Quality-adjusted Life-years For Men Research Articles

The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease.

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy ("uniform" or "age-adjusted") from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

Quality-Adjusted Life Expectancy Norms for the English Population

ObjectivesThe National Institute for Health and Care Excellence in England has implemented severity-of-disease modifiers that give greater weight to health benefits accruing to patients who experience a larger shortfall in quality-adjusted life-years (QALYs) under current standard of care than healthy individuals. This requires an estimate of quality-adjusted life expectancy (QALE) of the general population based on age and sex. Previous QALE population norms are based on nearly 30-year-old assessments of health-related quality of life in the general population. This study provides updated QALE estimates for the English population based on age and sex. Methods5-level version of EQ-5D data for 14 412 participants from the Health Survey for England (waves 2017 and 2018) were pooled, and health-related quality of life population norms were calculated. These norms were combined with official life tables from the Office for National Statistics for 2017 to 2019 using the Sullivan method to derive QALE estimates based on age and sex. Values were discounted using 0%, 1.5%, and 3.5% discount rates. ResultsQALE at birth is 68.24 QALYs for men and 68.21 QALYs for women. These values are significantly lower than previously published QALE population norms based on the older 3-level version of EQ-5D data. ConclusionThis study provides new QALE population norms for England that serve to establish absolute and relative QALY shortfalls for the purpose of health technology assessments.

Cost-effectiveness Analysis of Anatomic vs Functional Index Testing in Patients With Low-Risk Stable Chest Pain

Both noninvasive anatomic and functional testing strategies are now routinely used as initial workup in patients with low-risk stable chest pain (SCP). To determine whether anatomic approaches (ie, coronary computed tomography angiography [CTA] and coronary CTA supplemented with noninvasive fractional flow reserve [FFRCT], performed in patients with 30% to 69% stenosis) are cost-effective compared with functional testing for the assessment of low-risk SCP. This cost-effectiveness analysis used an individual-based Markov microsimulation model for low-risk SCP. The model was developed using patient data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. The model was validated by comparing model outcomes with outcomes observed in the PROMISE trial for anatomic (coronary CTA) and functional (stress testing) strategies, including diagnostic test results, referral to invasive coronary angiography (ICA), coronary revascularization, incident major adverse cardiovascular event (MACE), and costs during 60 days and 2 years. The validated model was used to determine whether anatomic approaches are cost-effective over a lifetime compared with functional testing. Choice of index test for evaluation of low-risk SCP. Downstream ICA and coronary revascularization, MACE (death, nonfatal myocardial infarction), cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of competing strategies. The model cohort included 10 003 individual patients (median [interquartile range] age, 60.0 [54.4-65.9] years; 5270 [52.7%] women; 7693 [77.4%] White individuals), who entered the model 100 times. The Markov model accurately estimated the test assignment, results of anatomic and functional index testing, referral to ICA, revascularization, MACE, and costs at 60 days and 2 years compared with observed data in PROMISE (eg, coronary CTA: ICA, 12.2% [95% CI, 10.9%-13.5%] vs 12.3% [95% CI, 12.2%-12.4%]; revascularization, 6.2% [95% CI, 5.5%-6.9%] vs 6.4% [95% CI, 6.3%-6.5%]; functional strategy: ICA, 8.1% [95% CI, 7.4%-8.9%] vs 8.2% [95% CI, 8.1%-8.3%]; revascularization, 3.2% [95% CI, 2.7%-3.7%] vs 3.3% [95% CI, 3.2%-3.4%]; 2-year MACE rates: coronary CTA, 2.1% [95% CI, 1.7%-2.5%] vs 2.3% [95% CI, 2.2%-2.4%]; functional strategy, 2.2% [95% CI, 1.8%-2.6%] vs 2.4% [95% CI, 2.3%-2.4%]). Anatomic approaches led to higher ICA and revascularization rates at 60 days, 2 years, and 5 years compared with functional testing but were more effective in patient selection for ICA (eg, 60-day revascularization-to-ICA ratio, CTA: 53.7% [95% CI, 53.3%-54.0%]; CTA with FFRCT: 59.5% [95% CI, 59.2%-59.8%]; functional testing: 40.7% [95% CI, 40.4%-50.0%]). Over a lifetime, anatomic approaches gained an additional 6 months in perfect health compared with functional testing (CTA, 25.16 [95% CI, 25.14-25.19] QALYs; CTA with FFRCT, 25.14 [95% CI, 25.12-25.17] QALYs; functional testing, 24.68 [95% CI, 24.66-24.70] QALYs). Anatomic strategies were less costly and more effective; thus, CTA with FFRCT dominated and CTA alone was cost-effective (ICERs ranged from $1912/QALY for women and $3,559/QALY for men) compared with functional testing. In probabilistic sensitivity analyses, anatomic approaches were cost-effective in more than 65% of scenarios, assuming a willingness-to-pay threshold of $100 000/QALY. The results of this study suggest that anatomic strategies may present a more favorable initial diagnostic option in the evaluation of low-risk SCP compared with functional testing.

