving the hip is not significantly different according to the probabilistic results from the model.

The Costs of Drugs for Schizophrenia

The Costs of Drugs for Schizophrenia

Mortality risks, costs, and decision making in transfusion medicine.

Traditional quality-adjusted life year (QALY) cost analysis is complex and assigns arbitrary dollar values to catastrophic outcomes such as death. Analysis of transfusion medicine technologies by an alternative approach that focuses on costs to avoid fatal outcomes might be a useful adjunct to QALY analysis for allocating limited financial resources. We estimated the cost per death averted for the following interventions: apheresis platelets vs random platelets, solvent detergent-treated plasma vs untreated plasma, and leukocyte-reduced vs unmodified transfusions in cardiac surgery. As a control, similar data were calculated for current donor viral testing. The estimated incremental costs per death avoided were as follows: single-donor apheresis platelets, $15 million; solvent detergent plasma, $17 million; leukocyte-reduced transfusions in cardiac surgery, $11,000; HIV-1 antibody testing, $22,000; and HIV-1 antigen testing, $3.9 million. The estimated number of deaths averted per year in our hospital were as follows: apheresis platelets, 0.1; solvent detergent plasma, 0.044; leukocyte-reduced transfusions, 14; HIV-1 antibody testing, 6.0; and HIV-1 antigen testing, 0.033. HIV-1 antibody testing and leukocyte-reduced transfusions in cardiac surgery are comparably cost-efficient means of averting mortality in patients receiving transfusions. Solvent detergent plasma and apheresis platelets are comparatively expensive approaches to reducing mortality from transfusion complications.

The quality of reporting in published cost-utility analyses, 1976-1997.

Cost-utility analysis is a type of cost-effectiveness analysis in which health effects are measured in terms of quality-adjusted life-years (QALYs) gained. Such analyses have become popular for examining the health and economic consequences of health and medical interventions, and they have been recommended by leaders in the field. These recommendations emphasize the importance of good reporting practices. This study determined 1) the quality of reporting in published cost-utility analyses through 1997 and 2) whether reporting practices have improved over time. We examined quality of reporting by journal type and number of cost-utility analyses a journal has published. Computerized databases were searched through 1997 for the Medical Subject Headings or text keywords quality-adjusted, QALY, and cost-utility analysis. Published bibliographies of the field were also searched. Original cost-utility analyses written in English were included. Cost-effectiveness analyses that measured health effects in units other than QALYs and review, editorial, or methodologic articles were excluded. Each of the 228 articles found was audited independently by two trained readers who used a standard data collection form to determine the quality of reporting in several categories: disclosure of funding, framing, reporting of costs, reporting of preference weights, reporting of results, and discussion. The number of cost-utility analyses in the medical literature increased greatly between 1976 and 1997. Analyses covered a wide range of diseases and interventions. Most studies listed modeling assumptions (82%), described the comparator intervention (83%), reported sensitivity analysis (89%), and noted study limitations (84%). Only 52% clearly stated the study perspective; 34% did not disclose the funding source. Methods of reporting costs and preference weights varied widely. The quality of published analyses improved slightly over time and was higher in general clinical journals and in journals that published more of these analyses. The study results reveal an active and evolving field but also underscore the need for more consistency and clarity in reporting. Better peer review and independent, third-party audits may help in this regard. Future investigations should examine the quality of clinical and economic assumptions used in cost-utility analyses, in addition to whether analysts followed recommended protocols for performance and reporting.

Quality of life measures in health care. III: Resource allocation.

BMJ 1992;305:1205-9 In our two previous papers we discussed the use of measures of health related quality of life in clinical trials and in describing the health of populations.12 We now turn to the difficult issue of using quality of life measures for allocating limited resources among com? peting health care programmes. We concentrate on the quality adjusted life year (QALYs) since this approach has received most attention. QALYs use an index combining changes in survival and quality of life of patients (and possibly others) to assess benefit brought about by the funded programme. For each programme this benefit can be divided by its economic cost and the resulting ratio used to help allocate resources. QALYs can be used to choose between alternative programmes for treating the same patients or, more controversially, to choose among programmes targeted at different groups. The underlying philosophy is that rationing of resources is inevitable and so it is best that it is explicit and accountable.3 To ration effectively some measures of output from health care must be established. However, it is important to distinguish between such general issues, with which most may agree, and the actual techniques used in published studies, which have been greatly criticised. For example, Williams describes a method to assess current life expectancy and quality of life in which quality of life is assigned a value q on a 0 to 1 scale, 1 representing perfect health and 0 representing death.4 Each future year is then counted as worth q, with the possibility of discounting the value of future years in a similar manner to that used for future costs. The total QALYs for the group are estimated with and without the intervention, and the difference between the two estimates is a single composite measure of the marginal output of the programme. Williams emphasised the possible role of QALY analysis in the marginal allocation of additional resources, and North Western Regional Health Authority made an early unsuccessful attempt at allocating its discretionary specialties revenue reserve fund to its district health authorities.5 However, dis? trict health authorities are now considering such schemes6 at a more basic level, and in at least one case serious attempts are being made at implementation.7 In this article we focus on British applications, although the most extreme example of a QALY type analysis is that attempted in Oregon.8 Here 714 condition treat? ment pairs were placed in rank order and Oregon proposed to fund them from the Medicaid budget according to those ranks; the future of this project is now, however, in doubt. The QALY analyses arouse strong opinions. Critics have questioned the assumptions underlying the pro? cedure, doubted the quality of the data for calcula? tions, raised ethical objections concerning equity, and questioned whose values were relevant and whether it is reasonable to compare different numbers of different groups of people by a single index.914 Supporters of the QALY approach have said that current examples of QALY analysis are not definitive, that the method is still in development, and that it is intended only as an aid to decision making rather than a strict recipe.1517 The lack of an alternative procedure has also been emphasised.16 To clarify the arguments below we identify the stages necessary to introduce a QALY system for resource allocation. We discuss whether progress from stage to stage is technically feasible or ethically desir? able, and conclude with some recommendations for the appropriate future role of QALY type analyses.