Cost-Effectiveness of Antihypertensive Therapy in Patients Older Than 80 Years: Cohort Study and Markov Model

BackgroundBlood pressure and antihypertensive treatment (AHT) generally increase with age, but there is uncertainty concerning the value of treatment at very advanced ages. ObjectivesTo estimate the cost-effectiveness of AHT in people aged 80 years and older. MethodsA Markov model compared AHT with no blood pressure treatment for prevention of cardiovascular disease. Outcomes were new stroke, coronary heart disease, and diabetes, with falls included as a potential complication of AHT. Costs were evaluated from a health system perspective. Incidence, mortality, and costs of healthcare utilization were estimated from linked primary and secondary care electronic health records for 98 220 individuals aged 80 years and older. Clinical effectiveness estimates were from the Hypertension in the Very Elderly Trial. Deterministic and probabilistic sensitivity analyses were conducted. ResultsIn the base case, AHT was associated with an additional 725 quality-adjusted life-years (QALYs) and £4.3 million per 1000, with an incremental cost-effectiveness ratio (ICER) of £5977 per QALY. The ICER was most sensitive to the cost of falls and relative risk reduction in stroke incidence. Probabilistic sensitivity analysis gave 95% uncertainty intervals: £5057 to £8398 per QALY in men and £4955 to £8218 per QALY in women. AHT for secondary prevention in participants with coronary heart disease gave an ICER of £9903 per QALY. ConclusionsAHT is estimated to be cost-effective in individuals aged 80 years and older, even if health benefits are smaller or side effects costlier than in the base case. Benefits and harms for vulnerable subgroups require further evaluation.

Weighing Risk of Cardiovascular Mortality Against Potential Benefit of Hormonal Therapy in Intermediate-Risk Prostate Cancer.

The purpose of this study is to determine the optimal strategy for men with newly diagnosed intermediate-risk prostate cancer by age and cardiac risk. A Markov model was calibrated to the EORTC 22991 trial, which randomly assigned men with intermediate-risk prostate cancer to radiation therapy (RT) with or without six months of hormonal therapy (HT). We compared quality-adjusted life-years (QALYs) in men age 50, 60, and 70 years by age decile and cardiac risk group. Competing risks of cardiovascular mortality were estimated from the published literature. Sensitivity analyses were used to assess the impact of varying model assumptions. HT was associated with a net decrease of 0.3 to 0.4 QALYs in men with a history of myocardial infarction. However, for all other men, HT improved QALYs (range = 0.4-2.6 QALYs). Younger men with fewer cardiac risk factors experienced the largest benefit from HT. In sensitivity analyses, the model was only found to be sensitive to the probability of biochemical failure. Men at low risk for biochemical failure (≤8.7% at five years) did not benefit from HT. Further, the benefits of HT did not begin to manifest until after 7.3 years of follow-up. The optimal choice of therapy depends upon age, cardiac risk, and disease recurrence risk. Young men with intermediate-risk prostate cancer with no cardiac risk factors benefit most from HT. Men with a history of myocardial infarction who are at very low risk for biochemical failure may be negatively impacted by the addition of HT.

Potential cost-effectiveness of therapeutic drug monitoring in patients with resistant hypertension.

Nonadherence to drug therapy poses a significant problem in the treatment of patients with presumed resistant hypertension. It has been shown that therapeutic drug monitoring (TDM) is a useful tool for detecting nonadherence and identifying barriers to treatment adherence, leading to effective blood pressure (BP) control. However, the cost-effectiveness of TDM in the management of resistant hypertension has not been investigated. A Markov model was used to evaluate life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios in resistant hypertension patients receiving either TDM optimized therapy or standard best medical therapy. The model ran from the age of 30 to 100 years or death, using a cycle length of 1 year. Efficacy of TDM was modeled by reducing risk of hypertension-related morbidity and mortality. Cost analyses were performed from a payer's perspective. Deterministic and probabilistic sensitivity analyses were conducted. In the age group of 60-year olds, TDM gained 1.07 QALYs in men and 0.97 QALYs in women at additional costs of €3854 and €3922, respectively. Given a willingness-to-pay threshold of €35,000 per QALY gained, the probability of TDM being cost-effective was 95% or more in all age groups from 30 to 90 years. Results were influenced mostly by the frequency of TDM testing, the rate of nonresponders to TDM, and the magnitude of effect of TDM on BP. Therapeutic drug monitoring presents a potential cost-effective healthcare intervention in patients diagnosed with resistant hypertension. Importantly, this finding is valid for a wide range of patients, independent of sex and age.

Abstract 502: Cost-effectiveness Of Therapeutic Drug Monitoring In Patients With Resistant Hypertension

Background: Non-adherence to anti-hypertensive medications poses a significant problem in the treatment of patients with presumed resistant hypertension (RH). Our recent study has shown that therapeutic drug monitoring (TDM) is a useful tool not only for detecting medication non-adherence but also exploring the barrier to antihypertensive drug therapy, resulting effective BP control. However, the cost effectiveness of TDM in the management of resistant hypertension has not been investigated. Method: A Markov model was used to evaluate life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios in RH patients receiving either TDM optimized therapy or standard best medical therapy (BMT). The model ran from the age of 30 to 100 years or death, using a cycle length of 1 year. Efficacy of TDM was modeled by reducing risk of hypertension-related morbidity and mortality. Results: In the age group of 60-year olds, TDM gained 1.07 QALYs in men and 0.97 QALYs in women at additional costs of є3,854 and є3,922, respectively. Given a willingness-to-pay threshold of є35,000 per QALY gained, the probability of TDM being cost-effective compared to BMT was ≥95% in all age groups from 30 to 90 years. Incremental cost-effectiveness ratios were influenced mostly by the annual frequency of TDM testing, the rate of non-responders to TDM, and the magnitude of effect of TDM on systolic blood pressure (Figure). Conclusion: Therapeutic drug monitoring presents a potential cost-effective health care intervention in patients diagnosed with RH. Importantly, this finding is valid for a wide range of patients, independent of gender and age.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis

Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective. A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management. In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women. Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources.

Risk assessment to guide prostate cancer screening decisions: a cost‐effectiveness analysis

To apply the most recent evidence from randomised trials of prostate-specific antigen (PSA) screening and explore the potential value of risk assessments to guide the use of PSA screening in practice. A decision model that incorporated a Markov process was developed in 2012 to estimate the net benefit and cost of PSA screening versus no screening as a function of baseline risk. Quality-adjusted life-2013s (QALYs) and costs. The harms of screening outweighed the benefits under a number of plausible scenarios. Conclusions were sensitive to the estimated quality-of-life impacts of prostate cancer treatment as well as the incidence of cancers not detected by screening tests (poorer prognosis) and those that were detected by screening tests (better prognosis). The base-case incremental cost-effectiveness ratio of PSA screening was $168,611 per QALY for men with average risk, $73,452 per QALY for men with two times the average risk, and $22,938 [corrected] per QALY for men with five times the average risk. PSA screening was not found to be cost-effective for men at an average-to-high risk of prostate cancer, but may be cost-effective for men at very high risk. Inexpensive approaches for identifying men at very high risk are needed, as is further research on the size of clinical benefit of early detection in this population. The potential for the costs of risk assessment to be offset by reduced costs of PSA screening also warrants investigation.

Simulating Lifetime Outcomes Associated with Complications for People with Type 1 Diabetes

The aim of this study was to develop a discrete-time simulation model for people with type 1 diabetes mellitus, to estimate and compare mean life expectancy and quality-adjusted life-years (QALYs) over a lifetime between intensive and conventional blood glucose treatment groups. We synthesized evidence on type 1 diabetes patients using several published sources. The simulation model was based on 13 equations to estimate risks of events and mortality. Cardiovascular disease (CVD) risk was obtained from results of the DCCT (diabetes control and complications trial). Mortality post-CVD event was based on a study using linked administrative data on people with diabetes from Western Australia. Information on incidence of renal disease and the progression to CVD was obtained from studies in Finland and Italy. Lower-extremity amputation (LEA) risk was based on the type 1 diabetes Swedish inpatient registry, and the risk of blindness was obtained from results of a German-based study. Where diabetes-specific data were unavailable, information from other populations was used. We examine the degree and source of parameter uncertainty and illustrate an application of the model in estimating lifetime outcomes of using intensive and conventional treatments for blood glucose control. From 15 years of age, male and female patients had an estimated life expectancy of 47.2 (95 % CI 35.2-59.2) and 52.7 (95 % CI 41.7-63.6) years in the intensive treatment group. The model produced estimates of the lifetime benefits of intensive treatment for blood glucose from the DCCT of 4.0 (95 % CI 1.2-6.8) QALYs for women and 4.6 (95 % CI 2.7-6.9) QALYs for men. Absolute risk per 1,000 person-years for fatal CVD events was simulated to be 1.37 and 2.51 in intensive and conventional treatment groups, respectively. The model incorporates diabetic complications risk data from a type 1 diabetes population and synthesizes other type 1-specific data to estimate long-term outcomes of CVD, end-stage renal disease, LEA and risk of blindness, along with life expectancy and QALYs. External validation was carried out using life expectancy and absolute risk for fatal CVD events. Because of the flexible and transparent nature of the model, it has many potential future applications.

Potential lifetime cost-effectiveness of catheter-based renal sympathetic denervation in patients with resistant hypertension

Recent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RDN) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages. A Markov state-transition model accounting for costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness was developed to compare RDN with best medical therapy (BMT) in patients with resistant hypertension. The model ran from age 30 to 100 years or death, with a cycle length of 1 year. The efficacy of RDN was modelled as a reduction in the risk of hypertension-related disease events and death. Analyses were conducted from a payer's perspective. Costs and QALYs were discounted at 3% annually. Both deterministic and probabilistic sensitivity analyses were performed. When compared with BMT, RDN gained 0.98 QALYs in men and 0.88 QALYs in women 60 years of age at an additional cost of €2589 and €2044, respectively. As the incremental cost-effectiveness ratios increased with patient age, RDN consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness-to-pay threshold of €35 000/QALY, there was a 95% probability that RDN would remain cost-effective up to an age of 78 and 76 years in men and women, respectively. Cost-effectiveness was influenced mostly by the magnitude of effect of RDN on systolic blood pressure, the rate of RDN non-responders, and the procedure costs of RDN. Renal sympathetic denervation is a cost-effective intervention for patients with resistant hypertension. Earlier treatment produces better cost-effectiveness ratios.

Abstract 319: Potential Lifetime Cost-Effectiveness of Catheter-Based Renal Sympathetic Denervation in Patients with Resistant Hypertension

Aims - Recent studies have demonstrated the safety and efficacy of catheter-based renal sympathetic denervation (RD) for the treatment of resistant hypertension. We aimed to determine the cost-effectiveness of this approach separately for men and women of different ages. Methods and results - A Markov state-transition model accounting for costs, survival, quality of life, and incremental cost-effectiveness was developed to compare RD with best medical therapy (BMT). The model ran from age 30 to 100 years or death, with a Markov cycle length of 1 year. All patients entered the model with elevated systolic blood pressure (SBP, 180 mmHg), but free from prior cardiovascular disease (CVD) events. Patients could remain in this disease-free state or could have one of the following primary CVD events: myocardial infarction, angina, stroke or heart failure. After an event, patients transitioned into chronic disease states and/or could suffer from secondary CVD events. In the base case scenario, RD resulted in a sustained SBP reduction of 20 mmHg and in a corresponding relative risk reduction of adverse CVD events and death. The cost analysis was conducted from a health care payer perspective. Effectiveness was expressed as quality-adjusted life-years (QALY) gained. Costs and effects were discounted at 3% per annum, respectively. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the results. As compared with BMT, RD gained 0.99 QALYs in men and 0.91 QALYs in women 60 years of age at an additional cost of $3,265 and $2,594, respectively. As the incremental cost-effectiveness ratio increased with patient age, RD consistently yielded more QALYs at lower costs in lower age groups. Considering a willingness to pay threshold of $50,000/QALY, there was a 95% probability that RD would remain cost-effective up to an age of 82 and 80 years in men and women, respectively. Cost-effectiveness was influenced most by the extent of SBP lowering by RD, the rate of RD non-responders, and the costs associated with the RD procedure. Conclusion - RD offers a cost-effective treatment option for the prevention of CVD events in patients with resistant hypertension. An earlier intervention produces better cost-effectiveness ratios.

Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs

BackgroundTo determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD). MethodsA decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD− (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis. ResultsFor men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (−€229 in men, −€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (−€231) but also less effective compared to SOC (−0.003 QALY) in men with a pre-test probability of ≥70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥70% in which case it was 59%. ConclusionsThe results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.

Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study

The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension. We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies-further blood pressure measurement in the clinic, at home, and with an ambulatory monitor-in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness. Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from -£56 [95% CI -105 to -10] in men aged 75 years to -£323 [-389 to -222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive. Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs. National Institute for Health Research and the National Institute for Health and Clinical Excellence.

A cost-effectiveness analysis of the Chlamydia Monday - A community-based intervention to decrease the prevalence of chlamydia in Sweden

The study was undertaken to assess the cost-effectiveness of the Chlamydia Monday, 2007. This is a community-based intervention aimed at reducing the prevalence of chlamydia by information and increased availability of testing, treatment and contact tracing in Stockholm. The aim was to analyze the cost-effectiveness by estimating costs, savings and effects on health associated with the intervention, and to determine if cost-effectiveness varies between men and women. A societal perspective was adopted, meaning all significant costs and consequences were taken into consideration, regardless of who experienced them. A cost-effectiveness model was constructed including costs of the intervention, savings due to avoiding potential costs associated with medical sequels of chlamydia infection, and health gains measured as quality adjusted life years (QALY). Sensitivity analyses were done to explore model and result uncertainty. Total costs were calculated to be 66,787.21; total savings to 30,370.14; and total health gains to 9.852324 QALYs (undiscounted figures). The discounted cost per QALY was 8,346.05 (10,810.77/QALY for women and 6,085.35/QALY for men). Sensitivity analyses included changes in effectiveness, variation of prevalence, reduced risk of sequel progression, inclusion of prevented future production loss and shortened duration for chronic conditions. The cost per QALY was consistently less than 50,000, which is often regarded as cost-effective in a Swedish context. The Chlamydia Monday has been demonstrated by this study to be a cost-effective intervention and should be considered a wise use of society's resources.

Clinical Outcomes and Cost-Effectiveness of Coronary Computed Tomography Angiography in the Evaluation of Patients With Chest Pain

The aim of this study was to project clinical outcomes, health care costs, and cost-effectiveness of coronary computed tomography angiography (CCTA), as compared with conventional diagnostic technologies, in the evaluation of patients with stable chest pain and suspected coronary artery disease (CAD). CCTA has recently been found to be effective in the evaluation of patients with suspected CAD, but investigators have raised concerns related to radiation exposure, incidental findings, and nondiagnostic exams. With published data, we developed a computer simulation model to project clinical outcomes, health care costs, and cost-effectiveness of CCTA, compared with conventional testing modalities, in the diagnosis of CAD. Our target population included 55-year-old patients who present to their primary care physicians with stable chest pain. All diagnostic strategies yielded similar health outcomes, but performing CCTA-with or without stress testing or performing stress single-photon emission computed tomography-marginally minimized adverse events and maximized longevity and quality-adjusted life-years (QALYs). Health outcomes associated with these strategies were comparable, with CCTA in men and women yielding the greatest QALYs but only by modest margins. Overall differences were small, and performing the most effective test-compared with the least effective-decreased adverse event rates by 3% in men and women. Comparable increases in longevity and QALYs were 2 months and 0.1 QALYs in men and 1 month and 0.03 QALYs in women. CCTA raised overall costs, partly through the follow-up of incidental findings, and when performed with stress testing, its incremental cost-effectiveness ratio ranged from $26,200/QALY in men to $35,000/QALY in women. Health outcomes were marginally less favorable in women when radiation risks were considered. CCTA is comparable to other diagnostic studies and might hold good clinical value, but large randomized controlled trials are needed to guide policy.

Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain

Patients at low risk for acute coronary syndrome (ACS) who present to the emergency department complaining of acute chest pain place a substantial economic burden on the U.S. health care system. Noninvasive 64-MDCT coronary angiography may facilitate their triage, and we evaluated its cost-effectiveness. A microsimulation model was developed to compare costs and health effects of performing CT coronary angiography and either discharging, stress testing, or referring emergency department patients for invasive coronary angiography, depending on their severity of atherosclerosis, compared with a standard-of-care (SOC) algorithm that based management on biomarkers and stress tests alone. Using CT coronary angiography to triage 55-year-old men with acute chest pain increased emergency department and hospital costs by $110 and raised total health care costs by $200. In 55-year-old women, the technology was cost-saving; emergency department and hospital costs decreased by $410, and total health care costs decreased by $380. Compared with the SOC, CT coronary angiography-based triage extended life expectancy by 10 days in men and by 6 days in women. This translated into corresponding improvements of 0.03 quality-adjusted life years (QALYs) and 0.01 QALYs, respectively. The incremental cost-effectiveness ratio for CT coronary angiography was $6,400 per QALY in men; in women, CT coronary angiography was cost-saving. Cost-effectiveness ratios were sensitive to several parameters but generally remained in the range of what is typically considered cost-effective. CT coronary angiography-based triage for patients with low-risk chest pain is modestly more effective than the SOC. It is also cost-saving in women and associated with low cost-effectiveness ratios in men.

Long‐term hormone therapy and radiation is cost‐effective for patients with locally advanced prostate carcinoma

In Radiation Therapy Oncology Group (RTOG) trial 92-02, after men received neoadjuvant hormone cytoreduction and radiotherapy for locally advanced prostate carcinoma, they were randomized to receive either 2 years of long-term androgen-deprivation (LTAD) or no further treatment (short-term androgen-deprivation [STAD]). The specific objective of the current study was to determine whether LTAD was a cost-effective treatment for patients with locally advanced prostate carcinoma. The cost-effectiveness of LTAD was tested using a Markov model that was designed using proprietary software. The analysis took a payor's perspective. Unit costs were obtained by estimation using a global Medicare fee schedule. Costs and outcomes were discounted by 3%. Distributions were sampled at random from the treatment utilities, transition probabilities, and costs using a second-order Monte Carlo simulation technique. The expected mean cost was 32,564 dollars for LTAD compared with 33,039 dollars for STAD after accounting for the additional cost of salvage treatment for men who were treated with STAD. The mean number of quality-adjusted life years (QALYs) for men who received LTAD was 4.13 QALYs compared with a mean of 3.68 QALYs for men who received STAD. The cost-effectiveness acceptability curve analysis showed a 91% probability that LTAD was cost-effective compared with STAD. Although overall survival was similar in the LTAD and STAD groups, the patients who received LTAD experienced gains in QALYs and had lower costs, because LTAD prevented biochemical failure and the necessitating salvage hormone therapy. The current analysis showed that LTAD was cost-effective for the entire population studied in RTOG trial 92-02.

The cost-effectiveness of bariatric surgery.

The purpose of the study was to estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity (body mass index > 40). A deterministic decision analysis that compared the lifetime expected costs and outcomes between open gastric bypass and no treatment of severe obesity from the payer perspective was performed. Men and women between the ages of 35 and 55 yr, with body mass index between 40 and 50 kg/m(2), who did not have cardiac disease and who failed conservative treatment, including pharmacotherapy, were included. Cost-effectiveness ratio of the base case conditions was made with parameter estimates from the literature and expert discussion and expressed as cost per quality-adjusted life-years (QALY). One- and two-way sensitivity analyses were performed on selected variables. Gastric bypass was not cost-saving, because the reduction in lifetime medical costs was less than the cost of treatment in any subgroup. The base case cost-effectiveness ratios ranged from 5,400 US dollars to 16,100 US dollars for women and from 10,700 US dollars to 35,600 US dollars per QALY for men. Sensitivity analysis demonstrated that in older, less obese men, the cost effectiveness ratio was responsive to the amount of weight lost, obesity-related quality of life, and complication rates. Parameter variation did not significantly affect cost-effectiveness ratios in the remaining patients. The authors concluded that gastric bypass is a cost-effective alternative to no treatment in the severely obese, at less than 50,000 US dollars per QALY.

The cost-effectiveness of bariatric surgery: Craig BM, Tseng DS. Cost-Effectiveness of Gastric Bypass for Severe Obesity, Am J Intern Med 2002;113:491–8

The purpose of the study was to estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity (body mass index > 40). A deterministic decision analysis that compared the lifetime expected costs and outcomes between open gastric bypass and no treatment of severe obesity from the payer perspective was performed. Men and women between the ages of 35 and 55 yr, with body mass index between 40 and 50 kg/m 2, who did not have cardiac disease and who failed conservative treatment, including pharmacotherapy, were included. Cost-effectiveness ratio of the base case conditions was made with parameter estimates from the literature and expert discussion and expressed as cost per quality-adjusted life-years (QALY). One- and two-way sensitivity analyses were performed on selected variables. Gastric bypass was not cost-saving, because the reduction in lifetime medical costs was less than the cost of treatment in any subgroup. The base case cost-effectiveness ratios ranged from $5,400 to $16,100 for women and from $10,700 to $35,600 per QALY for men. Sensitivity analysis demonstrated that in older, less obese men, the cost effectiveness ratio was responsive to the amount of weight lost, obesity-related quality of life, and complication rates. Parameter variation did not significantly affect cost-effectiveness ratios in the remaining patients. The authors concluded that gastric bypass is a cost-effective alternative to no treatment in the severely obese, at less than $50,000 per QALY.